505

FACIAL PLASTIC
SURGERY CLINICS
OF NORTH AMERICA
Facial Plast Surg Clin N Am 13 (2005) 505–510

Evolution of Eyelid Surgery

a,b b,c,*
Gabriela M. Espinoza, MD , John B. Holds, MD

& The history of blepharoplasty & Browlift surgery

& Modern blepharoplasty & More recent developments in browlift
& More recent advances in upper surgery
blepharoplasty surgery & Adjunctive tools and treatments
& More recent evolution of lower eyelid & Summary
blepharoplasty & References

The history of periocular surgery has been traced pendium written by Aulus Cornelius Celsus
as far back as the eighteenth century BC, when (c. 25 BC–50 AD) in about 30 AD contains detailed
Hammurabi’s code detailed the contract between medical and surgical therapies of the time. Celsus
a surgeon and patient undergoing the lancing of an himself was not a physician or surgeon, but as a
infected lacrimal sac [1]. The medical therapy of eye private citizen of a noble family he was able to
disease was documented throughout ancient Egyp- translate treatises on medicine into the textbook
tian times between 1550 and 3000 BC. The Ebers De Medicina. Periorbital diseases that had surgical
papyrus (c. 1550 BC) suggested medical treatments cures by that time included chalazia, cysts, der-
for ectropion, entropion, and trichiasis [2]. It is in moids, ankyloblepharon, purulent dacryocystitis,
the Edwin Smith papyrus (c. 1650 BC) that the lagophthalmos, trichiasis, ectropion, ectropion, and
earliest known description of stitching the eyebrow tumors of the lid [4].
is found [3]. Clearly, the medical traditions of the
ancient cultures predated any written records, mak-
The history of blepharoplasty
ing it difficult to know when many surgical proce-
dures originated. The traditions of Greek and Roman medicine were
Modern medicine owes much to the era of Greek preserved and expanded by the Arabs who invaded
medicine, which is best typified by the writings of Alexandria in AD 643. Over 30 textbooks on
the famous physician Hippocrates (c. 460–375 BC). ophthalmology were written in the Arabic language
Although diseases such as cellulitis, hordeolum, over the next 500 years. One of the most famous of
ectropion, ptosis, epiphora, and blepharitis were these texts is the Tadhkirat al-Kahhalin of Ali ibn
well documented throughout the Hippocratic trea- Isa of Baghdad (AD 940–1010) [5]. This text was
tises, there is little to no mention of ophthal- compiled in large part from the Greek writings
mic procedures. However, Roman medicine—which of Claudius Galen (AD 130–200), and included
derived from the Greek tradition—had more ex- one of the earliest descriptions of upper eyelid
pansive surgical interventions. An excellent com- blepharoplasty, which was used in the treatment

a
Departments of Ophthalmology and Visual Sciences, Washington University School of Medicine, 4921 Park-
view Place, Suite 12C, Saint Louis, MO 63110, USA
b
Department of Ophthalmology, Saint Louis University Health Sciences Center, 1755 South Grand Boulevard,
Saint Louis, MO 63104, USA
c
Department of Otolaryngology-Head and Neck Surgery, Saint Louis University Health Sciences Center,
3635 Vista Avenue at Grand Boulevard, Saint Louis, MO 63104, USA
* Corresponding author. 450 North New Ballas Road, Suite 266, Saint Louis, MO 63141.
E-mail address: [email protected] (J.B. Holds).

1064-7406/05/$ – see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2005.09.001
facialplastic.theclinics.com
506 Espinoza & Holds

of trichiasis, ptosis, and dermatochalasis. Albucasis, section of herniated periorbital fat in 1924, and
an Arabian contemporary of Ali ibn Isa, described then 1 year later published before-and-after photo-
crescent-shaped cauterization of the skin above the graphs of this procedure [18,19]. The importance
eye and eyebrow to correct ptosis [6]. of photographs in cosmetic surgery was further
The term blepharoplasty itself is derived from the advocated by the first female cosmetic surgeon
Greek term blepharon, meaning ‘‘eyelid,’’ and plastos, of note, Parisien A. Suzanne Noel. Her text La
meaning ‘‘formed,’’ and was initially used in the Chirurgie Esthetique: Son Role Social, published in
broad sense of this definition to include any sur- 1926, contained 59 before-and-after photographs
gery involving the eyelids. Its introduction into the and recognized the importance of reviewing these
medical literature has been traced back to a treatise photographs and making them available to pa-
written by Carl Ferdinand von Graefe in 1818 de- tients [15].
scribing the reconstruction of an eyelid using a
cheek advancement flap [7]. It was during the nine-
Modern blepharoplasty
teenth century that oculoplastic surgery of the eye-
lid began to flourish, with multiple independent Present-day blepharoplasty has variably focused on
reports of successful eyelid reconstruction includ- the removal of excess eyelid skin, the removal of
ing flaps and full-thickness skin grafting [8]. herniated fat, or the creation of an eyelid crease.
In 1844, Jules Sichel (1802–1868) was the first to The modern technique of blepharoplasty was first
accurately describe herniated orbital fat in associa- described by Salvador Castañares in his pioneering
tion with skin excess, to which he attributed de- article from 1951 that included a detailed anatomi-
creased movement of the lid and overhanging of cal description of the orbital fat compartments
the eyelid margin [9]. Ernst Fuchs (1851–1930) [20]. In the years between 1951 and 1967, Cas-
further recognized that the excess skin fold was tañares described seven treatable cosmetic eyelid
caused by weakening of the fascial attachments of deformities: blepharochalasis, dermatochalasis, hy-
the skin and the tendon of the levator muscle. In pertrophy of the orbicularis muscle, protrusion of
1892, Fuchs noted the cosmetic benefit of not only intraorbital fat, combination of these conditions,
removing excess skin, but reforming the skin at- hooding of upper lids due to brow ptosis, and lid-
tachment to the top of the tarsus [10]. Improved cheek bags [21]. His techniques included excision
understanding of the anatomy of eyelid disease led of excess eyelid skin, of hypertrophied orbicularis
to improved surgical techniques, which, with im- muscle, and of herniated intraorbital fat pads. He
proved control of sepsis, led to a greater acceptance also described the direct brow lift with excision of
of elective surgery. an ellipse of skin above the brow to treat hooding.
In 1907, Charles Conrad Miller (1881–1950) He was aware of the presence of festoons and the
published the first book devoted to cosmetic sur- descent of the midface causing lid-cheek bags, and
gery, entitled Cosmetic Surgery: The Correction of recommended direct skin excision versus suspen-
Featural Imperfections [11]. Miller also published sion of the skin through a lower eyelid blepharo-
the first photograph depicting a marking of lower plasty incision. His basic ‘‘subtractive’’ techniques
eyelid blepharoplasty incision in an article in 1907 have been modified over the years with several
that was further developed in his text from 1924 to adjunctive procedures.
an incision much like that used today in a subcili-
ary incision technique [12,13]. The second author
More recent advances in upper
to publish a text describing cosmetic surgery was
blepharoplasty surgery
Frederick Kolle (1871–1929) in 1911 [14]. His chap-
ter on blepharoplasty is thought to be the first to In the upper eyelid, the ‘‘complex’’ technique of
stress the importance of preoperative measure- Fernandez [22] was adapted from the Asian to the
ments and markings of excess skin [15,16]. In the Caucasian eyelid by Flowers [23]. Termed ‘‘anchor
years surrounding World War I (1914–1918), the blepharoplasty’’ by Flowers, this technique repre-
necessity for craniofacial reconstructive surgery led sented the aesthetic ideal for many in the 1970s,
to experimentation and rapid advancements in producing what Flowers termed the ‘‘stylized look,’’
plastic surgery. Techniques to repair and improve with a very high, deep lid fold. These very high,
disfiguring scars led naturally into the rejuvenation deep lid folds have fallen into disfavor with many
of wrinkled faces. In 1919, Raymond Passot de- surgeons, with a more recent focus on what might
scribed the use of multiple elliptical excisions of be termed a ‘‘reconstructive blepharoplasty’’ with
temporal and preauricular skin to remove ‘‘crow’s attention to the repair of anatomic defects from the
feet’’ and other periocular wrinkles [17]. levator aponeurosis to replacement of lost fat
Julien Bourguet (1876–1952) of France first de- volume in the lateral brow. Fagien reviewed these
scribed a transconjunctival approach to the re- concepts nicely in 2002 [24].
 Evolution of Eyelid Surgery 507

and lower forehead incisional lifts [35a]. That same

More recent evolution of lower eyelid
year, Passot described the excision of skin behind
blepharoplasty
the hairline, and in 1933 combined it with dener-
Noting the problems inherent in the ‘‘subtractive’’ vation of the temporal branch of the facial nerve.
approaches codified by Castanares, over the past In 1957, Bames described a direct eyebrow lift via
30 years surgeons have generally moved away from which he also excised the corrugators, undermined
traditional techniques of subciliary incision sub- the forehead up to the hairline, and crosshatched
tractive lower eyelid blepharoplasty. the frontalis muscle [35b]. Pangman and Wallace
‘‘Rediscovering’’ Bourguet’s technique of trans- described a hairline approach as well as a coronal
conjunctival lower eyelid blepharoplasty, Tomlinson approach with the incision 1 cm posterior to the
and Hovey published results of the transconjunctival hairline in 1961. In 1962, Gonzalez-Ulloa included
approach for the correction of redundant pseudo- the forehead lift as a part of his facelift procedure.
herniated lower lid fat with little or no excess skin In the late 1960s and early 1970s, reports by
[25,26]. Baylis and others have build on this with surgeons suggested that coronal forehead lift results
further description and refinement of this technique. were temporary, and the procedure lost favor. How-
Recognition of the potential for oversculpting of ever, these earlier approaches consisted of the exci-
the orbital fat and skeletonization of the orbital sion of forehead or scalp skin, occasionally without
contours in combination with better understand- undermining, but always without interruption of
ing of the aesthetic and anatomic sequelae of aging the frontalis muscle action. However, in 1957, Bames
have led to the current wave of approaches in lower had bluntly crosshatched the frontalis through the
blepharoplasty surgery emphasizing orbital fat superciliary incision.
preservation. The evolution of lower eyelid blepha- Other authors had incised the frontalis through
roplasty has led to techniques of periocular rejuve- different approaches. Subsequently, in the mid-
nation focusing on: (1) orbital fat repositioning 1970s, several authors demonstrated that the exci-
with arcus marginalis release; (2) subperiosteal or sion of a strip of frontalis muscle eliminated the
intra-suborbicularis oculi fat plane midface lifting; dynamic factors that contributed to the formation
(3) midface volume augmentation, usually in con- of horizontal wrinkles and permitted more stretch-
junction with one of the above. Loeb [27] and later ing of the superficial tissues. In 1975, Washio stud-
Hamra [28] began the era of fat repositioning in ied cadaver foreheads and concluded that removal
blepharoplasty, with preservation of the orbital fat of a transverse segment of muscle allowed signifi-
as a means of recontouring and softening the ‘‘tear cant passive elevation of the forehead. Tessier (in
trough’’ [29]. Mendelsohn and coauthors have fur- 1968) and LeRoux and Jones (in 1974) also advo-
ther studied the periorbital anatomy and describe cated complete removal of the frontalis muscle.
the release of the arcus marginalis or undermining The direct brow lift of Castañares has been en-
of the orbicularis retaining ligament to improve hanced by adding brow suspension to the fronto-
redraping and upward mobilization of the lower temporal fascia or the periosteum [36]. In 1990,
eyelid tissue [30,31]. McCord and Doxanas [37] described internal brow-
The sagging midface has long been an object of pexy through a standard blepharoplasty incision to
surgical correction in the treatment of postblepharo- avoid the scar tissue that ensues after suprabrow
plasty eyelid retraction [32]. Hester and colleagues skin excision. They also described the adjunctive
[33] have advocated transpalpebral midfacial lifting technique of sculpting or removal of the brow fat
in a subperiosteal plane in an effort to address the pad, or browplasty. The retro-orbicularis oculi fat
tear trough, malar fat pad ptosis, contour changes (ROOF, or preaponeurotic fat) may also herniate
in the eyelids, and the nasolabial fold. forward, and can be suspended or sculpted cen-
The detailed and precise micro fat grafting (lipo- trally and laterally to improve eyelid contour.
structure) technique of Coleman [34] offers new
possibilities in restoring youthful appearance, and
serves as a useful adjunct in many authors tech-
niques of midface lifting. More recent developments in browlift
surgery
The relationship of brow ptosis and upper der-
Browlift surgery
matochalasis has been long-recognized, and the
Lexer provided the first documented discussion of a extensive surgical approach and associated scalp
brow lift technique in 1910 [35]. In the same year, paresthesia associated with classic coronal browlift
Hunt described a coronal resection of tissue for has led to the widespread acceptance of the endo-
lifting the forehead. Joseph documented the mid- scopic approach to browlift pioneered by Vasconez
forehead lift in 1931, describing both pretrichial and colleagues [38]. The desire to achieve improve-
508 Espinoza & Holds

ment in brow position without an extensive sur- Botulinum toxin injections were first introduced
gical approach has led to continued work with in 1987 for the treatment of glabelar furrows and
‘internal’ techniques of brow fixation as originally have found a niche in the adjunctive treatment of
described by Smith [39]. The transpalpebral ap- facial cosmetic surgery. Pretreatment of the perior-
proach has undergone reexamination by many bital area before blepharoplasty is used to improve
surgeons, with evaluation of an Endotine (Coapt surgical evaluation of excess skin to be removed or
Systems, Inc.) currently ongoing as a fixation de- to limit the distortion that can be found due to
vice. Of increasing interest since the 1990s is vol- asymmetric brow tone [50].
ume enhancement, or fat sparing surgery. Ramirez
has been at the forefront of facial rejuvenation by
restoration of youthful contours and the use of
autologous fat injection [40]. Orbital rim remodel- Summary
ing by implants may also enhance cosmetic appear-
Cosmetic rejuvenation of the periorbital area has
ances without the need for fat harvesting.
been an area of continual advancement in surgical
Other surgeons have focused on the depressing
knowledge over the past century. It is anticipated
role of the corrugator supercilii and procerus mus-
that some new currently described advances will be
cles in the medial brow. Routinely removed or
incorporated into continuing practice patterns,
weakened in coronal and endoscopic techniques
with advances in nonsurgical rejuvenation and sur-
of browlift, Knize [41], Guyuron [42] and others
gical techniques.
have described surgical techniques and results after
excising the corrugator supercilii and procerus mus-
cles via transpalpebral approaches. Nonsurgical
approaches to brow elevation have included the References
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