Principles of Silver's Segmental Technique Applied to Upper and Lower Lid Blepharoplasty with and without Direct Browpexy

Abstract

The Silver segmental technique of blepharoplasty allows a conservative, multisegmental approach to skin removal. It affords several advantages over other techniques, the most important of which is an increased element of safety. Modifications incorporating other newer principles seem appropriate since Silver's original description. In 1969 Silver described a new technique for blepharoplasty in which serial segmental resection of excess skin (and not muscle) was performed. Although some consider this a difficult approach for the uninitiated, this author believes it to be safer than the usual “en bloc” excision of redundant skin and offers his conclusions following 17 years of experience with approximately 500 cases done with this approach. Although Silver originally utilized a downward sweep over both the medial and lateral canthi (Figure 1), we find it cosmetically advantageous to extend the incision upward into the glabellar fold medially and toward the bony orbit laterally, extending past the orbital rim when necessary (Figure 2). Several other modifications of Silver's original technique are perhaps appropriate, especially incorporation of the M-plasty (Webster) (Figure 3) for excess medial canthal skin rather than “rotating the upper flap laterally instead of downward to get rid of the excess skin in the inner aspect of the upper lid.” Laterally, the Z-transposition (Lewis) is easily added when indicated. Thus, advantages of the modified Silver technique include (1) prevention of excess skin removal by using multiple tailored segmental excisions, (2) possible improvement of lateral crow's-feet lines, (3) an easily integrated M-plasty (Webster) or Z-transposition (Lewis) for removal of excess skin of either medial or lateral lids, and (4) easier suturing from lateral to medial with avoidance of lateral skin redundancy. Importantly, this technique may have special merit in cases where markedly redundant skin is present (Figure 4). The simplest method of performing an upper lid blepharoplasty is to delineate the excess skin visually, mark the tarsal plate line, separate the skin from the underlying muscle, and remove the excess. A hemostat is used by some to crinkle the superfluous skin, traction then being exerted on that tissue to allow an appropriate resection. A Green fixation forceps is also commonly used to pick up and delineate the skin such that the excess can be marked prior to excision. All these approaches serve well, but excessive removal of skin with resulting asymmetry, ectropion, and corneal ulceration occurs. Silver's segmental technique is applied after creation of an apron of excess skin which overhangs the lid and lid margin. Although Silver restricted the number of demarcated segments to three (Figures 5 and 6), the author has found results to be improved when more segments are evolved and visibility of the tarsal plate line is improved. The apron is therefore marked from the distal skin edge at multiple loci which are at right angles to the supratarsal fold line (Figure 7). These vertical guidelines are incised and the segments of excess skin serially removed, carefully contouring to the incision below (Figure 8). The widest point of the lid is then sutured to the immediate suprajacent flap edge. The medial and lateral segments are dealt with separately and variably, tailoring into the respective canthi. Silver's technique has no racial limitations, being used in Orientals, Occidentals, and Blacks. Indeed, serial resection can be used to confirm how much preliminarily demarcated skin should be removed. There are no difficulties combining this approach with tarsal plate fixation or with any type of forehead lift or browpexy.