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Eyelid surgery (blepharoplasty) and brow lift
Before upper eyelid surgery the brow and the levator muscle are examined — because brow ptosis or eyelid ptosis need a different operation — and in the lower lid, laxity of the lid is checked; the dangerous complication is retrobulbar haematoma, which threatens vision and requires immediate lateral canthotomy.
Why it matters in the exam
The upper lid has two fat compartments — medial (nasal) and central — and laterally lies the lacrimal gland, which must not be excised if it is ptotic. The lower lid has three compartments — medial, central and lateral — and the inferior oblique muscle runs between the medial and central, so injuring it causes diplopia. The transconjunctival approach preserves the orbicularis muscle and reduces lid retraction, whereas the skin approach suits excess skin. Before surgery: visual acuity, a Schirmer test for dry eye, the lower lid snap and distraction tests (distraction of more than about 6 mm indicates laxity), and measurement of MRD1 and levator function to exclude ptosis. When laxity is present, canthopexy or canthoplasty is added to prevent ectropion.
Retrobulbar haematoma presents with severe pain, proptosis, a hard eye and falling vision in the first hours; treatment: open the sutures, lateral canthotomy and cantholysis immediately at the bedside, then mannitol, acetazolamide and steroids. Other complications: inability to close the eyelids (lagophthalmos) and dryness, lower lid retraction and ectropion, and under- or overcorrection. Brow lift: a woman's ideal brow lies above the orbital rim, with its peak roughly above the lateral limbus. Methods: endoscopic, coronal, hairline, "temple lift", and "direct suprabrow" — skin excision directly above the brow, which suits older patients or facial palsy but leaves a visible scar. A deep branch of the supraorbital nerve runs laterally under the galea, and injuring it causes scalp numbness.
Key points
- Upper lid — two fat compartments and a lateral lacrimal gland.
- Lower lid — three compartments; inferior oblique between them.
- Laxity — canthopexy to prevent ectropion.
- Retrobulbar haematoma — immediate canthotomy.
- Brow before lid.
Summary table
| Topic | Finding | Action |
|---|---|---|
| Upper lid — fat | Medial and central; lacrimal gland laterally | Do not excise the gland |
| Lower lid — fat | Medial, central, lateral | Inferior oblique between medial and central |
| Lower lid laxity | Slow snap, distraction over about 6 mm | Canthopexy or canthoplasty |
| Retrobulbar haematoma | Pain, proptosis, falling vision | Immediate canthotomy and cantholysis |
| Brow ptosis | Brow below the orbital rim | Brow lift before or instead of blepharoplasty |
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Sources
- American Academy of Ophthalmology Preferred Practice and oculoplastic guidance, current — Blepharoplasty and eyelid malposition
- Plastic Surgery (Neligan), 5th edition (2023) — Blepharoplasty; Forehead and brow rejuvenation
- Grabb and Smith's Plastic Surgery, 8th edition (2019) — Blepharoplasty complications
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.