eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery

Blepharoplasty, Upper Eyelid: Workup

Author: Vikram D Durairaj, MD, Associate Professor of Ophthalmology, Associate Professor of Otolaryngology-Head and Neck Surgery, Residency Program Director, Department of Ophthalmology, University of Colorado; Medical Director, Rocky Mountain Lions Eye Institute
Coauthor(s): Eric M Hink, MD, Instructor and Fellow, Oculofacial Plastic and Orbital Surgery, University of Colorado Health Sciences Center; Steven Gabel, MD, Fellow, Department of Surgery, Division of Otolaryngology, University of Missouri; Jill A Foster, MD, Associate Clinical Professor, Department of Ophthalmology, The Ohio State University
Contributor Information and Disclosures

Updated: Jan 26, 2009

Workup

Diagnostic Procedures

  • Patients must undergo a complete medical evaluation prior to upper eyelid blepharoplasty.
    • All current medical conditions must be discussed.
    • Whether cosmetic or functional, upper lid blepharoplasty is an elective procedure, and underlying medical conditions must be evaluated and treated prior to elective surgery.
    • Patients with thyroid eye disease should exhibit 12 months of stability in their orbitopathy before elective cosmetic surgery.
    • A history of keloid scar formation or dry eyes is concerning but not a contraindication for upper lid blepharoplasty.
    • Abnormal coagulation and actively inflamed blepharitis should be addressed prior to surgery.
    • Specific questions should be asked about Graves disease, other thyroid abnormalities, autoimmune and inflammatory diseases, dry eye syndrome, chronic blepharitis, previous refractive surgery such as laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK), and other conditions that may alter the natural recovery process after blepharoplasty.
    • A history of allergic reactions is obtained in order to avoid complications from medications used before or after the procedure.
  • Current medications, including vitamins, herbs, nonsteroidal anti-inflammatory medications, and aspirin, need to be documented. To avoid a postoperative hemorrhage, preoperative clearance must be obtained to stop all medications that cause platelet dysfunction and tendencies for increased bleeding.
  • The evaluation should include a thorough ophthalmologic evaluation that includes visual acuity, ocular motility, visual field testing, and basic tear secretion testing such as the Schirmer test. The Schirmer test is performed by placing a strip of test paper over the temporal palpebral conjunctiva and measuring the wetting on the strip after 5 minutes. If the measurement is less then 10 mm (reference range is >10 mm), the patient may have difficulty producing tears, which may be a contraindication to blepharoplasty. The value of the Schirmer test in predicting postoperative dry-eye problems is controversial.
  • Examination of the patient should include an evaluation of specific landmarks, including palpebral fissure distance; margin reflex distance-1 (MRD1), which is the distance between the center of the pupil in primary position and the central margin of the upper eyelid; margin reflex distance-2 (MRD2), which is the distance between the center of the pupil in primary position and the central margin of the lower eyelid; margin fold distance; and eyelid crease position (see Image 1). Ptosis of the upper eyelid should be suspected when the palpebral distance is less than 10 mm (reference range is 10 mm) and MRD1 is less than 4 mm (reference range is 4-4.5 mm).
  • The individual components of the periorbital region are thoroughly assessed prior to surgery.
    • The surgeon assesses the relationship of the brow position to the upper lid and makes an early decision as to whether isolated upper lid blepharoplasty is sufficient or whether brow position adjustment is necessary to achieve the desired results.
    • Manual elevation of the brow to the desired position allows the patient and surgeon to assess the role the brows play in the appearance of the upper eyelid. In males, the brow is positioned along the supraorbital rim. In females, the brow is elevated to a position at or up to 1 cm above the supraorbital rim. This is done with the patient in an upright position and with the patient looking in a mirror to help judge how brow position affects the upper eyelid.
    • Repositioning of the brow, the brow fat pad, and the skin between the lid crease plays a profound role in the appearance of the upper eyelid. Do not let the patient underestimate its relevance to the upper eyelid appearance.
  • Once brow position has been determined, the surgeon assesses the components of excess skin, skin laxity, and fat herniation in the upper lid. Upper eyelid aging changes are typically a combination of excess skin or skin laxity, causing redundancy of the tissues. Excess or herniated fat causes a protrusion or convex contour of the upper eyelid. The medial or nasal fat pad, the middle fat pad, and the lacrimal gland in the temporal upper eyelid influence the overhang of the upper lid fold. The sub-brow fat may also descend into the superior sulcus, altering the indentation between the lid fold and the brow. The position and protrusion of these tissues are amenable to surgical modification.
  • Photographs are taken to document the clinical findings in each patient (see Image 2). Traditional views include full face and a close up of the eyes in primary, upward, and downward gaze. Additional views may include right and left oblique views and a lateral view to document the globe position relative to the inferior orbital rim.

More on Blepharoplasty, Upper Eyelid

Overview: Blepharoplasty, Upper Eyelid
Workup: Blepharoplasty, Upper Eyelid
Treatment: Blepharoplasty, Upper Eyelid
Follow-up: Blepharoplasty, Upper Eyelid
Multimedia: Blepharoplasty, Upper Eyelid
References
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References

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  2. Pottier F, El-Shazly NZ, El-Shazly AE. Aging of orbicularis oculi: anatomophysiologic consideration in upper blepharoplasty. Arch Facial Plast Surg. Sep-Oct 2008;10(5):346-9. [Medline].

  3. Anwar M, Smith DE, Kaye AD. Anesthesia for cutaneous surgery. Int J Aesth Restorative Surg. 1997;5:108-115.

  4. Baylis HI, Goldberg RA, Kerivan KM, Jacobs JL. Blepharoplasty and periorbital surgery. Dermatol Clin. Oct 1997;15(4):635-47. [Medline].

  5. Black J. Complications following blepharoplasty. Plast Surg Nurs. Summer 1998;18(2):78-83. [Medline].

  6. Camirand A. The surgical correction of aging eyelids. Plast Reconstr Surg. Apr 1999;103(4):1325-6. [Medline].

  7. D'Assumpcao EA. Blepharoplasty: a personal tactical approach. Aesthetic Plast Surg. Jan-Feb 1999;23(1):28-31. [Medline].

  8. Flowers RS, DuValc C. Blepharoplastic and periorbital aesthetic surgery. Plastic Surgery. 1997;5th.

  9. Foster JA, Barnhorst D, Papay F, Oh PM, Wulc AE. The use of botulinum A toxin to ameliorate facial kinetic frown lines. Ophthalmology. Apr 1996;103(4):618-22. [Medline].

  10. Foster JA, Wulc AE, Castro E. The Botox Brow Lift. American Society of Ophthalmic Plastic and Reconstructive Surgery. 1999;Fall International Symposium.

  11. Januszkiewicz JS, Nahai F. Transconjunctival upper blepharoplasty. Plast Reconstr Surg. Mar 1999;103(3):1015-8; discussion 1019. [Medline].

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  13. Krupin T, Kolker AE. Eyelid Surgery. Complications in Ophthalmic Surgery. 1999;2nd:240-245.

  14. Meyer DR. Functional eyelid surgery. Ophthal Plast Reconstr Surg. Jun 1997;13(2):77-80. [Medline].

  15. Morax S, Touitou V. Complications of blepharoplasty. Orbit. Dec 2006;25(4):303-18. [Medline].

  16. Putterman AM. The History of Cosmetic Oculoplastic Surgery, Evaluation of the Cosmetic Oculoplastic Surgery Patient, Treatment of Upper Eyelid Dermatochalasis and Orbital Fat: Skin Flap Approach. Cosmetic Oculoplastic Surgery. 1999;II:3-10, 11-22, 77-89.

  17. Roberts E, Holck DE. Prospective clinical evaluation of wound healing after carbon dioxide laser upper lid blepharoplasty closed with polypropylene suture or octylcyanoacrylate tissue adhesive. Abstract Book-ARVO. 1999;152-b112.

  18. Teng CC, Reddy S, Wong JJ, Lisman RD. Retrobulbar hemorrhage nine days after cosmetic blepharoplasty resulting in permanent visual loss. Ophthal Plast Reconstr Surg. Sep-Oct 2006;22(5):388-9. [Medline].

  19. Zarem HA, Resnick JI, Carr RM, Wootton DG. Browpexy: lateral orbicularis muscle fixation as an adjunct to upper blepharoplasty. Plast Reconstr Surg. Oct 1997;100(5):1258-61. [Medline].

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Further Reading

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Keywords

blepharoplasty, upper eyelid blepharoplasty, dermatochalasis, steatoblepharon, eyelid skin, pseudoherniation of orbital fat, pseudoptosis, blepharoplasty, blepharoplasty surgery, cosmetic eyelid surgery, blepharochalasis

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Contributor Information and Disclosures

Author

Vikram D Durairaj, MD, Associate Professor of Ophthalmology, Associate Professor of Otolaryngology-Head and Neck Surgery, Residency Program Director, Department of Ophthalmology, University of Colorado; Medical Director, Rocky Mountain Lions Eye Institute
Vikram D Durairaj, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Ophthalmic Plastic and Reconstructive Surgery, Colorado Medical Society, and Pan-American Association of Ophthalmology
Disclosure: Alcon Labs Honoraria Speaking and teaching; Porex Surgical Honoraria Speaking and teaching

Coauthor(s)

Eric M Hink, MD, Instructor and Fellow, Oculofacial Plastic and Orbital Surgery, University of Colorado Health Sciences Center
Eric M Hink, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, and American Medical Association
Disclosure: Nothing to disclose.

Steven Gabel, MD, Fellow, Department of Surgery, Division of Otolaryngology, University of Missouri
Steven Gabel, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, and American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.

Jill A Foster, MD, Associate Clinical Professor, Department of Ophthalmology, The Ohio State University
Jill A Foster, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and American Medical Association
Disclosure: Allergan Consulting fee Consulting

Medical Editor

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Allergan Honoraria Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department Otolaryngology-Head and Neck Surgery, University of Missouri at Columbia
Keith A LaFerriere, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Missouri State Medical Association
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD 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 Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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