Where are the incisions placed in standard upper and lower blepharoplasty?

Blepharoplasty Incision Locations

In upper blepharoplasty, the incision is placed in the supratarsal crease approximately 10 mm above the lash line, extending from about 1 cm above and lateral to the medial canthus to just beyond the lateral eyebrow; in lower blepharoplasty, the incision is typically placed 1-2 mm below the lash line (subciliary approach) or can be positioned in the lower periorbital region for direct skin excision.

Upper Eyelid Blepharoplasty Incision Placement

Standard Incision Design

• The lower margin of the incision follows the supratarsal crease, positioned approximately 10 mm above the ciliary (lash) line 1
• The incision begins medially about 1 cm above and lateral to the medial canthus 1
• Laterally, the incision curves gently upward and outward above the lateral canthus, often placed within natural skin creases or crow's feet, extending to slightly below and beyond the lateral extremity of the eyebrow 1

Incision Shape Variations

The shape of the upper lid incision can be modified based on the specific anatomical concerns:

• Traditional crescent-shaped excision: Widest at the center of the lid with or without lateral extension, suitable for patients with generalized upper lid skin excess 1
• Scalpel-shaped excision: Widest laterally and tapering medially, specifically designed for patients with significant lateral hooding and normal brow position, creating a final suture line in the form of an oblique flattened lazy S 1

Mini-Incision Techniques

For patients seeking less invasive options:

• Three mini-incisions of 3-4 mm each can be made in the upper eyelid, allowing removal of pretarsal orbicularis oculi muscle and excessive fat while creating a stable supratarsal fold with minimal scarring 2, 3
• These mini-incisions are positioned along the planned supratarsal crease line 3

Lower Eyelid Blepharoplasty Incision Placement

Subciliary Approach

• The traditional lower blepharoplasty incision is placed 1-2 mm below the lower eyelash line (subciliary), which allows access to remove fat bags and limited skin excess 4
• This approach must avoid creating tension on the lower eyelid to prevent complications such as scleral show 4

Direct Excision Technique

For patients with significant lower periorbital tissue excess (crepe-like skin, festoons):

• A direct incision can be placed in the lower periorbital region below the traditional subciliary location, allowing removal of more skin than the traditional method without creating lower lid tension 4
• This technique is particularly useful when tissue excess is significant and the traditional subciliary approach would be insufficient 4

Critical Technical Considerations

Scar Concealment

• Upper lid incisions heal with scarcely noticeable scars in older individuals due to lax skin, often falling within pre-existing crow's feet creases 1
• In younger patients without crow's feet, lateral extensions may remain visible, making the extended technique less suitable 1
• The blepharoplasty incision creates a well-hidden, minimal scar in the natural folds of the eyelid, which addresses patient concerns about facial scarring 5

Functional Outcomes

• Proper incision placement can achieve significant functional and visual improvement in patients with visual field impairment from redundant eyelid skin 6, 1
• The scalpel-shaped upper blepharoplasty adequately addresses lateral hooding by removing excess skin in both vertical and horizontal directions 1

Common Pitfalls to Avoid

• Avoid placing lower lid incisions with excessive tension, as this can lead to scleral show and ectropion 4
• In patients without natural lateral crow's feet, avoid extended lateral incisions as the scar may be visible, especially if it widens 1
• Ensure adequate removal of pretarsal tissue in mini-incision techniques to prevent fold disappearance, though some shifting may occur over 3 years 3