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COVER FOCUS
COMMUNICATION AMONG
PHYSICIANS VITAL IN
BLEPHAROPLASTY CARE
Patient selection, screening, and evaluation are important components in preparation
for surgery.
BY THOMAS J. JOLY, MD, PhD; CHRISTOPHER J. KUC, OD; AND WALTER O. WHITLEY, OD, MBA, FAAO
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
A
Figure 1. Preoperative eyelid measurements.
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
B
Figure 2. Preoperative blepharoplasty patient (A) and postoperative results (B).
64 ADVANCED OCULAR CARE | JULY/AUGUST 2015
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 aponeu-
rosis 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.
COVER FOCUS
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.
CONCLUSION
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, scan the QR code or visit
eyetubeod.com/video/ocropotid. n
Further Reading:
• 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
n [email protected]
n
Christopher J. Kuc, OD
n
n
Virginia Eye Consultants, Norfolk, Virginia
[email protected]
Walter O. Whitley, OD, MBA, FAAO
Director of Optometric Services, Virginia Eye Consultants,
Norfolk, Virginia
n (757) 961-2944; [email protected]
n
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