What has been less understood, are the actual changes that occur to the upper eyelid crease and fold. Often the position of the eyelid crease is obscured by the appearance of redundant upper eyelid skin and fold displacement. A careful analysis of the crease in most individuals shows varied change from youth. The changes may also be asymmetric in any one individual (Fig. 8-8). This includes an elevated crease that may manifest in one or both upper eyelids. The solution has been, in most cases, to raise the eyelid crease of the affected upper eyelid with the excision of ‘excess’ soft tissue with or without brow lift. This maneuver, however, is routinely and repeatedly performed without respect for the presenescent appearance or understanding of the actual age-related changes of the upper periorbita (Figs 8-2, 8-3, 8-6).
The routine applications of traditional concepts in incision placement and soft tissue excision have also plagued some other technical aspects in upper blepharoplasty. The usual design of the upper eyelid crease commonly involves the use of 10 mm or greater (height) eyelid crease incision with excision of skin, orbicularis oculi muscle, and preaponeurotic fat.7‘8 This is customary whether or not upper blepharoplasty is performed with or without a brow lift. In part, the basis of this approach has been an attempt to elevate the upper eyelid crease, in essence, to expose a greater amount of the pretarsal surface and to ‘debulk’ the upper eyelid fullness by en-bloc or separate resection of skin and muscle.8 This approach, however, facilitated additional steps in upper blepharoplasty that are also aesthetically detrimental, including better access to the prcaponeurotic fat (resulting in further soft tissue reduction and volume depletion) and the levator aponeurosis for supratarsal fixation. Concerns with a lower placed incision included possible visibility of the upper eyelid incision scar, inability to achieve adequate final pretarsal exposure, and risk to the levator aponeurosis insertion to the pretarsal surface, especially when utilizing a full thickness skin muscle excision whether removed in separate ‘layers’ or ‘en-bloc’ The long-term consequences of the traditional approach, however, can be suboptimal. Deep or ‘hollow’ upper eyelid sulci are common effects, presumably from over-resection of soft tissue (Fig. 8-3), especially fat. In some, the upper eyelid crease scar becomes hypopig-mented (Fig. 8-9) and usually more visible with time, usually at a much higher level (15—20 mm). This is especially true in the patient with a prominent globe, negative upper periorbital vector, or in those who habitually elevate their eyebrows for a variety of reasons. The color transition can also at times become quite obvious, as the upper edge of the incision is placed in the darker and thicker sub-brow skin. The pretarsal skin also becomes progressively less taut (more ‘crepey’ in appearance) due to the sliding effect as most original points of fixation have been compromised by over-dissection.
