Motivation for Surgery

The ideal candidate for upper lid blepharoplasty has had a relatively longterm desire for reversal of the progressive deterioration of the lid appearance. The patient is in an employment or social situation that warrants facial attractiveness and is realistic about the possible outcome. There should be no expectations of external world changes as a result of the surgery (e.g., regaining a lost romance or obtaining an elusive job). The patient’s questions, answers, forethought, and general dress and manner should appear correct and “feel right” to the interviewing facial plastic surgeon. Interestingly, almost all patients coming for blepharoplasty are good candidates. The psychological and motivational problems seen in rhinoplasty and facelift patients are much less common in blepharoplasty patients.

Medical History

Obviously, any general medical problem that contraindicates elective surgery also contraindicates upper lid blepharoplasty. Particular attention must be given to any condition that may be aggravated by the use of local anesthetic with epinephrine. Many of the newer psychological agents interact with the sympathomimetic amines and must be discontinued before surgery. Homeopathic medications are becoming a common part of many Americans’ daily nutritional supplements. Many of these herbal preparations interact with medications used at surgery. St. John’s wort, yohimbe, and licorice root can have a monoamine oxidase inhibitory effect. Gingko biloba, used for shortterm memory loss, is a powerful anticoagulant. It is best to have a patient report all medications, including alternative medications.

Any condition that produces fluid retention, including the myxedema of hypothyroidism, must be considered in depth before surgery. Allergic dermatitis conditions, especially of the face and lid skin, should be controlled before blepharoplasty to avoid poor scarring or delayed wound healing.

Ophthalmic medical history is critically important. Use of eyeglasses, contact lenses, or eye medications must be documented. Any indication of dry eye syndrome (e.g., burning, tearing, use of artificial tears, waking at night with stinging pain in the eye, or sensitivity to windy conditions) merits a complete evaluation. Personally, the author will not perform upper lid blepharoplasty on any patient who presents with any degree of dry eye syndrome. Even minimal upper lid blepharoplasty can result in upper lid closure failure, exposing the corneal tissues and aggravating the dry eye syndrome with potentially severe complications. Judicious lower lid blepharoplasty can be performed in the presence of dry eye syndrome with much less worry about serious consequences. Unmasking or worsening the dry eye syndrome in an upper lid blepharoplasty patient creates one of the unrelenting postoperative problems in facial plastic surgery. It totally overwhelms even a perfect aesthetic surgical outcome.

A vision history should always be obtained. A near vision (reading) acuity examination can easily be incorporated into the questionnaire the patient is given to fill out in the waiting area before consultation.

The history of previous upper lid blepharoplasty, even if done many years ago, is important. The possibility of lagophthalmos is always present in these patients, and the indication for conservative secondary surgery is imperative. These patients can present with an impressive amount of apparent upper lid skin redundancy. However, when the eyes are closed the amount of upper lid skin redundancy that can be removed without causing lagophthalmos is usually minimal.

Brow Evaluation

The assessment begins with simple observation while the patient is talking and listening. Eyebrow position during animation and during repose is noted. The patient with low-position eyebrows often elevates them when speaking, producing deep, horizontal forehead creases. In the female patient, the lateral and central brow should ideally be above the superior orbital rim. If the lateral and central brow is at or below the orbital rim, a brow lift procedure should be considered. An upper lid blepharoplasty performed on a patient with brows below the orbital will invariably pull the brows into a lower position. Of particular interest is a patient with unilateral brow ptosis. This patient invariably sees the problem as a unilateral excess upper lid skin and sees the surgery required as removal of more skin from one eyelid than from the other. This is understandable because patients with unilateral brow ptosis in repose observe this as their natural appearance in a mirror and in a lifetime of family photographs. These patients are quick to see that the problem is not the eyelid but the ptotic eyebrow and are amenable to a concomitant unilateral brow lift. The patient with unilateral brow elevation present only with facial animation is also common. No attempt should be made to elevate the lower nonanimation eyebrow in these patients because this will only create an asymmetry in facial repose. After observation, the position of the eyebrow in relationship to the orbital rim is determined by palpation.

Lid Evaluation

The upper eyelid is examined. It should be kept in mind that in the simplest terms the aesthetic goals of upper lid blepharoplasty can be achieved by excision of redundant skin, removal of some part of the musculus orbicularis oculi when necessary, and resection of the pseudoherniated fat. The relative presence of medial fat and central fat is noted. The presence of a palpable lacrimal gland and lateral upper lid gland is also noted. The position of the eyelid crease at the superior tarsal margin is determined. The skin type is especially important in upper lid blepharoplasty. The patient with thin skin is usually an older individual requiring conservative resection of fat in the central compartment to avoid a retracted, hollow look postoperatively. Conservative muscle resection will also be required. In these patients, the eyelid appearance should be returned to one that was present at least a decade earlier. This can be demonstrated by using the wooden portion of a cotton-tipped applicator to roll the redundant skin toward the orbital rim while the patient is observing in the mirror. The patient with very heavy lateral orbital rims may be a candidate for removal of fat from beneath the orbitalis muscle in the region of the lateral brow. This procedure can be done in conjunction with upper lid blepharoplasty.

Special Considerations

The patient with heavy skin, and especially the younger patient with thick skin, has usually never had a discernible upper eyelid crease. Surgical creation of a sculpted eyelid requires excision of considerable fat and the musculus orbicularis oculi, and possibly a lateral extension of the lid skin excision. It is particularly important to show these patients how they will look postoperatively because they have never seen themselves with an eyelid sulcus. These patients often will say, “I’ve never had eyelids, not even when I was very young.” The patient with thick, heavy skin, especially in the outer third of the lid, may have some tendency toward scarring for several weeks after surgery. This should also be discussed with the patient. Also, when an upper lid blepharoplasty incision must cross the lateral orbital rim onto the facial skin (i.e., when there is considerable lateral hooding), the facial skin portion of the scar will take longer to mature.

The symmetry of the palpebral fissures is noted. The upper lid should cross the limbus just above the pupil in a bilateral symmetric position. A 2- to 3-mm noncorrectable, unilateral ptosis of the upper eyelid will often not be noted by the patient before surgery. Understandably, it is overlooked among the redundant skin and fat herniation. When blepharoplasty has eliminated all of the lid problems, the palpebral fissures asymmetry will be unmasked. If the surgeon fails to identify this condition and carefully show it to the patient before surgery, it will become a point of contention between the doctor and the patient after surgery. It will be the first thing that friends notice. Any postoperative explanation, even with pictorial evidence, becomes an excuse. If this palpebral fissure asymmetry is noted before surgery, the patient will think of the surgeon as a careful and astute observer.

Notation is made of any associated skin lesion (e.g., xanthoma, syringoma, trichoepithelioma, hypertrophic sebaceous glands, skin pigmentation, enlarged veins, and telangiectasias). Whether these lesions will be removed at the time of surgery, at a later secondary procedure, or not at all must be discussed.

Planning Incisions

The procedure begins with marking of the lids. To minimize “bleeding” of the skin marking and maximize the permanence of a fine-line drawing on the lid skin, the lids must be totally clean of natural skin oil. All makeup is removed the night before by the patient. The lids are degreased with alcohol or acetone before marking ( Fig. 16.1 ).

The initial lid marking is at the natural lid crease, which can almost always be seen clearly with a bright light and adequate magnification. This lid crease is at the upper margin of the underlying superior tarsal plate. If the natural lid crease is at 8 mm or more above the lid margin, it is always best to use this natural landmark. The lid crease is usually at the same level bilaterally. If there is a 1-mm discrepancy between lids, then adjustments in the lid crease marking are made so that both are 8 to 10 mm above the lid margin. The medial end of the incision is carried far enough nasally to include all of the fine creped skin but never beyond the nasal orbital depression to the nasal skin. Carrying the incision too far nasally causes almost irreversible webbing. Laterally, the lid crease line is carried in the natural crease of the sulcus between the orbital rim and the eyelid. At this point, the line breaks laterally or slightly upward ( Fig. 16.1 ). With the patient in a supine position, the real amount of the upper lid skin redundancy can only be determined after the brow is physically pushed downward. In the supine position, the mobility and weight of the scalp and forehead pull the brow above the orbital rim. This is not the true, natural position of the brow. The upper lid skin redundancy is transiently lessened. To plan the upper lid blepharoplasty correctly, the brow must be gently pushed down toward the orbital rim into a position noted when the patient was seated or standing ( Fig. 16.2 ). The upper lid skin is then gently grasped with forceps. One blade of the forceps is at the previously marked lid crease. The other blade grasps just enough redundant skin to smooth the lid but not to move the lid margin upward. In other words, if the skin between the forceps blades were to be removed, surgical elevation of the lid margin and lagophthalmos should not occur ( Fig. 16.3 ). This marking technique is used at several points across the lid. As these points are connected, a line is created that parallels the lid crease line. Medially and laterally, the lines join at a 30-degree angle. The medial skin redundancy should always be slightly underestimated in patients with a large amount of medial fat. The defect created by the excision of a large amount of fat medially may cause a dead space to occur subcutaneously. If slightly less skin is excised medially, the repaired medial end of the lid falls inward rather than tenting over the area of removed fat. If tenting of the medial lid skin occurs, dense scarring is almost a certainty in this region.

The lateral extent of the planned skin excision is determined by the amount of lateral hooding. If no hooding is present in a younger patient, the lateral excision ends just beyond the lateral canthus. If the lateral hooding is extensive, the excision may be carried 1 cm or more beyond the orbital rim laterally. The direction of the resultant scar should always lie between the lateral canthus and the lateral eyebrow ( Fig. 16.4 ). In this position, the incision can be camouflaged by eye shadow makeup in the female patient ( Fig. 16.5 ). The area demarcated by the surgical pen marking should be a gentle sinuous shape ( Fig. 16.6 ).