CC
A 61-year-old female presents for consultation regarding excess skin on her upper and lower eyelids (dermatochalasis). She states she would like to look younger.
HPI
The patient identifies regions of excess skin over her upper and lower eyelids. She is unhappy with the “bags” under her eyes, claiming that they age her. She denies any visual disturbances, dry eyes, or any other ocular problems. She has no surgical history.
PMHX/PDHX/medications/allergies/SH/FH
The patient has a history of hypertension controlled with hydrochlorothiazide. She has no endocrinopathies (Graves’ disease may present as eyelid edema, eyelid retraction, or proptosis). She has no history of coagulopathies. She denies usage of anticoagulation medications and herbal medications (a risk factor for increased intraoperative bleeding and retrobulbar hematoma).
Examination
General. Well-developed female in no apparent distress.
Ocular. The pupils are equal reactive to light and accommodation; extraocular muscles and visual fields are within normal limits. Schirmer’s test (a measure of baseline tear production) is normal. Minimal eyebrow ptosis noted (brow ptosis needs to be differentiated from dermatochalasis). (Evaluate the distance from the upper eyelid margin to the lower edge of the eyebrow – 10 mm. Suspect eyebrow ptosis if measurement is <10 mm. If this is the case, eyebrow lift is indicated to restore eyebrow height and eliminate eyelid hooding.)
Eyelids. Evaluation of frontal and glabellar lines is performed ( Fig. 89.1 ).
Skin laxity can be measured using forceps to capture redundant tissue and evaluate excess ( Fig. 89.2 ).
The patient has no ectropion (everted eyelid), entropion (inverted eyelid), or lagophthalmos (eyelid incompetence). The patient does not have Bell’s phenomenon (also called palpebral-oculogyric reflex, a protective mechanism, defined as an upward rotation of the eyeballs when the eyelid is closed).
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Lower eyelid skin evaluation should be done with the patient in an upward gaze ( Fig. 89.3 ).
• Fig. 89.3 Lower eye eyelid laxity evaluated with the patient in upward gaze. -
Lateral canthal rhytids, or crow’s feet, should also be evaluated.
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The upper eyelid margin is within normal limits (covers 2–3 mm of the superior iris).
The upper eyelid has two fat pads with the lacrimal gland located laterally and the lower eyelid with three fat pads. (Herniated fat pads are usually medial. Gentle pressure on the globe with the eyes shut exacerbates fat herniation to identify weaknesses in the septum.)
The eyelid crease is identified 9 mm above the eyelid margin.
The vertical interpalpebral fissure distance measures 10 mm (normal, 10–12 mm).
Reduction of vertical interpalpebral height is suggestive of blepharoptosis (low-lying eyelid).
An increase in vertical interpalpebral height is suggestive of eyelid retraction.
Lower eyelid laxity: The SNAP test is abnormal, measuring 2 seconds. (The lower eyelid normally reapproximates the globe within 1 second when it is pulled inferiorly and released; Fig. 89.4 .)
Imaging
Preoperative and serial postoperative photo imaging is mandatory for cosmetic procedures. Close-up views of the eyelids in both the closed and open eyelid positions are recommended.
Labs
Routine laboratory studies are normally not indicated for cosmetic eyelid surgery. Complex medical histories may dictate specialized workups.
Assessment
A 61-year-old female desiring bilateral upper and lower eyelid blepharoplasties to address excess eyelid skin (dermatochalasis).
Treatment
A robust mastery of facial structures, specifically orbital anatomy and fascial layers, is critical to performing blepharoplasty. Fig. 89.5 illustrates some of the key anatomic landmarks.
For this patient, bilateral upper and lower eyelid blepharoplasty with resection of orbicularis oculi and resection of prolapsed fat pads is indicated to address her chief complaint of dermatochalasis. This treatment will re-create her upper eyelid shelf. It is important to keep in mind that each patient requires a presurgical workup with a tailored treatment plan to achieve optimal cosmesis.
Although blepharoplasty surgery can be performed under local anesthesia in a cooperative patient, the authors recommend general anesthesia for patient comfort and a predictable working environment.
The eyelids are marked with the patient upright before the administration of sedatives of local anesthetics ( Fig. 89.6 ).
