Basics of upper eyelid surgery (blepharoplasty)

Successful upper eyelid surgery begins with the surgeon's artistic understanding of the relationships of the upper eyelids, eyebrows, forehead, and bony orbital boundaries, as well as a general understanding of the concept of the beautiful American face. The latter can be seen on the covers of many magazines. Today's beautiful faces are defined by the modeling agencies that select them, the photographers that shoot them, the advertising agents that hire them, and the product buyers that recommend them. Beautiful eyelids are a very static concept. Although they are influenced by fashion trends, they are not fast-changing fashions.

Today's look is the result of a process that has been slowly evolving over the past 30 years. Today's look for the female brow and eyelid includes a relatively full brow located at the orbital rim, centrally at or slightly above the orbital rim, and extending laterally above the orbital rim. The upper eyelid crease is usually less than 10 mm above the lid margin. The furrow beneath the orbital rim does not correspond to the bony rim. The lateral aspect of the eyelid does not have a hood or overhang of skin from the lateral orbital rim. The overall appearance of the eyelids is one of the hallmarks of healthy, positive youth. There are no high, thin, arched eyebrows located entirely above the bony rim of the orbit; no high, pronounced eyelid folds; and no deeply sculpted eyelid furrows. The elongated, refined, arrogant look became de rigueur in the late 1980s and remains so at the beginning of this century. New York mannequin makers have reworked the standard image of the beautiful American woman to give her a more solid, healthy, and assertive appearance. Individual faces and individual tastes allow for some latitude. For example, a young face with particularly thick, ruddy skin, relatively low eyebrows, and a weak cervicomental complex often looks much better after the brow-brow complex is raised to a relatively high level. Evaluation of potential patients for blepharoplasty includes an assessment of motivation, history taking, examination of the brow-eyelid complex, discussion of the proposed surgery, pre- and postoperative period, possible complications, and photographic documentation.

Motivations

The ideal candidate for upper eyelid surgery has a relatively long-standing desire to reverse the progressive deterioration of the eyelids. The patient is in a work or social situation that requires an attractive face and is realistic about the possible outcome. There should be no expectation that the environment will change as a result of the surgery (e.g., rekindling a broken romance or getting a hard-to-get job). The patients' questions, answers, intentions, clothing, and manner should appear correct and "correct" to the plastic surgeon interviewing them. Interestingly, almost all patients who come for blepharoplasty are usually good candidates. The psychological and motivational problems that arise in patients seeking rhinoplasty and facelifts are much less common in blepharoplasty candidates.

Medical history

General medical problems that contraindicate elective surgery are usually contraindications to blepharoplasty. Particular attention should be paid to any condition that could be aggravated by the use of a local anesthetic with epinephrine. Many of the newer psychotropic drugs interact with sympathomimetic amines and should be discontinued before surgery. Homeopathic remedies have become common components of many American daily dietary supplements. St. John's wort, yohimbe, and licorice root may inhibit monoamine oxidase. Ginkgo, used for short-term memory loss, is a strong anticoagulant. It is best for patients to report all medications, including those used in alternative medicine.

Any condition that causes fluid retention, including myxedema due to hypothyroidism, should be carefully considered prior to surgery. Allergic dermatitis, especially on the face and eyelids, should be treated prior to blepharoplasty to prevent poor scarring and delayed wound healing.

An ophthalmologic history is very important. Use of glasses, contact lenses, or ophthalmic medications should be recorded. Any sign of dry eye syndrome (e.g., burning, stinging, use of artificial tears, waking up at night with a burning pain in the eye, or sensitivity to windy weather) requires a full examination. Personally, I do not perform upper blepharoplasty on patients with any severity of dry eye syndrome. Even minimal upper blepharoplasty can lead to failure of the upper lid to close, exposing corneal tissue and worsening dry eye syndrome with potentially serious complications. In the presence of dry eye syndrome, one can perform a reasonable lower blepharoplasty and worry much less about serious consequences. The development or worsening of dry eye syndrome in a patient after upper blepharoplasty creates one of the constant problems in facial plastic surgery. It completely outweighs even a magnificent, from an aesthetic point of view, surgical result.

Visual acuity should always be asked. Near vision (reading) testing can easily be included in a questionnaire that all patients are asked to complete prior to the consultation.

A history of previous upper eyelid surgery, even many years previously, is important. In these patients, lagophthalmos is always a possibility, and a sparing revision surgery is strongly recommended. In such cases, there may be considerable apparent excess upper eyelid skin. However, when the eyes are closed, the amount of excess upper eyelid skin that can be removed without causing lagophthalmos is usually minimal.

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