Identify medical conditions that may increase the risk of complications

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  Blepharochalasis, Graves’ disease, glaucoma

  
  
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  Previous periorbital and facial procedures

  
  
  
  
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    Recent laser-assisted in-situ keratomileusis (LASIK) or cataract surgery: Should not undergo blepharoplasty for at least 6 months following procedure

  
  
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  History of dry eyes/seasonal allergies

  
  
  
  
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    Hormone replacement therapy: 70% higher risk of dry eye

Forehead analysis: Hairline (brow height), transverse and glabellarr hytids

Eyebrow analysis: “Ideal brow”

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  Location: Relation between hair-bearing brow and supraorbital rim

  
  
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  Peak: Should be located at or just lateral to the lateral limbus

  
  
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  Evaluate for brow ptosis and compensation

Upper eyelid analysis

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  Upper eyelid/Iris relationship: Covers 2–3 mm of superior limbus

  
  
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  Upper eyelid crease: Female (7–10 mm), male (6–8 mm), Asians (variable but low)

  
  
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  Lateral extension of the eyelid crease onto the lateral portion of the periorbital region is a marker of forehead ptosis (Connell’s sign)

Lower eyelid analysis

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  Lower eyelid/Iris relationship: Minimal to no scleral show, ideally covers 0.5 mm of the lower limbus

  
  
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  Tear trough deformity

  
  
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  Malar support

  
  
  
  
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    Positive vector

    
    
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    Negative vector— relative scarcity of skin, hemi exophthalmos

Ocular examination (Table 24-1)

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  Eyelid ptosis

  
  
  
  
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    Patient focuses on a light source with both eyes

    
    
  • 
    

    Margin reflex distance (MRD1): The distance from the pupillary light reflex to the upper eyelid margin (Fig. 24-1)

    
    
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    Normal MRD1: 4–4.5 mm

  
  
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  Levator excursion

  
  
  
  
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    Hold brow in resting position. Ask patient to look up and measure excursion of the upper eyelid with a ruler (normal >10 mm)

  
  
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  Dermatochalasis: Visual field test to document

  
  
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  Visual acuity

  
  
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  Dry eyes: Schirmer’s test, Bell’s phenomenon (see Chapter 25)

  
  
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  Ectropion/lower eyelid laxity

  
  
  
  
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    Lower eyelid distraction <7mm, lower eyelid snap test

    
    
  • 
    

    MRD2: Measure the distance from the pupillary light reflex to the lower eyelid margin (Fig. 24-2)

    
    
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    Normal MRD2: 5–5.5 mm

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

    Table 24.1 Ptosis classification

    Ptosis	Mild	Moderate	Severe
    MRD1	2–2.5 mm	1–1.5 mm	<1 mm
    Levator Excursion	Good >10 mm	Fair 5–10 mm	Poor <5 mm
    Abbreviation: MRD, margin reflex distance.