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Cosmetic upper eyelid blepharoplasty is not a procedure that is comprised of skin and fat resection only. Efficient and effective functional repair of the upper lid requires brow stabilization or elevation, levator aponeurotic repair, lacrimal gland suspension, and cutaneous laser resurfacing when necessary.

Determining brow level and contour

Palpating the superior orbital rim and observing its relationship with the eyebrow will determine whether brow ptosis exists, that is, an eyebrow level below the superior orbital rim [1-6]. Comparing the level and contour of the brow with that in old photographs will determine whether there has been a change in the level or configuration of the brow arch.

In general, the female brow is arched and sits superior to the superior orbital rim (Fig. 1A, B), whereas the male brow is flat and positioned just at the orbital rim (Figs. 2A, B and 3A, B) [7]. Elevation of the brow will reduce the amount of overlapping of the upper lid fold. In female patients, elevating the brow can recreate a pleasing arch and a deeper superior sulcus with a reduced lid fold; however, elevation is not indicated in all female patients. Although the upper lid fold and superior sulcus may have a clean sculpted look after an effective brow elevation, brows positioned more than 5 mm above the superior orbital may give the patient a surprised unnatural look.

Overelevation of the brow in male patients can feminize their appearance. Because of the short distance between the male brow and their upper lid margins, often, only internal brow suspension and fixation with minimal elevation is required (Fig. 4A, B) - If the male brow can be moved manually more than 2 or 3 mm, internal fixation is indicated (Fig. 5A, B) so that a distance of at least 8 to 10 mm can be left between the upper edge of the lid fold resection and the brow.

Principles of eyebrow and eyelash enhancement

Assessing the thickness, density, color, and contour of the eyebrows and eyelashes is essential in an evaluation of periorbital rejuvenation. To further accentuate the benefits of a successful blepharoplasty to create the frame for the eyes, attention must be directed to eyebrow and eyelash enhancement. Segmental or complete eyebrow or eyelash alopecia can be camouflaged by micropigmentation or corrected with single follicular unit hair transplantation [18-12]. For maximum effect and benefit, the planning for eyebrow and eyelash rejuvenation should occur when the blepharoplasty procedure is planned.

Principles of upper eyelid repair

An accurate evaluation of the upper eyelid fold can only be accomplished after the brow level and contour have been established [13]. Once the brow level and contour have been established, the amount of upper lid fold resection can be determined. Im­ages from high school or college graduations or old wedding pictures are invaluable for comparison of the superior sulcus contour, level of the upper lid crease, and degree of upper lid folding. Patients who have never had a deep superior sulcus will not recognize themselves if they are oversculpted. Conversely, patients who have ptosis, levator aponeurotic disinsertions, and retracted deep superior sulci should be informed that when the ptosis is repaired and the levator aponeuroses are advanced, their lids will again fill the superior sulci (Fig. 6A, B). The surgeon should be aware that even though the superior sulcus appears deep, when the levator aponeuroses are advanced, the upper lid folds will have to trimmed.

Fig. 1. (A) This patient had moderate upper lid fold redundancy and superior sulcus fullness with obscuration of her upper lid crease but maintained a pleasing feminine brow arch. She had mild lower lid fatty prolapse with mild tear trough depression and mild right lower lid inferior scleral show with mild lateral canthal angle rounding (B) Her upper lids have been conservatively recontoured, exposing her upper lid crease and preserving her feminine brow arch. Her lower lids were recontoured though a transconjunctival approach. The lateral canthal were plicated. Na laser resurfacing of fat transposition was performed.

"To resect or not to resect upper lid skin," that is the question. Again, evaluating the contour and extent of the upper lid folds in old photographs will help the surgeon to decide whether skin resection is appropriate. If there is a slight redundancy but an apparent change in texture, laser resurfacing alone may be an effective mode of treatment (Fig. 7A, B). If there is moderate or marked skin fold redundancy as well as changes in texture, resection and laser resurfacing are indicated (Fig. 8A, B).

Diagnosing blepharoptosis preoperatively will avoid an unwelcome surprise following blepharoplasty. A patient with a mild congenital ptosis or an acquired ptosis with levator aponeurotic disinsertion may compensate and obscure a narrowed palpebral aperture by unconsciously raising his or her brow. Unless the brow is held in its proper location just above the superior orbital rim when the vertical palpebral aperture is measured, blepharoptosis may be missed (Fig. 9). Other clues to diagnosing blepharoptosis include a raised brow, an elevated lid creasefold complex, and a deep superior sulcus.

Fig. 2. (A) While a cabaret singer in Berlin in the 1930s, this patient maintained a stylized exaggerated feminine brow arch. (B) Fifty years later, after too many upper eyelid skin resections and brow supportive procedures, her brow arch became ptotic and was transformed into a more masculine arch. When her brows were manually elevated to the level of the superior orbital rim, prominent lid lag and lagophthalmos were evident.

Fig. 3. (A) This patient exhibits a typical male brow contour - low and flat. (B) Internal brow suspension allows adequate lid crease exposure while maintaining an appropriate distance between the brow and the upper lid margin.

The upper lid contour must also be considered. There are central and nasal fat pockets in the upper lid. Often, the nasal pocket is most visible and bothersome to patients. There is no lateral fat pocket in the upper lid. Any convex contours in the outer third of the upper lid are secondary to a prolapsed or enlarged palpebral lobe of the lacrimal gland (Fig. 10A, B). Lacrimal gland prolapse is frequent in patients of African or Asian descent in whom the bony orbit is shallow. Patients with thick heavy brows and an ill-defined superior sulcus will need CO2 laser lipovaporization of the suborbicularis brow fat overlying the superior orbital rim, as well as lipovaporization of the preaponeurotic fat to create a superior sulcus (Fig. 11A, B).

Surgical techniques for upper eyelid blepharoplasty

Upper lid skin resection

If there is no levator aponeurotic disinsertion, the inferior aspect of the resection is delineated in the lid crease. If there is an aponeurotic disinsertion with lid crease retraction, the inferior aspect of the resection is delineated 8 to 10 mm above the lid margin, or at the same level of the contralateral lid crease. With the patient sitting in the upright position and facing the surgeon, the superior aspect of the resection is delineated, with care taken to maintain 8 to 10 mm between the superior aspect of the resection and the brow. If laser resurfacing is planned, the amount of skin resection is adjusted to compensate for 10% to 20% further skin contraction.

If internal brow support is planned, the brow is held in position while the skin is demarcated. The medial extent of the resection is limited by the superior punctum. If upper lid skin redundancy is evident further medially, it can be managed with a W-plasty or laser resurfacing to avoid creating a medial canthal web (Fig. 12A,B). The lateral extent of the resection is determined by the extent of temporal hooding not corrected by internal brow support. Ending the lateral aspect of the resection medial to the orbital rim is preferred; however, more lateral resections can be extended in a smile line. Care is taken to keep these resections above the level of the lateral canthal angle to avoid postoperative lymphedema.

Fig. 4. (A) This patient's masculine brow level and contour had to be stabilized so that an effective upper lid blepharoplasty could be performed. To clear his visual axes, bis brows were constantly elevated. (B) Following internal brow suspension, upper lid myocutaneous resection, and laser resurfacing, he has a satisfactory upper eyelid contour. His lower eyelids were stabilized with lateral canthal tendon plications. They were recontoured with transconjunctival CO2 laser lipovaporization and cuta­neous resurfacing.

Fig. 5. (A) The mobility and level of the brow (in relation to the superior orbital rim) are manually determined preoperatively. (B) The thin eyelid skin is differentiated from the thicker skin external to the orbital rims. Upper lid overresection will result in an inappropriate juxtaposition of the delicate eyelid skin with the thick brow skin. (From Bosniak S. Cosmetic blepharoplasty. New York: Raven Press; 1990; with permission.)

Fig. 6. (A) The hallmarks of upper lid blepharoptosis with aponeurotic disinsertions are compensatory' brow elevation and a deep superior sulcus, with good to excellent upper lid margin excursions. (B) Manually fixating the brows at the level of the superior orbital rim will accentuate the blepharoptosis.

Fig. 7. (A) Apparent upper lid fold redundancy may be secondary to marked texture changes and rhytidosis. (B) In these cases, gratifying results can be achieved with cutaneous laser resurfacing without skin resection.

There are several choices of instrumentation for incising the skin: cold steel (No. 15 blade), a finewire radiosurgical electrode (Vari-Tip, Ellman International, Oceanside, New York), cautery (Colorado needle), and the CO2 laser (0.2-mm handpiece, 5 mj, Ultrapulse mode, Lumenus Ultrapulse 5000) [13]. For skin incision, all of these modalities are about equal providing that the surgeon is adept and can apply smooth light rapid strokes when using radiofrequency, cautery, or the CO2 laser. This technique will avoid prolonged tissue dwell time, increased lateral heat spread, and indurated would edges.

Lipovaporization

The most efficient technique for sculpting fat in a bloodless field uses the CO2 laser. Defocusing the 0.2-mm handpiece (5-8 W in the continuous wave mode), moving it away from the tissue so that the aiming beam is not in focus, will increase lateral heat spread and vaporize fat. This defocused beam will also ablate larger caliber blood vessels as well. Intermittent gentle pressure on the globe encourages further fatty prolapse so that it can be vaporized. In this manner, the volume of the fat pockets can be diminished and their anterior surfaces accurately recontoured. The alternatives are clamping, cutting, and cauterizing; open sky resection with blood vessel cauterization when necessary; and radiosurgical re­section with localized blood vessel ablation.

Lacrimal gland suspension

A prolapsed palpebral lobe of the lacrimal gland will present as a temporal bulge in the upper lid. After cutaneous or myocutaneous resection and central and medial fat pocket lipovaporization, the grayish lobular palpebral lobe will be encountered. Its anterior surface can be tucked posterior to the lateral orbital rim with a mattress suture of 4-0 Prolene. Each arm of a double-armed suture is placed through the anterior surface of the gland (Fig. 13). The suture is then passed into the periosteum of the lacrimal fossa (posterior and internal to the lateral orbital rim, and superiorly at its junction with the superior orbital rim). When the suture is tied, the gland will be pulled posterior behind the orbital rim.

Fig. 8. (A) A full superior sulcus with true lid fold redundancy and skin texture changes will best respond to skin resection and cutaneous laser resurfacing. (B) A CO2 laser-assisted upper and lower lid blepharoplasty with eyelid and full face cutaneous laser resurfacing produced a dramatic improvement. {From Bosniak S, Cantisano-Zilkha M. Cosmetic blepharoplasty and facial rejuvenation. New York: Lippincott-Raven; 1999; with permission.)

Fig. 9. This patient's right upper lid ptosis is manifested by a deep superior sulcus, a retracted lid crease, and a narrowed vertical palpebral aperture (partially camouflaged by com­pensatory brow elevation). Her left upper lid has a full superior sulcus and a normal brow contour and level. It is reasonable to assume that when the right upper lid crease is returned to its normal position when the levator aponeurosis is repaired, the full lid fold will need to be trimmed.

Levator aponeurotic repair

When levator aponeurotic repair is planned, less than 1 mL of local anesthetic is infiltrated subcutaneously under the demarcated lid crease incision. This amount will provide adequate anesthesia without akinesia so that the levator aponeurosis can be identified, its movement observed, and the palpebral aperture evaluated after the aponeurosis has been reattached to the tarsus. The lid crease is incised. A skin flap is developed inferiorly, exposing the pretarsal orbicularis muscles but avoiding the eyelash follicles. A 5-mm wide strip of the superior pretarsal orbicularis muscle is resected, exposing the anterior surface of the superior tarsus. A myocutaneous flap is developed superiorly, exposing the glistening white orbital septum. Gentle pressure on the globe will cause preaponeurotic orbital fat to prolapse and the orbital septum to bulge. When the orbital septum is grasped and pulled inferiorly, it can be palpated at the arcus marginalis, just inferior to the superior orbital rim. The orbital septum is opened. The preaponeurotic fat is visualized and retracted. The diaphanous levator aponeurosis and its delicately rolled up disinserted inferior edge are now visible. Between the disinserted inferior edge of the aponeurosis and the superior border of the tarsus, the vascular Mutter's muscle with its transverse arteriolar arcade is clearly visible (Fig. 14). Three 6-0 black silk horizontal mattress sutures reapproximate the disinserted apo­neurosis to the anterior surface of the tarsus (Fig. 15). These sutures are tied over a suture bolster so that the knots can be released when adjusting the lid margin level and contour. Patients open and close their eyes to confirm a pleasing arch of the upper lid margin (without segmental peaking) and a vertical palpebral that corresponds to the contralateral side (Fig. 16A, B). If the orbital septum has been inadvertently included in the aponeurotic repair, lid lag on down gaze will be apparent. After the upper lid level and contour have been secured, the superior myocutaneous flap is resected.

Fig. 10. (A) After an upper lid blepharoplasty, residual convexities are apparent in the temporal aspects of both upper lids. The prolapsed lacrimal glands are demarcated. (B) The upper lid contours are improved following suture suspensions of the palpebral lobes of the lacrimal gland to the periosteum of the lacrimal gland fossas within the superolateral bony orbits.

Fig. 11. (A) The patient presented with bilateral brow ptosis and redundant upper lid folds, arid a narrowed distance between the brows and upper lid margins. He also had lower lid margin laxity, inferior scleral show, prolapsed inferior fat pockets, and malar festoons. (From Bosniak S, Cantisano-Zilkha M. Minimally invasive techniques of oculo-facial rejuvenation. New York; Thieme; 2005; with permission.) (B) His appearance is markedly improved following internal brow suspension, upper lid myocutaneous resections, lipovaporization of the brow suborbicularis fat and upper lid preaponeurotic fat, transconjunctival lower lid lipovaporization, lateral canthal plication, and upper and lower lid cutaneous laser resurfacing. (From Bosniak S. Cosmetic- blepharoplasty. New York: Raven Press; 1990; with permission.)

The wound edges are closed, and the lid crease is recreated with interrupted sutures incorporating the advanced edge of the leva-tor aponeurosis.

Patients with minimal ptosis (1 or 2 mm) whose eyelid elevates after the application of one drop of Neosynephrine 2.5% are candidates for the Fasanella-Servat procedure (Muller's muscle resection and advancement plus tarsectomy). Performed via the posterior lamella, the procedure can easily be performed in conjunction with skin and skin-muscle resections.

The upper eyelid is everted. The superior border of tarsus is retracted inferiorly while the eyelid skin is retracted superiorly, separating Muller's muscle from the levator aponeurosis. Two small curved hemostats are clamped (their concave surfaces away from the lid margin) across the superior tarsus (4 mm from the superior tarsal border), Muller's muscle, and con­junctiva (Fig. 17). Beginning at the nasal aspect of the upper lid crease, a running mattress suture of 5-0 nylon is passed through the skin, Muller's muscle, tarsus, and conjunctiva. It exits through the conjunctiva distal to the curved hemostat. It continues back and forth through conjunctiva, Muller's muscle, and tarsus until the lateral tarsus is reached.

Fig. 12. (A) Upper lid skin excess medial to the superior punctum can remedied with a W-plasty, avoiding the formation of a medial canthal web. (B) An additional technique for resecting upper lid skin medial to the superior punctum is a Burow's triangle. An incision perpendicular to the superior edge of the cutaneous resection is overlapped, and a base-down triangular skin resection is performed. (From Bosniak S. Cosmetic blepharoplasty. New York: Raven Press; 1990; with permission.)

Fig. 13. A double-armed 4-0 Prolene suture suspends the prolapsed palpebral lobe of the lacrimal gland from the periosteum of lacrimal fossa, retracting it into the orbit posterior to the superolateral orbital rim. (From' Bosniak S, Cantisano-Zilkha M. Cosmetic blepharoplasty and facia! rejuvenation. New York: Raven-Lippincott; 1999; with permission.)

The final pass is through conjunctiva, Muller's muscle, tarsus, and skin, exiting at the lateral lid crease. The two external ends of the suture are pulled from side to side, nasally and temporally, ensuring smooth pas­sage of the suture and ease of removal. The conjunctiva, Muller's muscle, and tarsus distal to the hemostats are resected. The clamps are released, the posterior lamella of the upper lid is smoothed, and the eyelid is returned to its normal anatomic position.

Fig. 14. The relevant eyelid anatomy is revealed during CO2 laser-assisted levator aponeurotic surgery. The needle is in the superior tarsal margin. The suture loop is in the disinserted inferior edge of the rarefied levator aponeurosis. The intervening tissue is Muller's muscle (note its vascular arcade just superior to the superior tarsal border). The incised orbital septum is retracted, and the preaponeurotic fat is visible anterior to the levator muscle.

Fig. 15. One 6-0 black silk suture fixates the levator apo­neurosis to the anterior tarsal surface. A second is being placed. Note that the rarefied levator aponeurosis appears very short (at least 10 mm is missing). This rarefaction may necessitate tying a loose suture loop to avoid inadvertent levator advancement and upper lid retraction.

The externalized ends of the suture are tied loosely to each other over the pretarsal skin. Care is taken not to tie them tightly to avoid buckling of the tarsus. Skin and orbicularis muscle resections are then performed.

Ablative laser resurfacing

Eyelid laser resurfacing can be purely ablative (erbium:yttrium-aluminum-garnet [EnYAG]) with minimal thermal spread, or the epidermis can be vaporized in a controlled fashion with a CO2 laser, also creating a secondary thermal effect of tissue tightening. The target chromophore for the erbium (2940 nm) and CO2 (10,600 nm) lasers is water. Because the erbium laser's affinity for water is greater than that of the CO2, its effect is more superficial (5-20 μ m of thermal injury) than that of the CO2 laser (50-125 μ m for each pass).

Minimal-to-mild rhytidosis can be ablated with Er:YAG laser resurfacing using a small square pattern (pattern 3, size 4, 2 J) and one to three passes (Lumenis Ultra Fine). Three passes of the Er:YAG laser is equivalent to one pass of the CO2 laser. Although more than three passes can be applied, the endpoint may be limited by punctate bleeding, and more intense resurfacing is better performed using a CO2 laser. The recovery after three passes of erbium resurfacing is rapid, 4 to 5 days for complete re-epithelialization, and the erythema after reepithelialization rarely persists longer than 3 to 4 weeks. Because there is little thermal effect following Er: YAG resurfacing, there is rhytid ablation without tissue tightening.

Fig. 16. (A) This patient had significant upper lid blepharoptosis with an obvious retraction of her left upper lid crease and compensatory brow elevation. She also had inferior scleral show and lower lid retraction. Correction of her upper lid ptosis without addressing the position of her lower lids would have resulted in an inappropriate widening of her vertical palpebral apertures. (B) Following bilateral aponeurotic repair, upper lid myocutaneous trimming and lipovaporization, lateral canthal plication, and lower lid transconjunctival lipovaporization, her palpebral apertures markedly improved. (From Bosniak S, Cantisano-Zilkha M. Minimally invasive techniques of oculo-facial rejuvenation. New York: Thieme; 2005; with permission.)

For mild rhytidosis, one pass of the CO2 laser using a lower power setting (Ultrapulse, 150-200 mj) and a small square pattern (pattern 3, size 4, density 5) may be all that is necessary. For moderate-to-marked rhytidosis, Ultrapulse power settings from 200 to 300 mj with two or three passes may be used. The duration of the postoperative erythema is determined by the intensity of the treatment and may persist for several months. Camouflage make-up after re-epithelialization provides sun protection as well as improved cosmesis. Sun exposure will prolong erythema and, in some cases, promote postinflammatory hyperpigmentation.

Fig. 17. The Fasanella-Servat tarsectomy and conjunctiva and Muller's muscle advancement and resection is a reliably predictable procedure for correction of I to 3 mm of ptosis in eyelids that respond to one drop of 2.5% Neosynephrine. (A) The upper lid is everted over a Desmarres retractor, and subconjunctival infiltration is administered at the superior border of the tarsus. (B) Two curved hemostats are applied to the everted tarsus, conjunctiva, and Muller's muscle. Their concave surfaces are applied facing the superior border of the tarsus, but care is taken not to create an exaggerated arch centrally. (C) A 4-0 nylon suture is passed from the lateral cutaneous lid crease, exiting distal to the hemostat on the conjunetival surface. It is continued in a running mattress fashion, angling the suture 45 degrees, until the nasal extent of the tarsus is reached. (D) The hemostats are released, and the conjunctiva, tarsus, and Muller's muscle are resected in the crush marks, distal to the suture. (From Bosniak S. Cosmetic blepharoplasty. New York: Raven Press; 1990; with permission.)

Fig. 18. (A) In addition to upper eyelid fold redundancy and lower lid fatty prolapse, this patient had segmental eyebrow alopecia and eyelash thinning. (B) Following laser-assisted upper and lower blepharoplasty and cutaneous resurfacing, her final appearance was enhanced with eyebrow and eyelash micropigmentation and single follicular unit hair transplantation to the eyebrows. (From Bosniak S. Cosmetic blepharoplasty. New York: Raven Press; 1990; with permission.)

Trichloroacetic acid peels

For eyelid pigment mottling and mild rhytidosis, 20% trichloroacetic acid (TCA) is an effective superficial peeling agent requiring only 4 days or less of downtime. A thin layer is applied with a sterile cotton-tipped applicator. A light frosting will appear within 5 minutes of application. After 5 to 10 minutes, the frosting will disappear, and a mild erythema will be apparent. Three to four days of mild brownish crusting may follow. The postpeel regimen is frequent lubrication (CU3 copper peptide cream) and vinegar washes (1 tablespoon of white vinegar in 4 cups of tepid water) [1, 14, 15].

Micropigmentation

Micropigmentation of the eyebrow and eye­lashes, when performed in an understated natural manner, yields longlasting cosmetic enhancement (Fig. 18A,B). It is typically performed using topical anesthetic cream, but anesthesia can be supplemented with local injections when necessary. Localized crusting may persist for several days and should be managed with frequent applications of bland ointment, avoidance of water, and skin care products. Touch-ups may be performed in 3 to 4 weeks.

[1] Bosniak S, Cantisano-Zilkha M. Minimally invasive techniques of oculofacial rejuvenation. New York: Thieme Publishers; 2005.

[2] Bosniak S, Cantisano-Zilkha M. Total eyelid rejuve­nation. Operative Techniques in Oculoplastic, Orbital, and Reconstructive Surgery 1999;2(4):198-203.

[3] Bosniak S. Cosmetic blepharoplasty. New York: Raven Press; 1990.

[4] Bosniak S, Cantisano-Zilkha M. Cosmetic blepharoplasty and facial rejuvenation. New York: Lippincott-Raven; 1999.

[5] Reifler DM. Upper eyelid blepharoplasty. In: Bosniak S, editor. Principles and practice of ophthalmic plastic and reconstructive surgery. Philadelphia: Saunders; 1996. p. 596-617.

[6] Wojno TH, Bosniak S. Cosmetic surgery. In: Bosniak S, editor. Principles and practice of ophthalmic plastic and reconstructive surgery. Philadelphia: Saunders; 1996. p. 543-5.

[7] Maries HM, Patrinely JR. Male blepharoplasty. In: Bosniak S, editor. Principles and practice of ophthal­mic plastic and reconstructive surgery. Philadelphia: Saunders; 1996. p. 632-8.

[8] Bosniak S, Cantisano-Zilkha M, Ziering C, et al. Eyebrow rejuvenation: a multi-disciplinary approach. Operative Techniques in Oculoplastic, Orbital, and Reconstructive Surgery 2001;4(2):100-3.

[9] Gandelman M. Eyebrow and eyelash reconstruction. Operative Techniques in Oculoplastic, Orbital, and Reconstructive Surgery 2001;4(2):94-9. [10] Mazza JF, Roger C. Blepharopigmentation: techniques, indications and comparison of modalities. In: Bosniak S, editor. Principles and practice of ophthalmic plastic and reconstructive surgery. Philadelphia: Saunders; 1996. p. 682-8.

[11] Meneuzes. The principles of permanent facial makeup. Operative Techniques in Oculoplastic, Orbital, and Re­constructive Surgery 1999;2(4):182-7. [12] Ploof H. Electropigmentation and the cosmetic sur­gery patient. In: Bosniak S, editor. Principles and practice of ophthalmic plastic and reconstructive surgery. [14] Rubin MG. Manual of chemical peels: superficial and Philadelphia: Saunders; 1996. p. 676-81. medium depth. Philadelphia: JB Lippincott; 1995. [13] Weiss RA. Brow ptosis. In: Bosniak S, editor. [15] Bosniak S, McDebitt T, Wojno TH. Alternative tech-Principles and practice of ophthalmic plastic and niques of fat removal. In: Bosniak S, editor. Principles reconstructive surgery. Philadelphia: Saunders; 1996. and practice of ophthalmic plastic and reconstructive p. 578-89. surgery. Philadelphia; Saunders; 1996. p. 632-8.

Stephen Bosniak, MD

Manhattan Eye, Ear and Throat Hospital, Private Practice,
135 East 74th Street, New York, NY 10021, USA