1974 · J. H. Sheen (supratarsal fixation)
Upper blepharoplasty
Approach. Crease incision; skin, sometimes a strip of orbicularis, and some medial and central fat removed
The surgeon marks the crease with the patient upright, removes the excess skin, opens the septum and removes only the fat that comes easily into the wound. Sutures or skin glue close the incision. Sheen published fixing the skin to the tarsus to set the crease in 1974.[1][2][3]
Suits. Excess upper lid skin that folds over the lid or blocks the upper outer field of vision.
Trade-offs. Removing orbicularis with skin raised the odds of lagophthalmos 7.98 times in a meta-analysis of 12 trials, with no difference in dry eye. Wound separation followed 1.4% of 2,376 upper lids.
Transcutaneous lower blepharoplasty
Approach. Subciliary incision below the lashes; skin-only pinch or skin-muscle flap
An incision just below the lash line lifts skin alone, or skin and orbicularis as one flap, down to the orbital rim. Fat is removed or repositioned through small openings in the septum, and the extra skin is trimmed.[1][2][3]
Suits. Older lower lids with true excess skin and muscle. The skin pinch suits skin laxity without fat bulging.
Trade-offs. In 100 skin-muscle flap patients the lid margin dropped a mean 0.33 mm, 2 needed revision for malposition and 25 had new dry eye. Skin-muscle flap surgery raised the rate of dry eye and chemosis in an 892-case series.
1924 · J. Bourguet; H. A. Zarem, J. I. Resnick
Transconjunctival lower blepharoplasty
Approach. Incision inside the lower lid through conjunctiva and lid retractors; skin, orbicularis and septum left intact
The incision is made 4 to 6 mm below the lid margin on the inside of the lid. Gentle pressure on the eye pushes the three fat pads forward, and fat is removed until it lies flush with the orbital rim. The incision is usually left open and heals within a week. It can be combined with a canthopexy, fat repositioning, or laser or chemical peel resurfacing.[1][2][3]
Suits. Lower lid bags without excess skin, younger patients, and darker skin at risk of scarring. One center calls it the first choice for primary eyelid bags.
Trade-offs. It does not remove skin. Zarem reported no prolonged lid retraction in 104 patients. In a 300-lid series, ectropion and scleral show were 0% after transconjunctival and 3.3% after transcutaneous surgery.
1995 · S. T. Hamra; R. A. Goldberg
Fat repositioning and septal reset
Approach. Arcus marginalis released; orbital fat moved over the rim into the tear trough, under or over the periosteum
Fat that would be removed is kept on its stalk and sutured over the orbital rim into the hollow of the tear trough. Hamra described arcus marginalis release with fat preservation in 152 cases in 1995 and added the septal reset in 2004. Fat can sit in the subperiosteal or supraperiosteal plane with no apparent difference in result.[1][2][3]
Suits. Lower lid bags with a tear trough or a visible orbital rim. In 232 patients the tear trough was eliminated in more than 85%, including patients with little fat bulge.
Trade-offs. Complications include persistent dark circles, fat lumps, granulomas, restricted eye movement and new double vision. In 1,152 patients, 0.7% needed revision for leftover lateral fat.
1979 · R. L. Anderson (tarsal strip); R. S. Flowers
Canthopexy and canthoplasty
Approach. Lateral canthal tendon sutured, or a tarsal strip anchored to the periosteum of the lateral orbital wall
A canthopexy tightens the outer corner with sutures. The lateral tarsal strip cuts the tendon and re-anchors a strip of tarsus to the orbital wall. Flowers proposed canthopexy as a routine part of lower lid blepharoplasty in 1993. One surgeon used a tarsal strip when the lid pulled 10 mm or more from the eye and a canthopexy otherwise, in 98% of 247 patients.[1][2][3]
Suits. Lower lids with laxity, to prevent malposition and ectropion after surgery.
Trade-offs. Canthopexy raised the risk of chemosis in an 892-case series. In 100 skin-muscle flap patients, those with a canthopexy or canthoplasty had a greater change in lid position.
1975 · L. T. Jones, M. H. Quickert, J. L. Wobig
Ptosis repair by levator advancement
Approach. Crease incision; levator aponeurosis reattached to the tarsus
Through a crease incision the surgeon finds the levator aponeurosis under the preaponeurotic fat and sutures it to the tarsus, setting the lid height. It is often combined with upper blepharoplasty. With levator function under 4 mm, advancement does not lift enough and a frontalis sling is used.[1][2][3]
Suits. Ptosis from a separated levator with good muscle function, in the same operation as an upper blepharoplasty.
Trade-offs. In a meta-analysis of 1,038 lids it had more over-correction and re-operation than Muller muscle resection. Muller muscle resection also had fewer complications and a shorter operation.
1961 · R. M. Fasanella, J. Servat; A. M. Putterman, M. J. Urist
Ptosis repair from inside the lid
Approach. Incision on the inner surface of the upper lid; Muller muscle and conjunctiva resected
Muller muscle-conjunctival resection is used when phenylephrine drops lift the lid to an acceptable height; Putterman's first series was satisfactory in 27 of 28 lids. The Fasanella-Servat operation, published in 1961, treats mild to moderate ptosis and lid contour problems.[1][2][3]
Suits. Mild to moderate ptosis that responds to phenylephrine. Fasanella-Servat succeeded in 89.5% of 153 lids.
Trade-offs. After Fasanella-Servat, dry eye symptoms followed in 6 of 144 patients and contour problems in 12 lids. Success was lowest in congenital ptosis, at 76.4%.
1896 · K. Mikamo; L. R. Fernandez
Asian double eyelid surgery, incisional
Approach. Crease incision; skin edges sutured to the levator aponeurosis
About 50% of Asians have no upper lid crease. In one technique the surgeon excises 1 to 2 mm of skin, opens the orbicularis and septum, pushes the fat up and sutures the skin edges to the levator aponeurosis to form a crease, most often 6 to 7 mm above the lid margin. A full-thickness bite of the levator is avoided to prevent lid retraction.[1][2][3]
Suits. A missing or low crease with puffy lids or excess skin, where fat and muscle need trimming.
Trade-offs. Sutures are removed at day 7. In one series the operation took about 75 minutes under local anesthesia, with same-day discharge. The aim is a crease that keeps the patient's ethnic features.
Asian double eyelid surgery, non-incisional
Approach. Buried sutures link the skin to the tarsus or the levator without an incision
Threads connect the inner and outer layers of the lid without an incision. Fixation is interrupted, to the tarsus, or continuous, to the levator.[1][2]
Suits. Lids without puffiness. It is widely performed in East Asia for its fast recovery.
Trade-offs. The crease can fade. In 513 patients followed 2 years, continuous fixation had 0.29 times the hazard of crease loss of interrupted fixation, and puffy lids lost the crease more often.
2011 · B. D. Cohen, A. J. Reiffel, H. M. Spinelli
Browpexy through the upper lid
Approach. Upper blepharoplasty incision; brow soft tissue anchored to bone
Through the same crease incision the brow tissue is anchored to bone, so brow and lid are treated without a coronal, scalp or forehead incision.[1][2][3]
Suits. A low or sagging brow found at the blepharoplasty exam. In 21 patients aged 54 to 70 there were no major complications and no reoperation for recurrent brow ptosis.
Trade-offs. The series is small: 21 patients. After upper blepharoplasty alone, the brow dropped in 34.2% of 70 patients, and internal brow fixation through the incision is advised for men and older patients.