Preblepharoplasty Facial Analysis

Blepharoplasty requires meticulous attention to preoperative planning. ^[1] In-depth knowledge of orbital and periorbital anatomy and physiology is necessary. The thoughtful surgeon recognizes preoperative conditions that predispose patients to complications and unfavorable outcomes, and strives to minimize both. ^[2]

As with any cosmetic procedure, assessing the patient's motivations and expectations is important. The simplest technique for this assessment is to ask patients to 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, the surgeon should describe in detail what additional procedures (eg, correction of ptotic brows or subtle preoperative blepharoptosis) may be necessary to safely achieve the patient's goals. Furthermore, the surgeon should provide the patient with realistic expectations regarding the final outcome based on his/her own experience and abilities. ^[3]

For further reading, please see the Medscape Drugs & Diseases articles Upper Eyelid Blepharoplasty and Lower Eyelid Laxity Blepharoplasty.

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 (initially) primarily medical and 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, exophthalmos, eyelid edema, and pseudoherniated fat should be stable before surgery.

Blepharoplasty in patients with dry eyes should be approached cautiously. A simple assessment can be done by asking patients if their eyes burn or sting when the wind blows. Some authors 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 or 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, a visual history is obtained, including the use of glasses and contact lenses. Previous trauma to the eyes or periorbita is noted. The presence of cataracts, glaucoma, retinal disease, or strabismus is recorded. Subjective, superolateral cuts in the visual field should be assessed.

Patients should also be questioned about whether they think that their superior or superolateral visual fields are impaired by their upper eyelids. Subjective changes in lid position should be determined, and these should be confirmed by examining old photographs.

The most important part of the preoperative physical examination is the assessment of visual acuity, which is done separately for each eye. Vision loss postoperatively can of course be catastrophic, but this is made even worse by inadequate preoperative documentation. 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. In the absence of a formal chart, a useful rule of thumb is that the ability to read newsprint approximates 20/40 vision.

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 are 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. Other authors disagree, 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. ^{[4, 5]}

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 criteria for refusing cosmetic blepharoplasty on the basis of 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. ^[6] In addition, the patient should completely understand the inherent risks. Finally, the surgeon should remember that many patients with dry eyes may have a negative test 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.

The cornea and sclerae are evaluated by applying side lighting to assess for obvious abnormalities. The protective 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.

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.

The skin is assessed for signs of actinic change, including discoloration, laxity, and dermal or subdermal masses. Preexisting scars are noted. The amount of excess skin should be assessed using atraumatic forceps to gently pinch the skin of the upper eyelid. If a simultaneous browlift is contemplated, the skin pinch is performed 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. However, in practice this presumed pseudoherniation is often volume loss in the superonasal compartment of the orbit. Suspected loss of volume can be confirmed by examining old photographs.

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. Levator function can be simultaneously assessed. The distance from the lash line to the crease at the midpupillary line is typically 8-11 mm in women and 6-9 mm in men. If this distance is substantially greater than the reference range, disinsertion of the levator aponeurosis is suspected and ptosis repair may be necessary. Clinically, in these cases, the upper lid appears vertically elongated.

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, abnormal 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.

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. Preexisting scars again are noted. Excessive skin may be pinched while the patient looks upward and opens 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 should 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. Informing the patient of this limitation before surgery is important. In addition, volume loss in the lower lid should be assessed. Nasojugal grooves and tear trough deformities should be documented, and the presence and position of malar fat should be noted.

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. According to a study by Griffin et al, characteristics commonly seen on preoperative physical examination in patients who experience postblepharoplasty lower eyelid retraction include orbicularis weakness, anterior lamellar shortage, inferior eyelid/orbital volume deficit, negative-vector eyelid topography, and eyelid laxity. The study included 46 patients with lower eyelid retraction following primary transcutaneous blepharoplasty. ^[7]

Another measurement made prior to blepharoplasty 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 unless concomitant lateral canthoplasty is contemplated. In equivocal situations, conservative intervention is recommended.

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 then 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.

Previous and recent use of neurotoxin (ie, botulinum toxin) in the periorbital area should be noted. Its use subtly alters periorbital geometry and lid position, and this may unfavorably influence surgical planning. Similarly, any use of injectable fillers in the preceding 2 years should be noted.

The patient interested in blepharoplasty usually presents with a chief symptom 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. ^[8] Brow ptosis can contribute to dermatochalasis in many patients. If blepharoplasty is performed without correcting ptotic brows, the patient can obtain a less-than-favorable cosmetic outcome and, even worse, can have a 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 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. ^[9] 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.

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 honor the Frankfurt plane and to use the same camera equipment, lens focal length, subject-to-lens distance, lighting, and background to ensure a valid comparison between preoperative and postoperative photographs. Standardization allows for regular, periodic reviews of photographs obtained before and after blepharoplasty. In this way, the surgeon can critically analyze his/her results. Finally, the preoperative analysis should also include a review of photographs after the patient has left the office, as important elements are often discovered upon two-dimensional assessment.

Twelve views are necessary for a comprehensive set of standard preoperative photographs, as follows:

• Full face frontal (1 view)

• Full face oblique views (2 views)

• Close-up frontal eyes open (1 view)

• Close-up lateral views, eyes open (2 views)

• Close-up frontal upgaze (1 view)

• Close-up lateral views, upgaze (2 views)

• Close-up frontal eyes closed (1 view)

• Close-up lateral views, eyes closed (2 views)

A study by Wagner et al looked at virtual (ie, photographic) versus in-office preoperative facial evaluation of patients with a chief complaint of drooping eyelids. The investigators determined that, compared with in-office evaluation, the fraction of agreement for the two virtual evaluators with regard to functional upper lid blepharoplasty as a surgical plan was 83%. For one of the virtual evaluators, in comparison with in-office assessment, diagnostic reliability for brow ptosis, blepharoptosis, and dermatochalasis was considered nearly perfect, substantial, and moderate, respectively, with Cohen’s kappa values of 0.86, 0.67, and 0.57, respectively. For the second observer, diagnostic reliability was considered moderate, moderate, and substantial, respectively, with values of 0.47, 0.59, and 0.79, respectively. ^[10]