or dry eye symptoms. Any other significant findings, such as the presence of an epicanthal fold, scar form previous surgery or trauma, lid lesion, or other irregularities, should be noted.

One of the more common risks of upper lid blepharoplasty is dry eye and this can be exacerbated by lower lid function. Lower lid tone, lid margin disease, lagophthalmos, and punctal position should all be recorded. Lax lower eyelids with an ineffective blink can place the patient at increased risk for dry eye postoperatively. A basic tear secretion test can be performed using Schirmer’s strips. These tests can be affected by environmental conditions in the exam room and other extraneous factors, making their results somewhat unpredictable. While they may be useful, a thorough clinical exam is essential. A slit lamp examination with the use of fluorescein drops and cobalt blue illumination is a valuable tool in determining the presence of punctate epithelial staining. Any preexisting corneal scarring should be noted. In patients with preexisting signs of dry eye and lower lid laxity, consideration for coincident lower lid tightening may be prudent to provide the patient with appropriate postoperative corneal protection.

When examining the upper eyelid, the presence of a lateral lid mass may represent lacrimal gland ptosis and could require repair during surgery. The examiner should note the brow position relative to the superior orbital rim and assess the potential for new or worsening postoperative brow ptosis. Aggressive blepharoplasty in a patient with preexisting brow ptosis, and significant compensatory forehead rhytids, is a recipe for dissatisfaction. These patients should be encouraged to have appropriate brow surgery in conjunction with upper lid blepharoplasty. If the patient declines brow surgery, a conservative blepharoplasty should be performed. The goal is to maintain the patient’s subconscious drive for frontalis contraction, minimizing the risk of postoperative brow descent. The patient must understand that this approach will not remove all of the redundant skin from their lids but is necessary to keep the brow from drooping and creating an unnatural appearance. Normal aging brow descent creates greater temporal upper lid fullness than that seen more medially. Patients with significant temporal hooding should be advised that blepharoplasty alone has limited ability to correct this condition.

Visual field testing may be necessary if the surgical procedure is to be considered a medically necessary one. Improvements in superior visual field testing between untaped and taped eyelids are a standard for this approval process. Photographs are generally taken prior to the consultation to be utilized during the patient interview. These photographs generally involve a full face, bilateral 45 and 90° profiles. Carefully taken standardized photographs are essential to the entire process. They are utilized preoperatively for

discussion, at surgery as a reference, and postoperatively to demonstrate change. As the surgeon frequently deals with postoperative concerns associated with cosmetic patients, there is no more useful tool than a good preoperative photograph.

9.6Preparation for Surgery

Appropriately marking the patient may be one of the most significant preparatory steps for a successful outcome. Many authors recommend marking the patient in a sitting position. My preference is to have the patient supine, with the surgeon sitting at the head of the bed. This allows for more accurate placement of intended surgical incisions.

Several patient instructions and techniques will help to increase the accuracy and sustainability of your marks. Prior to marking, a drop of topical anesthetic is placed into each eye. The eyelids are then cleaned with alcohol wipes (Fig. 9.7). This cleansing removes skin oils and eyelid debris, which may cause marking lines to spread. Prior to marking, the patient is instructed to gently close their eyes and to maintain closure, even if asked a question.

If existing eyelid creases are symmetric, and at the desired height, they are marked as the base of the proposed surgical excision. Frequently asymmetry in lid creases exists. A compass caliper can be very useful to create symmetric marks. The position of the surgical incision, which will create the postoperative lid crease, should be determined based upon ethnicity and patient desires, but there are some standard precepts. Using the calipers four reference points are placed to define the lower incision. Medially, a small dot is

Fig. 9.7 Alcohol wipes are used to clean skin oils in preparation for eyelid marking. This improves the accuracy of the markings and reduces surgical marker ink “bleed” along natural skin lines. Alcohol vapor may be irritating to the eye so a drop of topical ophthalmic anesthetic is first applied to the eye

Fig. 9.8 Compass calipers are useful to create symmetric cardinal points between the eyelids. This is not necessary in patients with welldefined and symmetric lid creases that are positioned at the desired height

Fig. 9.9 To ensure symmetry of the lateral extent of the lid crease incision, the calipers are used. The calipers are set between 12 and 15 mm, with one tip placed at the lateral commissure and the other directed superolateral. The calipers can be rotated based on the lateral flare desired. This technique helps to create incisions that are symmetric

made 5–7 mm above the medial commissure (Fig. 9.8). Centrally, a small dot is made 9–11 mm above the lid margin at mid-pupil. Laterally, a mark is made 8–10 mm above the lateral canthal angle. To ensure symmetry of the lateral extent of the incision, the calipers can also be used to measure the terminus of this marking. The calipers are set between 12 and 15 mm, with one tip placed at the lateral commissure and the other end directed superolateral. The calipers can be rotated up or down based on the lateral flare desired. This technique helps to create incisions that are bilaterally symmetric (Fig. 9.9). The markings are then drawn through each of these four reference points. To increase the accuracy of the

Fig. 9.10 The nondominant hand is placed on the brow, elevating the brow and stretching the eyelid skin against gentle closure by the patient. The drawing hand is placed on top of the nondominant hand which provides an excellent point of stabilization, improving incision accuracy

Fig. 9.11 Each line is dried three times. Most surgical markers leave excess ink and tend to dry slowly. This creates widening and rubberstamping of the marks

surgical marks, the surgeon sits above the patient’s head. The nondominant hand is placed on the brow and serves to elevate the brow and stretch the eyelid skin against gentle closure by the patient. The drawing hand is placed on top of the nondominant hand which provides an excellent point of stabilization (Fig. 9.10). Finally, after each line is drawn, it is dried three times. Most surgical markers leave excess ink and tend to dry slowly. This leads to widening and rubber-stamping of the marks. As each line is drawn, the assistant is instructed to dry by dabbing three times with gauze (Fig. 9.11). This technique establishes the placement of the inferior incision and will ultimately decide the postoperative lid crease position and symmetry (Fig. 9.12).

Fig. 9.12 Eyelid creases are compared for symmetry

Fig. 9.13 A Graffe fixation forceps is used to determine the amount of excess skin above the lid crease. Several measurements are made across the eyelid to insure adequate skin is left for eyelid closure. A conservative excision is favored

The forceps pinch technique is utilized at three or four locations across the upper eyelid to determine the amount of skin to be excised, and to define the position of the superior incision. This maneuver confirms an appropriate amount of skin excision without undue risk of lagophthalmos (Fig. 9.13). Preoperative photos, taken in an upright position, are used during the drawing process to help refine the markings. Excess medial skin can be addressed with a wider angle where the superior incision meets the inferior lid crease incision. Conversely, patients with less dermatochalasis medially would benefit from a narrower angle (Fig. 9.14). Although temporal hooding is best corrected with brow elevation, it may be partially remediated by a more aggressive lateral superior marking before descending to meet the inferior marking. A minimum of 1 cm of lid skin must be preserved

between the inferior most brow cilia and the superior aspect of the incision.

Patients with significant brow ptosis who decline correction should have conservative upper lid blepharoplasty. While the patient is supine, the brow rests higher than when they are sitting upright. As such, the markings should be more conservative in the supine position.

Finally, the patient is placed in a sitting position and symmetry is assessed with eyes open and closed (Fig. 9.15). Forceps are used to reconfirm that the proposed skin excision is appropriate.

9.7Anesthesia

The choice of anesthesia is driven by patient preference, patient health, financial concerns, and other simultaneous procedures performed. Local injection is always utilized for comfort (even under general anesthesia) and the hemostatic effect of the added Epinephrine. Systemic anesthesia may vary from mild to deep sedation requiring airway control with laryngeal masked airway or endotracheal intubation. For office-based blepharoplasty, oral sedation will reduce anxiety and improve comfort during the injection of local anesthetic. Monitored intravenous sedation anesthesia is best performed by appropriately trained personnel, allowing the surgeon to concentrate on the procedure. While general anesthesia is rarely necessary for an isolated blepharoplasty, it may be useful when other, more invasive procedures are also being performed.

For local anesthesia, Lidocaine (Xylocaine hydrochloride 1%) with epinephrine 1:100,000 is mixed in a 1:1 ratio with bupivacaine (Marcaine 0.5%) without epinephrine. This combination provides prolonged anesthesia with an epinephrine dilution of 1:200,000. The Lidocaine allows for a quick onset of anesthesia while the epinephrine and Marcaine help to prolong its effect.

The technique used to inject the local anesthetic is crucial to patient-comfort. This can easily be done without sedation or oral agents in appropriately chosen patients. If inappropriately performed, the patient will remember this portion of the procedure above others. Despite an excellent result, it may affect their referral of other patients. The use of 1 cc syringes with 30-gauge needles allows for a very slow infusion and accurate placement of the local anesthetic. By verbally preparing the patient for a brief sting, followed by spreading numbness, they will be more tolerant of the experience. With this technique it is not necessary to use bicarbonate with the local anesthetic. A useful technique in patients who are anxious or sensitive is to dilute 1 cc of the local anesthetic mixture noted above with 9 cc of normal saline. This one-tenth dilution is then placed into 1 cc syringes and utilized as the initial block to the eyelid. The normal saline dilution

Fig. 9.16 A superficial injection into eyelid skin will ease dissection and encourage vasoconstriction

Fig. 9.17 A 4–0 silk traction suture helps to position the eyelid for surgical incisions