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Blepharoplasty plays a dual role in eye care. Cosmetic blepharoplasty offers facial rejuvenation to those seeking a more youthfully contoured appearance. Functional blepharoplasty can offer visual improvement when significant dermatochalasis is present, and in such cases it is often considered medically necessary by insurers.
Understanding how to effectively screen and take preoperative measurements is essential in proper integrated care for patients who are potential candidates for blepharoplasty. In our multiphysician, multispecialty practice, communication among eye care providers helps to ensure that we provide the best possible care for these patients.
Dermatochalasis is a progressive bilateral condition that becomes most prevalent after the fourth decade of life. It occurs when a loss of elasticity in connective tissue leads to the redundancy and drooping of upper or lower eyelid skin. Hooding is a term used to describe the overhang of excess lid skin across the upper eyelashes, affecting the superotemporal field of view. Patients with this condition may complain of late day brow fatigue (because they are using the frontalis muscle to compensate for the overhang), a noticeable effect on vision, or irritation due to skin folds.
SCREENING AND EVALUATION
Preoperative evaluation for blepharoplasty includes taking a thorough history, conducting a detailed exam, and making preoperative measurements. The patient’s history of chronic diseases, trauma, skin conditions, medications, and allergic reactions should be considered prior to surgery. Diabetes, cardiac disease, bleeding diathesis, and keloid formation are of particular importance. Patients undergoing blepharoplasty may be advised to discontinue use of aspirin, anticoagulants, nonsteroidal antiinflammatory drugs, and vitamin E 2 weeks before surgery, although this is not always required.
Ophthalmic examination should include screening for dry eye, glaucoma, and thyroid eye disease, any of which can be potentially complicating when the surgical plan is considered. Exophthalmometry can be used to screen for prominent or deep-set eyes. Assessment of the periorbital soft tissue should include evaluation of prolapsing orbital fat pads for upper and lower lids. Malar anatomy should also be examined for periorbital hollows when lower lid blepharoplasty is being considered.
Identifying the patient’s goals and expected results is an important factor in achieving ideal outcomes. Probing questions can help to identify patients with unrealistic expectations, and realistic outcomes should be discussed with all patients during the initial ophthalmologic exam.
Brow and lid ptosis should also be considered when maximal improvement in function is desired. Brow ptosis can be evaluated by observing the location of the eyebrow in relation to the superior orbital rim. Lid ptosis can be evaluated using three measurements: interpalpebral fissure (IPF), margin reflex distance (MRD-1), and maximal levator function. IPF is the distance between the lower and upper lids in primary gaze. MRD-1 is the distance between the center of the pupil and the central upper lid margin. These two measurements should be compared between eyes to look for asymmetry in order to quantify the ptosis. Maximal levator function is the greatest excursion the upper eyelid margin makes from maximal downgaze to maximal upgaze. This measurement helps to ensure that the ptosis is not due to underaction of the levator muscle, but rather a dehiscence of the levator aponeurosis. In order to confirm this, the examiner must confirm that this measurement is equally asymmetric as the patient’s MRD-1 and IPF. Ptosis does not preclude blepharoplasty; however, if ptosis is present, the procedure may be combined with a lid ptosis correction (Figure 1).
Old photographs are helpful for evaluation of dermatochalasis and planning for the natural location of the lid crease. Setting the crease higher than it is in younger photos may cause an unnatural appearance. The normal eyelid crease is situated above the ciliary margin 7 to 8 mm in men and 8 to 9 mm in women of Caucasian heritage, lower in Asians. The surgeon should determine the maximal skin excision to ensure that postoperatively there is a distance of at least 20 mm from brow to lid margin to allow for full lid closure.
Visual field testing is crucial to demonstrate functional upper lid blepharoplasty, either by kinetic perimetry or static automated upper field perimetry. In either case, the test should be performed twice, once with the eyelids in the relaxed position, and then with the dermatochalasis taped up to lift it off the eyelid. This will imitate the result of surgery and demonstrate the expected improvement in visual field. This documentation is often the basis needed for insurance reimbursement. Preoperative photographs demonstrating primary gaze and lateral views are also used to justify reimbursement.
SURGERY and postoperative care
The surgical procedure is easier than most patients anticipate. Surgery may be performed either in an in-office procedure suite or an ambulatory surgery center. Anesthesia can be via local injection alone or injection combined with sedation (Figure 2).
In an upper lid blepharoplasty, the surgeon excises a crescent of skin and the underlying orbicularis muscle, either with or without opening of the orbital septum to remove prolapsing preaponeurotic fat pads. If the septum is opened, the lid crease may be defined and reinforced by suturing the levator aponeurosis to the back side of the skin incision.
Lower lid blepharoplasty can be performed either through an external incision in the skin just below the lash line, if dermatochalasis excision is desired, or through a posterior approach incision in the conjunctiva, if excision of prolapsing fat pads is the goal.
Patients should be given clear instructions regarding the postoperative period. Patients should be advised to expect significant swelling and possibly bruising. For the first 2 days, patients should use ice packs for 15 minutes every hour to reduce edema and prevent ecchymosis. Topical antibiotic ointment should be applied twice daily until sutures are removed.
Pain management is normally accomplished with extra strength acetaminophen, two 500-mg tabs, up to three times per day. If a fever of greater than 101.5°F persists and is not relieved by acetaminophen following surgery, the patient should contact the office, as this may be a sign of secondary infection. Erythema and swelling, however, are often simply the normal inflammatory reactions to surgery—or occasionally an allergic reaction to the antibiotic ointment—rather than an infectious process. If nonabsorbable sutures are used, they can be removed after 1 to 2 weeks.
There is more to consider when referring a patient for blepharoplasty than most eye care practitioners assume. The importance of patient selection, proper screening, lid measurements, and thorough examination cannot be overstressed. Good postoperative care is a critical factor in optimizing outcomes. Whether for cosmetic or functional blepharoplasty, a detailed approach will help to ensure a satisfied patient. To see the procedure, visit eyetubeod.com/video/ocropotid. n
• Naik M, Hanovar S, Das S, et al. Blepharoplasty: an overview. J Cutan Aesthet Surg. 2009;2(1):6-11.
• Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast Surg Int. 2012;2012:252368.
• Kanski J. Clinical Ophthalmology, 5th ed. Oxford, England: Butterworth Heinemann; 32-39.
• Cahill K, Bradley E, Meyer D, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery. Ophthalmology. 2011;118(12):2510-2517.
Thomas J. Joly, MD, PhD
• Ophthalmic Plastic Surgery, Virginia Eye Consultants, Norfolk, Virginia
Christopher J. Kuc, OD
• Virginia Eye Consultants, Norfolk, Virginia
Walter O. Whitley, OD, MBA, FAAO
• Director of Optometric Services, Virginia Eye Consultants, Norfolk, Virginia
• ( 757) 961-2944; firstname.lastname@example.org