Last Monday, I had the pleasure of lecturing to the maxillofacial surgery residents at Emory on preoperative evaluation and surgical techniques for upper and lower blepharoplasty. It was a time for reflection, and for appreciating how my technique is constantly evolving and individualized for patients.
As an ophthalmologist, the most important element of blepharoplasty is preserving function. Some patients simply cannot tolerate the removal of any additional tissue because doing so would compromise the surface of their eye. Eyelid function abnormalities are often the byproduct of cosmetic surgery in which too little attention was paid to the lid tone and position. This is but one piece of wisdom that one of my mentors, Dr. Sonny McCord, imparted to me. The amazing thing is that if you look for these subtle abnormalities, you will find that they are walking into your office every week with functional and cosmetic complaints. Not uncommonly, they complain of irritation due to impaired blink mechanics. (By the way, that is the topic of a review article that we are submitting to the Aesthetic Surgery Journal this week!)
So, with that in mind, you may wonder what goes into an upper eyelid evaluation during the consideration of blepharoplasty.
1. Lid position: Ptosis (droop)? Retraction (too high)? Entropion (turned in)? Ectropion (turned out)?
2. Lid tone: Can the lid close? Does the eyelid excursion during blink cover the whole cornea?
3. Does the normal protective mechanism of the eye rolling back during forced closure exist? (Some people do not have this mechanism intact!)
4. Does the surface of the eye have problems? Has the patient had LASIK? Does the patient have dry eye syndrome?
5. Are the eyebrows in the proper position, or are they low? If the eyebrows are low, removed skin from beneath them will “lock” them into this position forever… and sometimes low eyebrows evoke a feeling of anger, even if the patient does not mean it.
6. Is there fullness or hollowing of the upper lids? Is it fat? The tear gland? Something else?
7. What is the patient’s ethnicity? Where is the eyelid crease? Is it formed? Is it symmetric?
8. Are the lid folds symmetric? Is there true skin excess?
What’s the point?
It’s a fairly complicated examination, even though it probably seems quick and simplistic to the average patient. This doesn’t take into account some of the elements that go into assessing the neurological and medical health of the patient prior to surgery. And here’s the point: oculoplastic surgeons who have trained in ophthalmology are well-suited for this comprehensive approach to the patient. Those who haven’t trained in ophthalmology are unlikely to be able to precisely and accurately assess #1, #2, #3, #4, #6, #7, and #8. So ask yourself who you want to do your “simple” blepharoplasty!
Next time around, I’ll mention some of the considerations when considering a lower lid blepharoplasty.