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Cosmetic: Original Articles

Rethinking Upper Blepharoplasty: The Impact of Pretarsal Show

Alghoul, Mohammed S. M.D.; Bricker, Jonathan T. B.A.; Venkatesh, Vishnu B.A.; Gupta, Aakash R. B.A.; Vaca, Elbert E. M.D.; Sinno, Sammy M.D.; Ellis, Marco F. M.D.; Mustoe, Thomas A. M.D.

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Plastic and Reconstructive Surgery: December 2020 - Volume 146 - Issue 6 - p 1239-1247
doi: 10.1097/PRS.0000000000007330
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Blepharoplasty is the fifth most common operation performed by plastic surgeons in the United States. For those aged 65 years and older, it is the most common procedure, reflecting how aging affects the delicate structures of the eyelid.1 Despite how common this procedure is, few studies have examined the relationship between eyelid proportions and attractiveness.2–6

Youthful upper eyelids have a smooth upper lid fold that increases in height from medial to lateral, with a well-defined pretarsal space that is symmetric along its length.7,8 An attractive upper eyelid has a distinctive volume distribution that is subtle and flatter medially and fuller laterally, creating a convex surface that blends seamlessly with the lateral brow fat.9 Recent work by our group has examined the upper lid fold–to–pretarsal space ratio in attractive Caucasian female models and found that the ratio averages 1.8 at the medial limbus and increases to a maximum of 3.0 at the lateral limbus.10 With aging, fat content in the upper lid can increase or decrease, leading to either localized bulges or a hollowed appearance of the upper lid sulcus and lateral brow, respectively.11–13 In addition, downward displacement of the superficial musculoaponeurotic system and upper lid fold skin may contribute to lid hooding.14 Ultimately, the youthful ratio of the upper lid fold to pretarsal space is altered or obscured, leading to an aged and less cosmetically appealing eyelid. The goal of upper blepharoplasty is to restore the ideal upper lid fold–to–pretarsal space proportions, and to recreate youthful convexity of the upper lid fold.13 As such, upper blepharoplasty has evolved over the years to a “volume-conserving” operation, preserving and redraping tissue to recreate ideal proportions.12–16 However, the procedure remains reductive in nature, as the core principle of the operation relies on skin excision.

It has been our experience that there is a group of patients presenting for upper blepharoplasty who have a complete pretarsal show preoperatively. We hypothesize, based on the aforementioned topographic principles, that these patients will have worse cosmetic outcomes, as they are at risk of having unfavorable upper lid aesthetic ratios with conventional skin excision techniques. The purpose of this study was to compare upper blepharoplasty cosmetic outcomes as they relate to their aesthetic topographic proportions.


This study was a retrospective review of patients who underwent upper or four-lid blepharoplasty performed at our institution by eight independent surgeons from 1997 to 2017. Exclusion criteria included Asian ethnicity, ptosis (marginal reflex distance-1 <2 mm) without repair, missing preoperative or postoperative photographs, poor image quality, patient expression, and postoperative photographs that were taken sooner than 2 months or more than 2 years postoperatively. Information regarding patient demographics, age at surgery, surgery performed (upper versus four-lid), surgery details (including resection of skin and muscle, fat grafting, ptosis repair, and concurrent brow lift), revisions, and complications were recorded.

Photographs were standardized using Adobe Illustrator (Adobe Systems, Inc., San Jose, Calif.) to an iris diameter of 11.5 mm.17 Each eye was analyzed independently. Curves were drawn along the lash line, lid crease, and brow line and connected with vertical lines drawn at five points along the eye: (1) punctum, (2) medial limbus, (3) midpupil, (4) lateral limbus, and (5) lateral canthus (Fig. 1). The distance from lash line to lid crease (pretarsal space) and lid crease to inferior brow margin (upper lid fold) were recorded for each of the five locations, and the ratio of the upper lid fold to the pretarsal space was calculated. Marginal reflex distance-1 was measured as the distance from the center of the pupil to the upper lid margin. Ptosis was defined as a marginal reflex distance-1 less than 2 mm to the upper lid margin. Brow peak distance from the lateral canthus and brow curve favorability were also recorded (Fig. 2). Patients were classified into one of three groups based on pretarsal segments: (1) no pretarsal show, (2) partial pretarsal show (at least two of five points), or (3) complete pretarsal show at all five points (Fig. 3). Preoperative and postoperative image periorbital areas were cropped, randomized, and rated by four male plastic surgeons on a scale from 1 to 5, with 5 representing most attractive. Raters were asked to base their ratings solely on the upper eyelid–brow unit, and ratings were performed in a snap-judgment fashion without spending too much time per eye. Raters were given a sample of images for each score (1 to 5) to give them an idea of the aesthetic range. Four to 6 weeks later, raters repeated ratings on 40 of the initial images to assess intrarater reliability.

Fig. 1.
Fig. 1.:
Image analysis was completed using Adobe Illustrator. Photographs were cropped and standardized to an iris diameter of 11.5 mm. Curves were drawn along the lash line, lid crease, and inferior brow margin. Vertical lines were drawn connecting these curves at the punctum, medial limbus, midpupil, lateral limbus, and lateral canthus. Pretarsal and upper lid fold heights were recorded.
Fig. 2.
Fig. 2.:
Favorable brows were determined by marking the inferior brow margin at the lateral orbital rim and the medial canthus. If the lateral orbital rim point was higher than the medial canthus point, the brow was deemed “favorable” (i.e., downsloping medial brow). If the opposite was true, the brow was deemed “unfavorable.”
Fig. 3.
Fig. 3.:
(Left) No pretarsal show; (center) partial pretarsal show; (right) complete pretarsal show.

Data were analyzed using IBM SPSS (IBM Corp., Armonk, N.Y.). The independent samples t test was used to compare continuous variables between two groups. One-way analysis of variance with post hoc Tukey analysis was used for comparing continuous variables between three or more groups. Intraclass correlation with a two-way random model assessing consistency was used to calculate interrater reliability. Intraclass correlation with a two-way mixed model assessing absolute agreement was used to calculate intrarater reliability. Chi-square tests were used for comparisons of two categorical variables. Pearson r was used to assess correlation between two continuous variables. Alpha was set to 0.05 for all statistical tests.



Three hundred sixteen patients were included, 274 women (87 percent) (Table 1) and 42 men (13 percent) (Table 2), with a mean age of 55 years (range, 25 to 81 years). One hundred thirty-two (42 percent) underwent upper blepharoplasty and 184 (58 percent) underwent four-lid blepharoplasty. Group 1 (i.e., no pretarsal show) included 101 eyes (16 percent), group 2 (i.e., partial pretarsal show) included 159 eyes (25 percent), and group 3 (i.e., complete pretarsal show) included 372 eyes (59 percent). The majority of women presented with complete pretarsal show (63 percent), whereas most of the men presented with partial show (43 percent). Women with complete pretarsal show were significantly younger (n = 55) than those with no show (n = 58) (p < 0.01); men with complete pretarsal show were significantly younger (n = 52) than those with both partial (n = 60) and no show (n = 61) (p < 0.05). The most common excision type was both skin and muscle (68 percent). Fat grafting was performed in 24 eyes (4 percent), and fat repositioning was performed in six (1 percent). Ptosis repair was performed in 10 percent of patients.

Table 1. - Female Characteristics
Group 1 (%) Group 2 (%) Group 3 (%) p
No. 82 (15) 121 (22) 341 (63)
Age, yr 58 55 55 0.007
Ptosis repair 6 (7.3) 5 (4.1) 41 (12) 0.03
Preoperative MRD1 in those without ptosis repair 3.67 3.75 3.51 0.039
Favorable brows 29 (48.3) 43 (40.2) 129 (41.1) 0.54
Brow lift 26 (31) 56 (46) 124 (36) 0.078
Preoperative aesthetic score 1.47 1.67 1.9 <0.001
Postoperative aesthetic score 2.4 2.39 2.32 0.508
Change in aesthetic score 0.93 0.76 0.4 <0.001
No change or decrease aesthetic score 5 (6.1) 10 (8.3) 80 (23.5) <0.001
MRD1, marginal reflex distance-1.

Table 2. - Male Characteristics
Group 1 (%) Group 2 (%) Group 3 (%) p
No. 17 (20) 36 (43) 31 (37)
Age, yr 61 60 52 <0.05
Ptosis repair 5 (29.4) 7 (19.4) 2 (6.5) 0.104
Preoperative MRD1 in those without ptosis repair 3.46 3.40 3.18 0.537
Brow lift 4 (24) 11 (31) 9 (29) 0.867
Preoperative aesthetic score 0.96 1.34 1.91 <0.001
Postoperative aesthetic score 2.1 2.16 2.52 <0.05
Change in aesthetic score 1.13 0.82 0.6 <0.01
No change or decrease aesthetic score 0 (0) 3 (8.3) 4 (12.9) 0.302
MRD1, marginal reflex distance-1.

Aesthetic Score

Mean aesthetic score for all eyes increased from 1.74 preoperatively to 2.34 postoperatively (p < 0.001). Women in group 3 had higher preoperative scores (1.9) compared to group 2 (1.67) and group 1 (1.47) but had a significantly lower increase in score postoperatively (0.4) compared to the other two groups (0.93 and 0.76, respectively) (p < 0.001). Postoperative scores did not differ significantly between groups (p = 0.51). Men in group 3 had higher preoperative and postoperative scores (1.91 and 2.52, respectively) compared to group 2 (1.34 and 2.16, respectively) and group 1 (0.96 and 2.1, respectively) (p < 0.05), but also had a significantly lower increase in score postoperatively (0.6) compared to the other two groups (0.82 and 1.13, respectively) (p < 0.01). In addition, for women, group 3 had a significantly higher number of patients who experienced no change or a decrease in cosmetic score from preoperatively to postoperatively (24 percent) compared to group 2 (8 percent) or group 1 (6 percent) (p < 0.001). There were no significant differences found for men (p = 0.3). In group 3, patients who underwent fat grafting had higher postoperative scores (2.47) compared with those who did not (2.31) (p = 0.56), and greater increases in aesthetic score (0.48 versus 0.39; p = 0.47); however, these changes were not significant.

Ptosis Repair

Ten percent of women underwent ptosis repair, with a significantly higher percentage in group 3 (12 percent) compared to group 2 (7 percent) and group 1 (4 percent) (p < 0.05). Seventeen percent of men had ptosis repair, but the rates were not significantly different between groups (p = 0.1). For those who did not have ptosis repair, preoperative marginal reflex distance-1 values were significantly less for women in group 3 (3.51 mm) compared to group 2 (3.75 mm) (p = 0.04) but did not differ significantly between the three groups for men (p = 0.54). In group 3, preoperative and postoperative scores were significantly lower for those who underwent ptosis repair (1.52 and 1.98, respectively) compared to those who did not (1.97 and 2.36, respectively) (p < 0.001), but the change in aesthetic score was not significantly different (0.45 and 0.40, respectively) (p = 0.46).

Brow Shape

Thirty-eight percent of patients presented with favorable brow aesthetics. Eyes with a preoperative favorable brow had higher preoperative and postoperative cosmetic ratings (1.9 and 2.46, respectively) than those with an unfavorable brow (1.7 and 2.28, respectively) (p < 0.05). Patients with unfavorable brows who underwent brow lift had significantly higher postoperative scores (2.37) than those who did not (2.23) (p < 0.05). The percentage of patients with favorable brow aesthetics did not differ significantly between the three groups for women or men.

Pretarsal Height and Upper Lid Fold–to–Pretarsal Space Ratios

There were no significant differences in the ratios of upper lid fold to pretarsal space found between those rated as less attractive (≤2) and more attractive (≥3). However, among women with complete pretarsal show (group 3), a significantly greater pretarsal height was seen at all five points among those who were rated less attractive (≤2) compared to those rated more attractive (≥3) (p < 0.001). Those with midpupil pretarsal heights greater than 4 mm had a significantly lower postoperative aesthetic score (1.95) compared with those less than or equal to 4 mm (2.50) (p < 0.001) (Fig. 4). In addition, a moderate negative correlation was observed between aesthetic score and pretarsal height at all five points across the eyelid for women with complete show (r = −0.33, r = −0.43, r = −0.45, r = −0.40, and r = −0.30, respectively) (p < 0.001) (Fig. 5). Finally, those rated as more attractive (≥3) in group 3 had a significantly lower standard deviation between means of the pretarsal heights at all five points (0.60) compared with those rated less attractive (≤2) (0.75) (p < 0.05).

Fig. 4.
Fig. 4.:
(Above) Example of a 39-year-old woman with complete pretarsal show (PS) treated with only skin/muscle excision. Postoperative photograph at 4 months shows that pretarsal height increased beyond 4 mm and thus led to almost no improvement in aesthetic score. (Center) Another example of a group 3 patient, 40 years old, treated with skin/muscle excision. Postoperative photograph at 6 months shows pretarsal height greater than 4 mm, leading to a reduction in aesthetic score. (Below) Example of a 53-year-old woman with complete show treated with fat grafting to both upper lids and conservative skin excision. Follow-up at 1 year shows a decrease in pretarsal show and significant improvement in aesthetic score.
Fig. 5.
Fig. 5.:
Graph representing the pretarsal height measured at the midpupil versus aesthetic score in patients with complete pretarsal show (group 3). The graph demonstrates that as pretarsal height increases, aesthetic score decreases. Pearson r of −0.44 (p < 0.001) demonstrates a significant moderate negative correlation between these two variables.


The goal of upper blepharoplasty is to restore the ideal aesthetic upper eyelid topographic proportions.10,13,18 It appears logical that conventional techniques should more easily achieve this goal in patients presenting with no or partial pretarsal show (groups 1 and 2) (Fig. 6). Skin excision unveils the crease and the obscured pretarsal space, resulting in improvement in proportions and aesthetics. Our study questioned whether this improvement is achieved in patients who already have a visible crease and complete pretarsal show (group 3), and whether skin excision alone would result in a detrimental increase in the pretarsal height. Our study cohort of 316 patients consisted of all comers who presented for upper blepharoplasty to eight different plastic surgeons over a 20-year period, who mostly performed excisional procedures with or without a brow lift. Therefore, we believe that our sample is representative of the range of aesthetic pathologic conditions commonly encountered by plastic surgeons. The reason why we chose to separate the partial show and no-show groups is that their upper lid morphology has implications on surgical planning and may ultimately affect cosmetic outcomes (Fig. 6).

Fig. 6.
Fig. 6.:
(Above, left) Example of a 35-year-old woman with medial show (group 2) who was treated with skin/muscle excision and temporal brow lift. (Above, right) Three-month results. (Below, left) Example of a 70-year-old woman with no pretarsal show (group 1) treated with skin/muscle excision and internal browpexy. (Below, right) Three-month results.

To our surprise, most women who presented for upper blepharoplasty already had complete pretarsal show. Even after excluding patients with ptosis, more than 50 percent still had complete show. This group of patients (group 3) had a significantly higher preoperative aesthetic score compared with the two other groups. This is explained by the fact that the visibility of the crease and pretarsal space has a positive impact on our perception of attractiveness.10,19,20 As we predicted, however, they had the least change in their aesthetic score postoperatively, and almost one-fourth had no change or a decrease in postoperative scores. On further analysis, it seems likely that the perception of attractiveness is negatively impacted when the pretarsal height reaches or exceeds 4 mm. The change in ratios was not different between groups; this is explained by the fact that the upper lid fold–to–pretarsal space ratio is expected to decrease in all groups postoperatively.

Our study suggests that there are different aging patterns in the upper lid and periorbital areas.18,21 All patients present with dermatochalasis and complain of excess skin, and therefore it is intuitive for the treating surgeon to excise the skin fold to accomplish the patient’s goals. However, depending on the aging pattern, skin excision alone without taking into consideration the existing upper lid proportions and shape of the three arcs (i.e., lid margin, crease, and inferior border of the brow)10 may negatively impact the cosmetic outcome. Groups 1 and 2 consist of patients who may complain of visual field obstruction, as the upper lid fold skin hangs over the lid margin. In group 3, in contrast, the excess skin just sits over the lid and creates a fold. We believe the reason why this occurs is likely related to two factors. First, failure to diagnose mild ptosis likely results in a lower lid margin, increased pretarsal show, and a localized skin fold that does not hang over the lash line.18,21 Second, there may be an element of volume depletion in the orbital fat that similarly results in a hollowed sulcus and a recessed space where the skin can accumulate.12,21 As a result, to excise the excess skin in group 3 while maintaining or improving upper lid aesthetic proportions, skin excision should be combined with ptosis repair22,23 and/or fat grafting9,12,24,25 or transposition16,26–28 as deemed necessary, as they are both major contributing causes to the presenting morphology in this group. Perhaps this is why patients in group 3 presented at a significantly younger age than those in the other two groups, as their genetic predisposition to mild ptosis and decreased periorbital volume may have put them at risk for localized skin fold formation in the upper lid. Our subgroup analysis of group 3 showed improvement in aesthetic scores with fat grafting that did not reach statistical significance, likely because of the small number of patients who underwent fat grafting. Patients who underwent ptosis repair did not have a significant change in aesthetic scores compared to the ones who did not; however, those patients had severe ptosis to begin with, and it is difficult to draw conclusions from comparing them to other patients in group 3 who probably had mild ptosis and did not undergo repair.

Measurements of the marginal reflex distance-1 showed lower means in group 3, which is in line with our hypothesis. Those measurements may not reflect the real marginal reflex distance-1, because patients with mild ptosis could have been compensating with gentle brow elevation and therefore adjusting their real marginal reflex distance-1 value. It is not surprising that men presented with slightly different aesthetic morphology than women. The majority fell under groups 2 and 1, respectively. This could be explained by the fact that men who present for upper blepharoplasty generally have heavy, ptotic brows.29 This is evident by the uniform short vertical distance of the upper lid fold seen in this patient population. More studies are needed to further analyze the upper eyelid–brow unit in men to get a better understanding of the best surgical approach. Brow shape played an important role in cosmetic outcomes in women, and this is in agreement with previous publications analyzing the ideal brow shape.10,29–32 Despite that, significantly fewer men underwent concomitant brow elevation, although they are the group who could potentially benefit the most from this procedure to improve their aesthetic proportions.

Based on our results, it is clear that upper blepharoplasty has to be rethought as a procedure, taking into consideration the impact of preoperative pretarsal show. It is no longer solely a skin excision operation, and more thought has to be put into understanding the patient’s presenting features, the aging pattern, and surgical planning. We reintroduce questions that Fagien asked almost two decades ago: What should the surgeon strive for to achieve the best aesthetic results? What is the justification for any given approach?18 We propose that upper blepharoplasty should be approached as upper eyelid and periorbital rejuvenation and should incorporate other previously tested treatment modalities, when indicated, such as Müllerectomy22,33,34 to adjust the upper lid tension, fat repositioning,16,26–28 fat grafting,9,12,24,25 and temporal brow lift.35–38 It is our belief that a greater emphasis has to be placed on the adjunct procedures in residency training so that future plastic surgeons are comfortable with their planning and execution to remain at the forefront among aesthetic practitioners. It has been the senior author’s (M.S.A.) practice recently to use phenylephrine drops in patients presenting with complete show to evaluate changes in the upper eyelid and brow positions. In the majority of cases, an improvement in upper lid proportions is seen immediately. We are by no means advocating for ptosis repair in every group 3 patient presenting for upper blepharoplasty, as the choice of such procedure should be balanced against improvement in aesthetics and preexisting conditions such as dry eyes.

There were several limitations to this study. First, because we included patient data back to 1997, we are analyzing over 20 years of changes and advancements in upper blepharoplasty. For example, many patients in the study were not treated with fat grafting or repositioning, which is more common in practice today. In addition, image measurements were performed in two dimensions, which does not reflect the natural curves of the upper lid and brow areas. Third, aesthetic score was not assessed using a validated method and was done by only male plastic surgeons. However, we did distribute an example photograph for each rating from 1 to 5 to all raters to make the process more standardized. Our high interrater reliability metric suggests this was effective. We did not include a layperson because the rating process was too complicated and required a trained eye that could focus on the upper eyelid without distraction created by the eye and periorbital area. In future studies, layperson ratings should be looked at as well. Finally, our patient population consisted mostly of Caucasian women, and there were no patient satisfaction scores available for analysis. Therefore, our results are not generalizable to all ethnicities. Future studies are needed to show whether adjunct procedure such as ptosis repair and fat grafting will indeed improve the cosmetic results in patients with preoperative pretarsal show.


Patients presenting for upper blepharoplasty have different aging patterns. Many patients presenting for upper blepharoplasty have complete pretarsal show and are at risk for worse cosmetic outcomes using conventional skin excision techniques. A pretarsal space height of greater than or equal to 4 mm seems to be associated with negative cosmetic outcomes. Preoperative favorable brow shape has a positive impact on postoperative outcomes in women. Adjunctive procedures such as fat grafting and ptosis repair should be considered in comprehensive upper eyelid rejuvenation, particularly in patients with complete pretarsal show.


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