Keywords

Excessive upper eyelid tissue excision during blepharoplasty can compromise ocular surface health by compromising eyelid function. This can lead to lagophthalmos, dry eyes, visual disturbances, and pain. Because I practice in a very dry climate, I ask every patient about subjective dry eye issues and perform careful slit-lamp examination for more subtle findings of dry eyes, chemosis, and conjunctival injection. It is critical to verbally discuss these issues before surgery and explain the importance of leaving sufficient skin for proper postoperative eyelid function. This is a conversation I often repeat during preoperative skin marking, and patients agree they want enough skin following surgery that their eyelids will close properly even if it means having a “little less lift” performed. Leaving approximately 22 mm or more of actual upper eyelid skin is crucial. For dermatochalasis patients with extreme eyelid weakness, I often recommend addressing the visual field loss through a brow approach (e.g., direct) if suitable, and if an upper blepharoplasty is still necessary to improve visual function, then only remove skin leaving the underlying orbicularis intact.

Reasons to undercorrect:

  • Poor tear film

  • Poor Bell’s or blink response

  • Poor ocular movements

  • Lower eyelid retraction

  • Chronically large pupil(s) or superior pupillary defect

  • Orbicularis weakness (e.g., Parkinson’s disease, seventh nerve injury, myasthenia gravis) and/or lagophthalmos

  • Reduced corneal sensation

  • Preexistent photophobia, keratitis, ocular irritation/injection, and chemosis

  • Severe proptosis

  • Simultaneous forehead/brow lift planned (preferable to perform forehead lift first followed by the blepharoplasty to avoid removing too much skin)