Lower eyelid plasties: preoperative evaluation

To minimize postoperative complications, careful and systematic preoperative evaluation of blepharoplasty candidates is necessary. Therefore, patient analysis is aimed at determining how much eyelid skin, orbicularis muscle, and orbital fat should be resected to optimize aesthetic and functional results, as well as assessing whether the visual and adnexal structures can tolerate such surgery without adverse effects.

Risk factors for developing postoperative dry eye symptoms

Given that after blepharoplasty, the protective physiological functions of blinking and closing the eyelids are temporarily impaired, preoperative examination should identify factors that may cause a greater risk of developing dry eye syndrome in the postoperative period. Excessive tearing or a feeling of sand, eye discomfort, foreign bodies, mucus production, crusting, and frequent blinking are symptoms that indicate borderline or insufficient tear production. It is necessary to exclude the possibility of an atopic cause for this.

Some systemic diseases, especially collagenoses (i.e., systemic lupus erythematosus, scleroderma, periarteritis nodosa), Sjogren's syndrome, Wegener's granulomatosis, ocular pemphigoid, and Stevens-Johnson syndrome, may affect the lubrication function of the lacrimal glands and should be identified. Infiltrative ophthalmopathy in Graves' disease may result in vertical retraction of the eyelids and inadequate corneal protection after surgery. This condition requires preoperative medical treatment and a conservative surgical approach. Also, hypothyroidism and myxedema, which may simulate eyelid bags or dermatochalasis, should be excluded. Incomplete recovery from facial nerve palsy may impede eyelid closure and predispose to dry eye syndrome.

Risk factors for the development of postoperative blindness

Postoperative blindness, the most catastrophic complication of blepharoplasty, is associated with retrobulbar hemorrhage. Therefore, factors influencing the predisposition to bleeding should be identified and corrected before surgery. Aspirin, nonsteroidal anti-inflammatory drugs, antiarthritic drugs, corticosteroids, and vitamin E should be discontinued at least 14 days before surgery because of their effect on platelet count. Over-the-counter medications should also be discontinued, as, for example, ginkgo biloba provokes increased bleeding. The same applies to St. John's wort, which has a hypertensive effect through the mechanism of inhibition of monoamine oxidase. To normalize the level of prothrombin time, warfarin derivatives should be discontinued for 48-72 hours, if it is medically possible.

Any history of easy bruising after contusions, prolonged thrombus formation time, or a family history of bleeding requires evaluation of the hemostatic profile. Hypertensive patients should have their blood pressure stabilized with medication for 2 weeks prior to surgery. In women, the risk of bleeding increases significantly during menstruation and this should be taken into account when planning surgery. Other important factors include alcohol consumption and smoking, as the former (in large quantities) can affect platelet function and the latter is associated with delayed wound healing and impaired flap viability. Finally, all patients with documented or suspected glaucoma should be evaluated preoperatively by an ophthalmologist to normalize intraocular pressure and prevent an acute attack of angle-closure glaucoma. Some facial plastic surgeons recommend that all their patients have an ophthalmological examination prior to surgery.

Eye assessment

The eye examination should begin with a general examination. The eyelids should be assessed for symmetry (noting the width and height of the palpebral fissures), the position of the lower lid margins in relation to the inferior limbus, scleral exposure, and the presence of ectropion/entropion or exophthalmos/enophthalmos. Skin scars and lesions should also be noted, as they may need to be included in the resected tissue fragment. Areas of skin discoloration or abnormal pigmentation should also be noted.

The main features of the periorbital areas should be emphasized in the discussion with patients, especially since they cannot be corrected by blepharoplasty. Fine wrinkles and "creased paper" eyelid skin cannot be corrected by blepharoplasty alone. Areas of abnormal pigmentation or discoloration (e.g., due to venous congestion) will not change if they are outside the surgical area and may even become more noticeable after surgery (due to changes in light reflection associated with the transformation of a convex surface into a concave one or with its flattening). One of the main sources of dissatisfaction after lower eyelid surgery is the presence of malar bags. The patient must understand that the supporting structures of the lower eyelid will not cope with the upward pull necessary to reduce such soft tissue protrusions, and ectropion may develop. Finally, the lateral smile lines (crow's feet) are not amenable to correction by standard blepharoplasty, despite the lateral extension of the dissection. All these points should be discussed with patients.

At a minimum, a basic visual evaluation should document visual acuity (ie, best visual correction if patients wear glasses or contact lenses), extraocular movements, visual field comparisons, corneal reflexes, and the presence of Bell phenomenon and lagophthalmos. If there is any question regarding dry eye, the patient should be tested with the Schirmer (quantitative tear production) and tear film breakdown intervals (to assess the stability of the precorneal tear film) should be determined. Patients who have abnormal results on one or both tests or who have history or anatomic factors that predispose them to dry eye complications should be carefully evaluated by an ophthalmologist preoperatively. Takese should consider sparing excision of skin and muscle (if not staged resection of the upper and lower eyelids).

Assessment of cellular pockets

Evaluation of the adnexal structures should include a description of the orbital fat pockets. A necessary component of this evaluation is palpation of the inferior orbital rim. The surgeon should recognize that a prominent rim limits the amount of orbital fat that can be removed without creating a discrepancy at the junction of the lower eyelid and anterior cheek. What appears to be adequate fat resection may, if present with a very prominent rim, create a sunken appearance to the eyes. Evaluation of the orbital fat pockets is best accomplished by directing the patient's gaze in certain directions; upward gaze highlights the medial and central pockets, whereas upward and outward gaze highlights the lateral pocket. Further confirmation of fat prominence can be obtained by gently retropulsing the globe with the eyelids closed; this will displace the associated fat pads anteriorly.

Evaluation of the supporting structures of the eyelid

Since the most common cause of lower eyelid ectropion after blepharoplasty is underestimation of lower eyelid laxity before surgery, it is important to properly assess the supporting structures of the eyelid. Two simple clinical tests are helpful in this regard. The lid pull test (snap test) is performed by gently grasping the middle portion of the lower eyelid between the thumb and index finger and pulling the eyelid outward away from the eyeball. Eyelid movement greater than 10 mm indicates abnormally weak supporting structures, requiring surgical shortening of the eyelid. The lid abduction test is used to assess eyelid tone as well as the stability of the medial and lateral canthal tendons.

By retracting the lower eyelid with the index finger downwards towards the orbital rim, the displacement of the lateral canthus and the lacrimal punctum is assessed (displacement of the lacrimal punctum more than 3 mm from the medial canthus indicates abnormal weakness of the canthal tendon and requires tendoplication). After releasing the eyelid, the nature and speed of its return to the resting position are noted. A slow return or return after repeated blinking indicates poor eyelid tone and poor eyelid support. In such situations, economical resection of the skin and muscle with shortening of the lower eyelid is justified.

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