History

In taking a medical history, the surgeon questions the patient about illnesses, medications, allergies, and edema. Emphasis is on ruling out thyroid disease, heart failure, hypertension, bleeding tendencies, and unusual edema. For example, patients with thyroid disease may look as if they need cosmetic surgery, but the treatment needed is frequently medical, not surgical. Also, patients with thyroid disease must be followed up for at least 6 months until their eyelid retraction measurements and amounts of eyelid edema and herniated fat are stable before surgery can be considered. Patients should also be questioned about intake of aspirin or anti-inflammatory medications, such as ibuprofen, vitamin E, anticoagulants and herbal remedies. These drugs must be discontinued for several weeks pre-operatively to avoid the possibility of complications of bleeding during and after surgery.

The surgeon should also try to find out why the patient wants surgery now. In this way, the surgeon can differentiate patients who have realistic, mature reasons for requesting surgery from those who do not.

The examination includes an evaluation of the forehead, eyebrows, upper and lower eyelids, cheeks, face, and skin condition. I encourage all surgeons to step back and view the patient’s entire face first before they focus on specific structures. The purpose of this examination is to determine which cosmetic problems are correctable so that they can be compared with the patient’s expectations.

Forehead and eyebrow examination

In examining the forehead and eyebrows, the cosmetic surgeon is looking mainly for brow ptosis (drooping), which causes excessive upper eyelid folds. The surgeon also looks for asymmetric brow ptosis or ptosis of parts of the brow (e.g. nasal or temporal). In patients with apparent dermatochalasis (excess skin) of the upper eyelid that is actually due to a brow ptosis, excising upper eyelid skin without elevating the eyebrow only minimally improves appearance. Additionally, forehead wrinkles and frown lines caused by overactive corrugator, procerus and frontalis muscles are examined.

Measuring the distance from the central upper eyelid margin to the central inferior brow edge (brow upper lid, BUL) with the patient gazing in primary position can help identify patients with brow ptosis. If this measurement is much less than 10 mm, especially in women, surgical elevation of the brow may be desirable.

Another useful measurement is the distance from the central inferior part of the eyebrow to the inferior corneal limbus (brow inferior limbus, BIL) as the patient gazes in primary position. The measurement is commonly about 22 mm. If this measurement is much less than that amount, especially in women, elevation of the brow is also suggested. Also, this measurement is frequently more reliable than that of the brow to upper eyelid, which varies with upper eyelid ptosis or retraction.

The amount of brow ptosis can be determined in several ways. The first is to line the zero mark of a millimeter ruler with the central superior brow edge (Fig. 3-2). The brow is then elevated to a cosmetically acceptable level with the examiner’s finger, and the amount of excursion of the brow is noted on the ruler where the superior central brow edge meets the ruler. This measurement is repeated over the temporal and nasal aspects of the brow about 10 mm from the brow ends, and similar measurements are made over the opposite brow.

Figure 3-2 Measurement of the amount of eyebrow ptosis. A, The zero (0) mark of a millimeter ruler is aligned adjacent to the top of the central ptotic brow. B, The surgeon lifts the ptotic brow to the desired postoperative position, and the amount of excursion of the central superior brow is noted by the level of the brow adjacent to the ruler. In this case, the brow has been elevated 7.5 mm.

The same measurement can be made by first placing the brow in a cosmetically acceptable position with the examiner’s finger, lining the 20-mm mark of the ruler with the superior central brow edge, and then releasing the brow and noting how many millimeters the brow drops as it assumes its ptotic position.

Still another method of measuring brow ptosis or asymmetry is to use the ocular asymmetry measuring device (Bausch & Lomb Storz^® Instruments),¹ an instrument that Chalfin and I devised. It consists of a headband, a ruler, and a T-shaped crosspiece. When the band is placed around the patient’s forehead, it fixes the ruler vertically over the midforehead. The crosspiece line intersects the medial canthus and levels the crosspiece. The crosspiece is then aligned with the central superior brow, and the location where the indicator is positioned on the ruler is noted (Fig. 3-3). The brow is elevated with the examiner’s finger to a cosmetically acceptable level. The crosspiece is then elevated to the new superior central brow position, and the excursion of the indicator on the ruler is noted. The measurements are repeated temporally and nasally and on the opposite brow.

Figure 3-3 Ocular asymmetry measuring device for determining the amount of brow ptosis. In asymmetric brow ptosis, the measuring rod is set at the central superior aspect of the more ptotic brow, and the point of indicator on the ruler is noted. The measuring rod is then elevated to a similar position on the more normal brow, and the millimeters of excursion of the indicator determine the amount of brow ptosis.

The ocular asymmetry measuring device is especially useful in unilateral brow ptosis. In these cases, the crosspiece is raised to the highest position on the arch of the lower eyebrow, and the position of the indicator on the millimeter ruler is noted. The crosspiece is then raised to the corresponding point on the opposite eyebrow, and the position of the indicator is again noted. The excursion of the indicator is a direct measurement of asymmetry, as the indicator is fixed to the crosspiece and they move as one unit. Measuring the amount of brow ptosis aids in determining the amount of skin that must be removed to elevate the brow surgically. (The ocular asymmetry measuring device is also useful in measuring asymmetric canthi and eye positions.)

Examination of the upper eyelid

The upper eyelid is evaluated for excessive skin, herniated orbital fat, abnormal eyelid creases, ptosis, retraction, and prolapse of the lacrimal gland.

Eyelid skin-fat examination

The amount of excessive skin and whether the skin is more redundant over part of the upper eyelid are determined. The surgeon finds herniated orbital fat by noting fullness in the upper eyelid, especially nasally and, at times, centrally. Lifting the lid fold by elevating the brow and simultaneously pushing on the eye through the lower eyelid can increase the fat herniation in the suspected areas and verify that the fullness is due to fat, not edema. Fat generally flows forward during this maneuver, whereas edema of the eyelids remains unchanged. Preoperative determination of excessive skin and herniated orbital fat establishes candidates who would benefit by the excision of these tissues.

Eyelid crease examination

The examiner can find the upper eyelid crease by lifting the eyebrow and asking the patient to look downward first, then slightly upward, and then downward again. The distance from the central upper eyelid margin to the central crease as the patient looks down and as the eyelid fold is elevated with the examiner’s finger determines the margin crease distance (MCD) measurement described by Urist and me (Fig. 3-4). Normally, this is 9–11 mm. If the distance is much less, reconstruction of the eyelid crease and excision of the skin fat should be considered (see Chapter 7). If the MCD is much greater than normal, a disinsertion of the levator aponeurosis should be suspected. As the levator aponeurosis recesses into the orbit, it frequently elevates the eyelid crease upward.

Figure 3-4 The margin crease distance (MCD) is a measurement of the distance from the lid crease to the lid margin over the central upper eyelid on down gaze.

The surgeon must discuss reconstruction of an upper eyelid crease with the patient preoperatively. Although most patients find a high upper eyelid crease to be cosmetically appealing, some, especially Asians, may strongly dislike its appearance. It is therefore advantageous to be able to demonstrate to patients preoperatively how they will look with crease reconstruction and to predetermine the desired level at which to reconstruct the upper eyelid crease.

To predetermine the position at which to reconstruct an upper eyelid crease, the surgeon will need a curved instrument for compression of the upper eyelid skin. I formerly used an unwound, slightly curved paper clip and pressed it at various positions of the upper eyelid. Many of my patients reacted negatively to the use of a paper clip to determine the eyelid crease, saying how crude an instrument it was. This negative reaction led to my development of a more sophisticated instrument, the upper eyelid creaser (Bausch & Lomb Storz^® Instruments).²

This creaser consists of a 4-cm, curved, thin metal wire attached to a handle (Fig. 3-5). The wire has a curvature similar to the normal upper eyelid crease, but it is flexible and can be bent by the examiner if the curve needs to be flattened or extended. The examiner holds the handle and presses the wire into the upper eyelid at various positions until the surgeon and patient agree on a desirable level at which the reconstruction is to be performed (Fig. 3-6). A measurement is made between the upper eyelid margin and the chosen position and is used intraoperatively to determine the position for reconstructing the crease.

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