Upper Lid Blepharoplasty Clinical Presentation

Updated: Aug 10, 2020
  • Author: Bhupendra C K Patel, MD, FRCS; Chief Editor: James Neal Long, MD, FACS  more...
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Patients may report a decrease in peripheral vision, most commonly associated with temporal hooding from redundant skin in the superotemporal visual field. Weight from excessive upper eyelid skin may mechanically depress the eyelashes, resulting in lash ptosis, which may interfere with visual acuity. Patients may also report frontal headaches or brow ache secondary to chronic attempts to elevate the brow to combat the redundant upper eyelid skin from interfering with the visual field.


Physical Examination

A thorough eyelid examination is essential in the patient presenting with upper eyelid dermachalasis, with the patient evaluated for the following:

  • Quantity and quality and symmetry of the upper eyelid skin
  • Lid crease position
  • Eyelid margin height (to look for concomitant blepharoptosis)
  • Amount of orbital fat prolapse
  • Lagophthalmos and amount of skin from lid margin to inferior border of brow hairs
  • Bell phenomenon (both forceful and gentle lid closure)
  • Lacrimal gland prolapse (may be addressed at time of surgery)
  • Brow height and effect of mechanical brow lifting on amount of dermachalasis
  • Strength of orbicularis

A preoperative ophthalmic examination with assessment of visual acuity, pupillary response, and assessment of the ocular surface for preexisting dry eye conditions is recommended.

Patients typically present with a heaviness of the upper eyelids and may report drooping of the eyelids. In many cases, once this skin is manually elevated, the true height of the eyelid margin can be seen and reveals a normal position. If the lid height is indeed low, then blepharoptosis may also need to be addressed at the time of surgery. The aging upper eyelid, with crepe paper skin, ptotic fat, or both, is well known. The diagnosis of each component problem and the proper correction are sought from the competent cosmetic surgeon.

The best approach is to begin with a large area and then narrow to specifics. The following format may be followed.

When a patient reports a tired look and desires correction of the upper eyelid, confirm the problem and that its correction will lead to a happy patient. Other than in cosmetic surgery, a patient diagnosing the problem and telling the physician which correction is required is unusual. Asking the patient to disclose what bothers him or her about his or her appearance and then diagnosing the cause and discussing appropriate correction(s) is best. Few patients request an appendectomy; rather, they present with abdominal pain, nausea, and progressive symptomatology. The physician must diagnose the problem. Similarly, many patients present with heavy upper eyelids. The physician must diagnose if the true problem is brow ptosis, ptosis, lacrimal gland ptosis, blepharochalasis, or another problem.

Directly check the position and fixation of the brow. Is a component of ptosis leading to the upper eyelid heaviness? Are crow's feet present that will not be corrected with upper eyelid blepharoplasty but are a major concern to the patient? Proper brow position varies in individuals and by gender. Discuss this with the patient. Diagnose exophthalmos if present and perform exophthalmometry if necessary. Exclude systemic causes. Surmise the symmetry and shapes of the bony orbit and incorporate them into the facial gestalt. [10]

Once the diagnosis has been narrowed to an upper eyelid problem, an anatomic evaluation, as follows, is suggested:

  • Skin of the upper eyelid - Is it texturally in need of improvement? Is much epidermal etching present, or is the dermis creased as well? Are growths or pigmentary changes present that need to be addressed? Has heavy brow skin encroached on the upper eyelid?
  • Support of the upper eyelid - Is the orbicularis muscle overactive or is a tick present? Is the lid fold well-defined along its length? Are the folds even for both eyes vertically, horizontally, and in depth? Do the eyes close evenly both gently and forcefully?
  • Ascertain the presence of preaponeurotic or septal fat ptosis. Is fullness present throughout the upper eyelid or proximally? Is excess fat present in the medial or lateral fat compartment? If so, how much?
  • The upper eyelid should occlude only 1-2 mm of the iris. Is ptosis present? Is the eye opening evenly on both sides? Is lid retraction present? If ptosis is present, are anhydrosis and meiosis present as well?

The discussion of secondary problems, although common, is complex and vast and is not included in this article. The associated procedures of corrugator supercilii excision, procerus excision, and lateral epicanthoplasty and/or epicanthopexy are considered beyond the discussion of upper eyelid problems.