In the 1913 American Encyclopedia of Ophthalmology, blepharoplasty is defined as the reformation, replacement, readjustment, or transplantation of any of the eyelid tissues. In contemporary usage, blepharoplasty refers to the excision of excessive eyelid skin, with or without the excision of orbital fat, for either functional or cosmetic indications. The cosmetic indi-cations have been recognized by physicians only since the turn of the 20th century, but are now the most common reasons for such surgery on the eyelids. This change followed the development of improved operative techniques, better surgical results, and control of sepsis as well as changing social mores.
It is difficult to determine whether the 'relaxed eyelid' described by Celsus was a true ptosis or an excess skin fold. In any event, by the late 1700s, reports began to appear in Germany specifically identifying the excess fold of the upper eyelid. Beer's 1817 text is credited with providing the medical literature with the first illustration of this eyelid deformity.' Many different authors from the first half of the 19th century began advocating excision of this excess skin, including Mackenzie,8 Alibert,9 Graf, and Dupuytren.
The first 'accurate' description of 'herniated orbital fat,' written in 1844 by Sichel, did not create a wave of surgical excisions because surgery at that time was performed only for functional reasons. The case of Fetthernien reported in 1899 by Schmidt-Rimpler, which described herniated orbital fat, was clouded by the later report by Elschnig, who called the same patient's condition a lipoma.
Near the turn of the 19th century, Ernest Fuchs attempted to decipher the confusing terminology that had developed in the literature. 'Ptosis adiposa,' the misnomer used by Sichel, and 'ptosis atonica,' used by Hotz,16 had been introduced earlier in the 19th century. Sichel had claimed that the excess upper lid fold was filled with fat, which caused it to hang down over the lid margin. Hotz believed that the skin was normally attached to the top of the tarsus, and that the loss of this attachment created an excessive upper lid skin fold with a pseudoptosis. It was Fuchs who recognized the importance of the weakening of the fascial bands con¬necting the skin and orbicularis with the tendons of the levator in the development of the excess skin fold. In his 1892 text, Fuchsb wrote:
So also the ptosis adiposa of Sichel, which consists in the fact that the covering fold of the upper lid is of unusual size, so as to hang down over the free border of the lid in the region of the palpebral fissure, does not belong under the head of ptosis proper. It was formerly assumed that this enlargement was caused by an excessive accumulation of fat in the covering fold, for which reason the name of ptosis adiposa was given to it. Its true cause, however, depends upon the fact that the bands of fascia connecting the skin with the tendon of the levator . . . and with the upper margin of the orbit are not rigid enough; consequently the skin is not properly drawn up when the lid is raised, but hangs down in the form of a flabby pouch (Hotz). Except for the disfigurement it causes ptosis adiposa entails no disagreeable symptoms. It can be removed by simple ablation of the excess of skin, but it is better, although also more tedious, to attach the skin to the upper border of the tarsus by Hotz's operation, and thus prevent its drooping.
And so Fuchs was the first to recognize the cosmetic value of reformation and elevation of the eyelid crease. Fuchs1'' is also credited with originating the often misused term blepharochalasis in 1896. Sometimes used to describe the changes associated with herniated orbital fat, this term should be reserved for those cases of thickened and indurated eyelids, most often found in younger women, and associated with recurrent episodes of idiopathic edema.IS' The term derma-tochalasis was introduced 56 years later by Fox2 to describe the apparent excess eyelid skin associated with aging.
In the early 1900s, the historical focus on cosmetic eyelid surgery shifted to the United States, where Conrad Miller, in 1907, produced Cosmetic Surgery: The Correction of Featural Imperfections, the first published book on cosmetic surgery. This edition, which covered many aspects of plastic surgery, contained the first photograph in medical history to illustrate the lower eyelid incision for removing a crescent of excess skin. It is interesting to note Miller's surgical technique. In his discussion of the lower eyelid incision, Miller stated that 'just sufficient skin is left along the margin of the lid to permit the stitches being passed in closing. The line of union is brought in this way under the shadow of the lashes, and is entirely invisible.' On excision of the fold above the eye, Miller wrote that 'the fold above the eye after infiltration is picked and trimmed away. The line of closure here is at the upper extremity of the lid so that the slight line of the union is hidden in the fold between the lid and the brow when the eye is open, and only shows slightly when the eye is closed.' Miller's enlarged text," which followed in 1924, provided diagrams of incision sites for upper and lower eyelid blepharoplasty that are remarkably similar to those commonly used today.'
Frederick Kolle, in a 1911 text on plastic and cosmetic surgery, wrote about wrinkled eyelids in a chapter on blepharoplasty. He probably was the first to recognize and note the safety and value of marking the skin preoperatively to determine the amount of excess skin to excise.
Adabert Bettman added to the contributions by Miller and Kolle in his publications in the 1920s, in which he described precautions, specifically related to surgery about the eyelids, to be taken in minimizing postoperative scarring. He emphasized gentle treatment of the tissues, exact apposition of wound edges, elimination of tension on all wound edges, and timely suture removal. These, of course, are concepts that are still important today.
The first work in English devoted solely to oculo-plastic surgery was written by Edmund Spaeth. Newer Methods of Ophthalmic Plastic Surgery, published in 1925, deals entirely with eyelid reconstruction and does not mention cosmetic surgery.
By the late 1920s, still no mention had been made in the United States of the excision of herniated orbital fat for cosmetic reasons. Although advances and progress in medicine (including antibiotics, finer suture materials, improved technology, and better control of sepsis) allowed for the beginnings of the public desire for and acceptance of cosmetic surgery, it was still frowned on by the majority of physicians.
In the same decade in Europe, Julian Bourguet was also developing new techniques in cosmetic eyelid surgery. In 1924, he was probably the first to describe transconjunctival resection of the pockets of herniated orbital fat. In the following year, he published probably the first before and after photographs of patients who had undergone cosmetic lower eyelid surgery. In 1929, Bourguet described the two separate fat compartments of the upper lid and advocated their removal. Many surgeons followed his lead, including Claoue and Passot. Passot is also credited as
Figure 1-2 A, An upper eyelid incision. B, An upper eyelid closure. C, A triangular resection modification to lower eyelid incision to prevent ectropion. D, A lower eyelid closure. From Miller CC: Cosmetic Surgery: The Correction of Featural Imperfections. Philadelphia, FA Davis, 1924. With permission.
Figure 1-3 Earliest photographs illustrating preoperative (A) and postoperative (B) appearances of lower eyelid blepharoplasty. From Bourguet J: Chirurgie esthetique de la face: Les nez concaves, les rides et les 'poches' sous les yeux. Arch Franco-Beiges Chir 1925; 28:293. With permission.
being the first to name the supraciliary brow incision for the correction of brow ptosis. It is also quite interesting that Passot expressed his objections to the secrecy of techniques practiced by some of his contemporaries: 'By keeping their methods secret, they allow a certain suspicion to exist about their procedures.' These 'suspicions' for many procedures can be related to the present.
At the same time, one of the first female surgeons to appear in the history of cosmetic surgery was perfecting her techniques in Paris. Suzanne Noel's 1926 book on cosmetic eyelid surgery3 was the earliest to include numerous preoperative and postoperative photographs. Noel also initiated the emphasis, for the benefit of other surgeons, on the advantages and the importance of looking at these photographs and showing them to one's patients. She was also the first to be photographed performing a blepharoplasty. Thanks to the contributions of Noel and others and to the development of photography as an art and science, photographic documentation is now an integral part of the practice of the cosmetic oculoplastic surgeon. In addition, Noel must certainly be credited for recognizing the importance of the psychological implications of cosmetic surgery for both the patient and the patient's family. She distinguished between the attitudes of American and European men: 'American men are anxious to encourage their wives to have such an operation. ... [Sjuch is not the case with the European male; as a result, French women have the operation performed and do not talk about it.'
In the first two decades of the 1900s, a surgical technique widely used in Europe for elevation of the eyebrow was commonly known as the 'temporal lift.' Its benefits remained controversial. Bourguet, in 1921, was the first to condemn this type of surgery. In 1926, Hunt described a coronal skin resection to achieve a forehead lift. Joseph, in 1931, described hairline and forehead crease incisions to raise the brows. The coronal brow lift, as described by Hunt, lost favor because the results with the methods performed in a matter similarly ascribed by him were thought to be too transient.
A number of authors then recognized the importance of manipulating the frontalis and other muscle activity to achieve better results with the forehead lift. The importance of attenuating the action of the procerus and corrugator muscles was recognized by Salvadore Castanares in 1964.
Since the 1930s, additional individual contributions have been made to cosmetic eyelid surgery. An offering in 1951 by Castanares of a detailed description of the fat compartments of the upper and lower orbit and their relationship to the eyelids cannot be overlooked. It was also Castanares who recognized the importance of the orbicularis muscle (including its hypertrophy and excision, when indicated) as part of the overall evaluation and technique in cosmetic blepharo-plasty. Furnas later elaborated on the origin of eyelid and cheek contour abnormalities (including festoons) in his landmark chapter in Clinics of Plastic Surgery edited by Flowers.
In 1954, Sayoc reported on the use of the Hotz trichiasis procedure for the cosmetic alteration of the Asian upper eyelid crease/fold complex. Pang's 1961 report on the Far Eastern method of the surgical formation of the upper lid fold was the first to advocate the technique of supratarsal fixation, although this term was reintroduced 13 years later by Jack Sheen. Khou Boo-Chai's 1963 report was the initial description of eyelid crease elevation with upper eyelid blepharoplasty, but he advocated dermal fixation to the tarsal plate and referred only to the Asian eyelid.
Significant contributions to cosmetic eyelid surgery in the 1970s focused on the levator aponeurosis and crease-fold complex. In 1974, Sheen recognized the low eyelid crease as the cause of apparent failure in many Caucasian patients undergoing upper lid blepharoplasty. He advocated orbicularis fixation to the levator aponeurosis 16 mm above the lid margin; 3 years later, iatrogenic postoperative ptosis prompted him to lower it to 12 mm.09 At that time, observing postoperative lid retraction, he inadvertently discovered a way to strengthen the levator aponeurosis by tucking it. The next year, Dryden and Leibsohn reported on intentional levator advancement for simultaneous blepharoplasty and repair of ptosis. The current thinking for the next 20 years for a high-definition and enhanced upper eyelid 'invagination' with blepharoplasty were in part due to contributions from Flowers and Siegel.
Putterman and Urist recognized the role of the crease-fold complex in upper eyelid asymmetry associated with ptosis, trauma, and other eyelid abnormalities. Sheen also advocated tarsal fixation in the lower eyelid to achieve a 'youthful' appearance.
In the last 25 years, there have been significant additional contributions to the development of cosmetic oculoplastic surgery. With the increased frequency of operations, there has been a growing awareness of potential complications. The importance of the preoperative evaluation has been emphasized as essential to minimizing complications; this also has resulted in the development of adjunctive surgical procedures.
With a perceived improved understanding of orbital and periorbital anatomy and failure of existing methods relating to upper blepharoplasty, a focus was directed to the preoperative evaluation of the (upper) blepharoplasty patient that should detect the presence of a prolapsed lacrimal gland. This trend also reflected the age of the most common presenting patient for upper blepharoplasty at that time; currently this may have less relevance. In 1978, Smith and Petrelli described the surgical repair of a prolapsed lacrimal gland. Specific adjunctive dacryoadenopexy in upper eyelid blepharoplasty was described in 1983 by Smith and Lisman. This technique has been used far more frequently in geriatric blepharoplasty, but illustrates well (in an albeit macroscopic way), some of the involutional changes that relate to attenuation of the retaining ligaments that can be ascribed to many of the aspects of facial aging.
Because of an escalating concern regarding complications from cosmetic periorbital surgery, in 1975 Putterman recommended that the eyes not be patched after cosmetic blepharoplasty so that a potential sight-threatening retrobulbar hemorrhage could be more easily identified. Putterman and Urist also demonstrated that baggy eyelids can occur as a true hernia resulting from detachment of the septum from capsulopalpebral fascia and levator aponeurosis.
In the 1970s, reports first appeared in the plastic surgery literature describing and confirming the existence of the dry eye syndrome after blepharoplasty. In 1976, Tenzel recommended that each patient be given a Schirmer tear test to evaluate basic tear secretion before cosmetic blepharoplasty. These tests however have been used and abused, and consistency has been lacking. However, they are still widely performed today. He recommended that function take precedence over cosmesis in patients with decreased tear function. His observations have however dictated the necessity of caution in patients with compromised ocular lubrication and a greater awareness that dry eye syndrome can be a real and devastating problem after surgery. The decade of the 1980s witnessed the development of a better understanding of the causes of dry eye symptoms and procedures that could aid in the reduction of these occurrences.
The recognition in 1972 of lower eyelid laxity as a cause of postblepharoplasty lower eyelid malposition has also significantly reduced the incidence of this complication. Tenzel recommended combined horizontal shortening and lower eyelid blepharoplasty when lower eyelid laxity is recognized preoperatively. In 1979, Webster and colleagues described a temporary lateral canthal suspension suture in cases of minimal to moderate horizontal eyelid laxity. In 1982, Putterman edited the first textbook dedicated to cosmetic oculoplastic surgery. In it, he described and illustrated the use of Byron Smith's modification of the Kuhnt Szymanowski procedure for tightening the lower eyelid at the time of cosmetic blepharoplasty. This involved a full-thickness resection at the eyelid margin. Katzen and Tenzel were the first to recommend that horizontal shortening be performed at the lateral canthus at the time of cosmetic lower eyelid blepharoplasty, thus eliminating the need for eyelid margin sutures. Horizontal shortening procedures such as the lateral tarsal strip, remained the most popular of procedures for treating horizontal laxity for the next 20 years. The 'tear trough', although seemingly a recent phenomenon, written about extensively in not only the medical literature but fashion magazines to the lay public, represents a periorbital region of continued frustration. Raul Loeb in the 1970s wrote about his perception of the cause and even described the treatment, including his version of fat transposition and transplantation, which probably was not as well appreciated until his concepts were published in English several years later.
Historical developments in the 1980s have sometimes seemed less significant. Blepharopigmentation, for example, was a trend introduced more by industry and in the lay press than in the scientific literature. Blepharopigmentation, or as it is commonly called 'tattooed eyeliner' was introduced to ophthalmologists by Giora G. Angres. It was initially developed for aphakic and presbyopic patients and by handicapped persons who were unable to accurately apply their own eyeliner. Although it waned in popularity, it has since been used as an adjunct to cosmetic blepharoplasty, as well as eyebrow enhancement for cosmesis and in patients with alopecia. The consumer demand for the cosmetic procedure was predicted to be great by the equipment manufacturers but never really developed. The procedure has still remained reasonably popular, more so in the Asian and Hispanic communities, who were first to accept delivery by non-physicians. It is now widely offered in spas and by cosmetologists and less often by surgeons.
In 1980, Orkan Stasior described posterior eyebrow fixation, a technique for brow elevation through a blepharoplasty incision. Since then, similar techniques were independently developed and described in the literature as a response for the obvious need for brow elevation and or stabilization in the appropriate patient.
In 1982, trichloroacetic acid (TCA) exfoliation was first described in the ophthalmic literature by Allan Lorincz as a 'superficial chemical cautery for circumscribed eyelid skin lesions.' Ten years earlier, Wolport and colleagues had described a chemical peel with trichloroacetic acid for fine wrinkles of aging skin. This technique has been gaining popularity as a 'light chemical peel' to reduce the fine wrinkle lines in the periorbital area. The efficacy and duration of chemical peels used today (mostly TCA, but other agents are also used) relate to a host of factors including concentration and method of application.
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