Approach Considerations

Prior to blepharoplasty, a thorough history should be obtained to exclude bleeding diathesis, blood-thinning medication, and the use of over-the-counter medications with anticoagulant effect. Although some blepharoplasties can be performed in patients who are taking anticoagulants, four-lid procedures or surgeries involving extensive retroseptal dissection may be more prone to bleeding or retrobulbar hemorrhage. Patients with hypertension should be reminded to take their regular antihypertensives on the day of surgery.

Patients with marked pedal edema may have persistent morning fluid retention in their eyelids.

Laboratory Studies

In most cases of dermatochalasis, no laboratory work is necessary.

In rare cases where hereditary angioedema is suspected, a C1-esterase inhibitor level should be performed.

Similarly, if amyloidosis is suspected, then a protein electrophoresis is appropriate.

If thyroid-associated orbitopathy is suspected, thyroid-stimulating hormone serum (TSH) testing should be performed.

Imaging Studies

In most cases, no imaging studies are necessary. If a patient is noted to have proptosis or enophthalmos, CT scan of the orbit is indicated.

Other Tests

Schirmer testing with topical anesthetic drops may be considered in patients who have significant dry eye symptoms and who desire blepharoplasty.^[5]However, Schirmer testing may be nondiagnostic in patients with dry eye symptoms, and many oculofacial surgeons do not consider Schirmer tear testing to be the medical standard of care in evaluating blepharoplasty patients.^[6]

Other tear function testing, including the Schirmer test I, Schirmer test II and the phenol red thread test may be indicated.

Procedures

Blepharoplasty is the procedure of choice for upper and/or lower eyelid dermatochalasis. This can be combined with fat removal in patients with steatoblepharon.

In patients noted to have ptosis of the upper eyelid, a concurrent ptosis surgery may be indicated. Similarly, patients with lower eyelid laxity or malposition may require corrective surgery.

Periocular fillers may be considered in patients with minor hollowing, steatoblepharon, or lid abnormalities. Several authors have also proposed the injection of periocular fillers in place of blepharoplasty for periorbital rejuvenation.^{[7, 8]}

Patients taking neuromodulators should be instructed to discontinue neuromodulator treatment 3-4 months prior to blepharoplasty surgery.

Histologic Findings

In most cases of dermatochalasis, normal skin and muscle are identified. With dermatitis, a chronic nonspecific inflammatory infiltrate may be seen.

Treatment & Management

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Media Gallery

Preoperative image prior to upper blepharoplasty.
Postoperative image after upper blepharoplasty.
Preoperative image of a patient with thyroid eye disease, dermatochalasis, eyelid retraction, and steatoblepharon.
Postoperative image after 4-lid blepharoplasty and canthopexy.
Pinch technique for measuring redundant skin in upper eyelid blepharoplasty.