You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Preblepharoplasty Facial AnalysisArticle Last Updated: Aug 30, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Brian W Downs, MD, Assistant Professor, Department of Otolaryngology, Section of Facial Plastic and Reconstructive Surgery, Oregon Health and Science University Brian W Downs is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Cleft Palate/Craniofacial Association Coauthor(s): J Madison Clark, MD, Director, Division of Facial Plastic and Reconstructive Surgery, Assistant Professor, Department of Otolaryngology, Medical University of South Carolina; Ted A Cook, MD, Professor, Department of Otolaryngology/Head and Neck Surgery, Division of Facial Plastic Reconstructive Surgery, Oregon Health Sciences University Editors: Paul S Nassif, MD, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Southern California at Los Angeles, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: preblepharoplasty facial analysis, preoperative blepharoplasty evaluation, cosmetic surgery, eyelid defect, blepharoplasty, pre-blepharoplasty, pre-blepharoplasty facial analysis INTRODUCTIONSection 2 of 10
  Blepharoplasty requires meticulous attention to preoperative planning, perhaps more attention than that needed in most other procedures that facial plastic and reconstructive surgeons perform. In-depth knowledge of orbital anatomy and physiology is necessary. The careless surgeon approaches blepharoplasty as a quick, harmless, ancillary procedure. The thoughtful surgeon recognizes preoperative conditions that predispose the patients to outright complications and unfavorable outcomes and strives to minimize both. As with any cosmetic procedure, assessing the patient's motivation and anticipated results is necessary. The simplest technique for this assessment is to have patients look in a mirror along with the evaluating surgeon and to describe what they like and dislike about their facial features. After completing the preoperative evaluation, as reviewed in this article, the surgeon has a responsibility to describe in detail what additional procedures (eg, correction of ptotic brows unrecognized by the patient) may be necessary to safely achieve the patient's goals. Furthermore, analyzing his or her own results, the surgeon should provide the patient with realistic expectations regarding the final outcome. MEDICAL HISTORYSection 3 of 10
The general medical history is important for any patient undergoing surgery and should include an evaluation of the patient's allergies, current medications (including vitamins and supplements), past illnesses, surgeries and injuries, and a social history including any amount of cigarette and alcohol consumption. For patients undergoing blepharoplasty, special attention should be directed to preexisting conditions such as facial palsy, thyroid disease, autoimmune disease, bleeding diatheses, and unusual eyelid edema. Facial nerve disorders compromise tear-film transfer and eye protection if the zygomatic branch is affected. Any facial palsy must be resolved before cosmetic blepharoplasty to avoid ocular desiccation, keratitis, and vision loss. Thyroid disease can mimic benign eyelid conditions easily corrected with blepharoplasty. However, the treatment for thyroid-related ocular disease is primarily medical not surgical. The patient with thyroid disease should be stabilized medically for at least 6 months before blepharoplasty is considered. Furthermore, thyroid-related lagophthalmos, eyelid retraction, eyelid edema, and pseudoherniated fat should be stable before surgery. Blepharoplasty in patients with dry eyes should be approached cautiously. Some have suggested that patients with subjectively dry eyes can safely undergo blepharoplasty. However, autoimmune diseases, such as Sjögren syndrome and pemphigus and/or pemphigoid, are associated with dry eyes and generally preclude cosmetic blepharoplasty. As an incidental note, patients who can tolerate wearing contact lenses generally do not have dry eyes unless they require frequent use of wetting drops. The patient's intake of aspirin (pill or powder form), other anti-inflammatory drugs (eg, ibuprofen, naproxen), anticoagulants (eg, warfarin, megadose vitamin E) should be determined. Health food or natural products are commonly omitted from the usual list of medications but may lead to bleeding problems intraoperatively or postoperatively. Specific examples are ginkgo, ginger, garlic, and ginseng; all have anticoagulant effects, and their use should be elucidated preoperatively. A history of severe, unpredictable, or recurrent, eyelid or periorbital edema may represent blepharochalasis, a chronic familial allergic syndrome that may respond unfavorably to standard cosmetic blepharoplasty. Other causes of eyelid edema include hypertension, diabetic renal disease, systemic allergy, hereditary angioneurotic edema, sodium retention, long-standing blepharospasm, anemia, lymphedema, and parasitic infections. Finally, obtain a visual history, including the use of glasses and contact lenses. Record previous trauma to the eyes or periorbita. Ask specific questions about surgery for cataracts, glaucoma, retinal disease, or strabismus. Subjective, superolateral cuts in the visual field should be determined. Patients are also questioned about whether they think that their superior or superolateral visual fields are impaired by their upper eyelids. GENERAL OCULAR EXAMINATIONSection 4 of 10
The most important part of the preoperative physical examination is the assessment of visual acuity, which is done separately for each eye. Visual acuity may be determined by the use of a wall-mounted or hand-held chart, with the patient wearing corrective glasses or contact lenses. Accurate preoperative documentation of visual acuity can prevent confusion if vision decline occurs in the postoperative period. Ocular motility testing is performed by asking the patient to follow a finger or light through the cardinal positions of gaze. A cover-uncover test and an alternate-cover test is performed to rule out tropia (deviation) and phoria (movement). Abnormalities should prompt an ophthalmologic evaluation. Preoperative evaluation of tear secretion for blepharoplasty is controversial. Some authors recommend performance of tear-film breakup and Schirmer tests in selected patients undergoing cosmetic blepharoplasty, whereas others do not, citing the unreliability of testing. In general, preoperative testing is not needed if a thorough history does not elicit any symptoms of dry eyes. However, if dry eyes are suspected, a Schirmer test of basic tear secretion is performed. After topical proparacaine is instilled into each eye for anesthesia, a Schirmer strip (SMP Division, Cooper Laboratories, San German, Puerto Rico) is bent at 5 mm and placed into the lateral fornix. After 5 minutes, the strip is removed, and the amount of wetting is measured. The reference range is 10-15 mm. Less than 10 mm represents an abnormal result. Each surgeon must establish his or her own criterion for refusing cosmetic blepharoplasty on the basis of basic tear production. If the procedure is to be performed in a patient with abnormal basic tear production, surgery should be performed conservatively, with preservation of the orbicularis oculi muscle. In addition, the patient completely understands the inherent risks. Finally, the surgeon should remember that many patients with dry eyes may have a negative result. Formal visual-field testing is performed if peripheral loss is suspected. Insurance companies may require documentation of visual-field cuts for reimbursement in patients undergoing functional blepharoplasty. In this case, referral to an ophthalmologist is warranted. The cornea and sclerae are evaluated by applying side lighting to assess for obvious abnormalities. The Bell phenomenon (a normal finding representing upward and outward rotation of the globe with attempted eyelid closure) is assessed. Proptosis is ruled out by examining the globes from above and behind the patient. The fundus is examined with a hand-held ophthalmoscope for papilledema and retinal abnormalities. Any abnormalities detected in the cornea, sclera, or retina should prompt referral to an ophthalmologist before cosmetic blepharoplasty is performed. UPPER EYELID EXAMINATIONSection 5 of 10
The upper eyelid is evaluated for the quality of the skin, the quantity of excess skin, pseudoherniation of orbital fat, the position and symmetry of the supratarsal crease, blepharoptosis, retraction, and prolapse of the lacrimal gland. Assess the skin for signs of actinic change, including discoloration, laxity, and dermal or subdermal masses. The amount of excess skin can be assessed by using atraumatic forceps to gently pinch the skin of the upper eyelid. If a simultaneous browlift is contemplated, perform the skin pinch while elevating the brow into the desired location. Pseudoherniated fat is more commonly found in the nasal compartment of the upper eyelid than in the central compartment. Gentle ballottement of the globe can make subtle weakness in the orbital septum evident. The supratarsal crease is most easily found by lifting the brow and asking the patient to look downward to stretch the eyelid skin and then asking the patient to slowly look upward. The distance from the lash line to the crease at the midpupillary line is 8-11 mm in women and 6-9 mm in men. If this distance is substantially greater than the reference range, suspect disinsertion of the levator aponeurosis. Blepharoptosis is determined by measuring the marginal reflex distance (MRD)-1. While the patient remains in neutral gaze, the MRD-1 is measured from the corneal light reflex to the eyelid margin at the midpupillary line. The reference range for MRD-1 is 4-4.5 mm. Values below the reference range suggest ptosis, whereas values above the reference range suggest upper eyelid retraction. Abnormalities should alter surgical planning accordingly. Because orbital fat in the temporal compartment is minimal, fullness in this area should alert the surgeon to the possibility of a prolapsed lacrimal gland and the potential need to reposition the gland back into the lacrimal fossa at the time of blepharoplasty. Lacrimal gland infection and neoplasm must also be ruled out in cases of fullness in the temporal compartment of the upper lid. LOWER EYELID EXAMINATIONSection 6 of 10
The lower eyelid is evaluated for the quality of the skin, the quantity of excess skin, pseudoherniation of orbital fat, retraction, and laxity. Similar to the upper-eyelid skin, the lower-eyelid skin should be assessed for signs of actinic change, including discoloration, laxity, and dermal or subdermal masses. Excessive skin may be pinched, and the patient is asked to look upward and open the mouth, which places the skin under tension. Any excess skin found in this position can be excised without risking retraction of the lower eyelid. Pseudoherniated fat in the lower eyelid occurs in 3 compartments and is most easily assessed by asking the patient to look upward or by gently balloting the globe with gentle pressure on the upper-eyelid skin. Hypertrophy of the orbicularis oculi muscle can be assessed by asking the patient to smile and squint. This maneuver highlights redundant or hypertrophied muscle. In addition, this test can be used to identify fine wrinkles inferior and lateral to the lower lid, which are not corrected with blepharoplasty. It is important to inform the patient of this limitation before surgery. Lower-eyelid retraction usually occurs in the context of thyroid orbitopathy or after aggressive blepharoplasty. The amount of retraction is measured as the distance from the inferior limbus to the margin of the lower eyelid. Another measurement is the MRD-2, which is measured from the corneal light reflex to the margin of the lower eyelid in neutral gaze. The reference range for MRD-2 is 5-5.5 mm. Ectropion, a pulling away of the lower lid from the globe, should be noted preoperatively and is generally a contraindication to cosmetic blepharoplasty. Lower-eyelid laxity is measured by means of the snap test and the lower-lid distraction test. The snap test is performed by pulling the lower lid downward and outward and allowing the lid to snap back to apposition with the globe. The lid should snap back immediately and into full apposition. If it does not, laxity is suggested. The distraction test refers to how much the lower eyelid can be manually pulled or distracted from apposition with the globe. More than 10 mm of distraction is abnormal and suggests laxity. Another important measurement is the relative position of the medial and lateral canthi in the horizontal plane. The lateral canthus is normally positioned 1-2 mm superior to the medial canthus with the eyes open. A position inferior to this suggests laxity. FACIAL ANALYSIS RELEVANT TO BLEPHAROPLASTYSection 7 of 10
The patient interested in blepharoplasty usually presents with a chief complaint of baggy eyelids, "tired eyes," or too much eyelid skin. Although some patients may have isolated dermatochalasis, the effects of aging frequently involve more than just the skin of the eyelids. The surgeon must assess and understand the 3-dimensional interrelationships of the eyes with surrounding structures and appreciate the profound changes in the anatomy resulting from eyelid surgery. The eyes should be viewed in the context of the entire aging face, especially the forehead and cheeks. The forehead and brows play an important role in the appearance of the eyes. Brow ptosis can account for most of the dermatochalasis in many patients. If blepharoplasty is performed without correcting ptotic brows, the patient is left with a less-than-favorable cosmetic outcome at least and probable worsening of the brow ptosis. Settling of the malar fat pad is common after the fourth decade and can be surgically improved by performing extended lower lid blepharoplasty. This procedure is frequently combined with lateral canthoplasty to tighten laxity of the lower eyelid. The final relationship routinely analyzed is the relationship between the anterior projection of the globe, the lower eyelid, and the malar eminence. This relationship is best assessed by examining the close-up lateral view. Jelks and Jelks (1993) correctly identified a preoperative negative vector relationship (ie, the most anterior projection of the globe lies anterior to the lower lid and orbital rim) as an indication of potential problems with lower-lid retraction after surgery. A positive vector relationship occurs when the most anterior projection of the globe lies posterior to the lower eyelid margin, which lies posterior to the anterior projection of the orbital rim. A positive relationship suggests solid bony and tarsoligamentous support of the lower lid complex, which minimizes the risk of postoperative retraction of the lower lid. PHOTOGRAPHYSection 8 of 10
After careful history taking and physical examination, the next essential part of the preoperative workup is photodocumentation. The standard preoperative blepharoplasty series of photographs is listed below. Make every effort to use the same camera equipment, lens focal length, subject-to-lens distance, lighting, and background matte to ensure a valid comparison between preoperative and postoperative photographs. Standardized photography allows for regular, periodic reviews of photographs obtained before and after blepharoplasty to critically analyze the results. Twelve views are necessary for a comprehensive set of standard preoperative photographs, as follows:
MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Preblepharoplasty Facial Analysis excerpt Article Last Updated: Aug 30, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
