Keywords

When evaluating a patient for upper blepharoplasty, I go through the following anatomic checklist:

  • Brows: Brow ptosis contributes to the appearance of dermatochalasis and fullness of the superior sulcus. Brow elevation can be a compensatory response to eyelid ptosis or dermatochalasis. An elevated brow diminishes the appearance of dermatochalasis. Brow asymmetry may be congenital or related to the above factors. Brow hair may have been plucked, waxed, or shaved. The natural location of the brow can be identified by palpating the brow fat pad and noting the rather sharp transition between the thicker brow and thinner eyelid tissue.

  • Bony Orbits: There is significant individual variation in orbital size. Orbital asymmetry can be present. A small orbit contributes to crowding and fullness of the superior sulcus, while patients with large orbits usually have naturally deep and hollow superior sulci. The eyelid crease is often lower in patients with smaller orbits.

  • Eyelid Skin: The amount of redundant skin is graded for each upper eyelid. Note the position and quality of the upper eyelid crease. Webbing in the medial canthus may be related to anatomic variation or redundancy and poor fixation of the medial canthal-glabellar tissue. Blepharoplasty can accentuate medial canthal webs. While dependent edema occasionally develops within marked dermatochalasis, the presence of lid swelling warrants further evaluation for conditions such as thyroid disease. Eyelid inflammation (blepharitis) can be caused by allergy, mechanical trauma, and a variety of dermatologic conditions. Blepharitis should be treated before considering surgery.

  • Orbital Fat: Fullness in the central or medial upper eyelid is usually related to prolapse of the orbital fat. The prominence of the fat pockets is graded prior to surgery.

  • Lacrimal Glands: The primary lacrimal glands are located in the superior lateral orbits. These glands occasionally become ptotic, contributing to fullness in the lateral upper lids.

  • Lid Margin: While there is great variability, the natural position of the upper eyelid margins is usually about 2 mm below the corneal limbus when the patients look in primary gaze. The lid margins are evaluated for symmetry, ptosis, or retraction. Further evaluation is needed if abnormalities are present. Review of old photographs is helpful in determining if changes are of recent onset. Blepharoplasty should not be used to surgically alter the position of the eyelid margin. The lower eyelid positions are also evaluated. Preexisting lower lid retraction or scleral show can predispose a patient to ocular dryness following upper lid surgery.

  • Ocular Evaluation: Patients considering blepharoplasty should have an eye exam to determine if there are ocular conditions that could complicate surgery. The corneal surface and tear film are evaluated. A basal secretory rate (Schirmer’s test performed with topical anesthesia) can be used to evaluate tear production. Patients undergoing recent refractive surgery may be at increased risk for developing postblepharoplasty ocular irritation.

  • Visual Fields: Visual fields should be performed with and without elevating the redundant eyelid tissue in patients desiring functional upper eyelid blepharoplasty. It is best to request prior determination of insurance coverage in such individuals.

  • Photographs: External photographs are obtained to document the preoperative findings. Informed consent: The risks of surgery are discussed and documented. It is reasonable to cover noticeable scarring, bleeding, infection, loss of vision, incomplete eyelid closure with ocular irritation, asymmetry, and need for additional treatment.

  • Preoperative Instructions: While surgery can occasionally be safely performed on patients taking anticoagulants or platelet-inhibiting medications/supplements, these agents should ideally be withheld prior to blepharoplasty. Facial cosmetic products, jewelry, and contact lenses should not be worn the day of surgery. Patients with the following conditions may be at higher risk for complications following blepharoplasty or require specialized surgical techniques: unrealistic expectations, prior eyelid/facial surgery, dry eye symptoms, thyroid disease, prominent eyes, marked orbital asymmetry, significant coexisting medical problems.