Evaluation of the brow-vein complex

Eyebrow assessment

The assessment begins with simple observation while talking to the patient. The position of the eyebrows is noted on the mobile face and at rest. A patient with low-set eyebrows often raises them when talking, creating deep horizontal creases in the forehead. In women, the medial and lateral ends of the eyebrows should ideally be above the superior orbital rim. If the ends of the eyebrows are at or below the orbital rim, brow lift surgery should be considered. Upper eyelid surgery performed on patients with eyebrows below the orbital rim will undoubtedly move the eyebrows even lower. Of particular interest are patients with unilateral brow ptosis. These patients perceive the problem as unilateral excess upper eyelid skin and believe that more skin must be surgically removed from one eyelid than the other. This is understandable because patients with unilateral brow ptosis normally perceive this as their natural appearance in the mirror and in photographs. These patients should be explained that the problem is not with the eyelid but with the drooping eyebrow, which can be corrected with a unilateral brow lift. Patients with a unilaterally raised eyebrow, which is only visible on the mobile face, are also common. In such patients, no attempt should be made to raise the lower eyebrow, as this will only lead to facial asymmetry at rest. After observation, the position of the eyebrows in relation to the orbital rim is determined by palpation.

Rating of the century

The upper eyelid is examined. It should be remembered that the aesthetic objectives of upper eyelid surgery can be achieved by excising excess skin, removing, if necessary, some of the orbicularis oculi muscle, and resecting the pseudofatty hernia. The individual development of median and central fat is noted. The presence of a palpable lacrimal gland and lateral gland of the upper eyelid should also be noted. The position of the upper eyelid fold at the upper edge of the eyelid cartilage is determined. The skin type is especially important for upper eyelid surgery. Patients with thin skin are usually elderly individuals who require sparing resection of fat in the central area to prevent a sunken appearance after surgery. Sparing resection of the muscle will also be required. In these patients, the appearance of the eyelids should be brought to that which existed at least ten years ago. This can be demonstrated to the patient in the mirror by lifting the excess skin to the orbital rim with a spatula. Patients with very severe lateral brows may require removal of fat from under the orbicularis oculi muscle in the lateral part of the brow. This surgery can be done together with upper eyelid surgery.

Special considerations

Patients with thick skin, and especially younger patients with thick skin, never have a noticeable upper eyelid fold. Surgical creation of a reshaped eyelid requires excision of a significant amount of fat, orbicularis oculi muscle, and possibly extension of the eyelid skin excision laterally. It is very important to show these patients what they will look like after surgery, since they have never seen themselves with eyelid folds. They will often say, "I never had eyelids, even when I was young." Patients with thick, dense skin, especially in the outer third of the eyelids, may have scarring for several weeks after surgery. This should also be discussed. Also, when the incision for upper eyelid surgery must cross the lateral orbital rim and enter the facial skin (i.e., in the presence of significant lateral bags), the facial part of the skin scar will mature longer. Symmetry of the palpebral fissures is noted. The upper eyelid should cross the limbus just above the pupil, symmetrically on both sides. A 2-3 mm uncorrectable unilateral drooping of the upper eyelid is often not noticed by the patient before surgery. It is understandable that it can be overlooked among the excess skin and protruding fat. When blepharoplasty eliminates all the problems of the eyelids, the asymmetry of the palpebral fissures will become noticeable. If the surgeon fails to identify this condition and clearly demonstrate it to the patient before surgery, it will cause disagreement between the doctor and the patient after surgery. It will be the first thing that friends will notice. Any postoperative explanation, even with the demonstration of photographs, will look like an excuse. If the asymmetry of the palpebral fissure is pointed out before surgery, the patient will think of the surgeon as a careful and astute observer.

All associated skin lesions (e.g. xanthoma, syringoma, trichoepithelioma, sebaceous gland hypertrophy, skin pigmentation, varicose veins, and telangiectasias) are recorded. A discussion should be made about whether to remove these lesions at the time of surgery, at a later date, or not at all.

Preparing for surgery

The decision to perform upper eyelid surgery is based on positive results of psychological, general medical and ophthalmological examinations. It is necessary that the patient's expectations are in balance with the possibilities of the surgery. The patient should be prepared for the surgery by a detailed discussion of pre-operative recommendations, the surgical intervention itself, the usual course of the post-operative period and possible complications.

Preoperative guidelines include avoiding aspirin, vitamin E, ibuprofen, and other nonsteroidal anti-inflammatory drugs for 2 weeks. All of these drugs are known as anticoagulants. Use of any of them before surgery increases the risk of intraoperative bleeding and almost certainly results in moderate to severe postoperative bleeding. Drinking alcohol shortly before surgery may cause edema; the anticoagulant effect of daily wine consumption is harmful before surgery.

The patient should be warned against any physical activity, exercise programs, or travel that may adversely affect the immediate postoperative outcome. It is best to assume at the initial consultation that the patient is completely ignorant of these issues.

The patient must fully understand the financial arrangements so that there is no confusion prior to surgery.

The patient is photographed either in the office or by a photographer. Standard views include frontal, close frontal (eyes open, eyes up, and eyes closed), close oblique, and close side.

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