Upper Eyelid Blepharoplasty Workup

Updated: Feb 05, 2021
  • Author: Eric M Hink, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Diagnostic Procedures

Patients must undergo a complete medical evaluation prior to upper eyelid blepharoplasty.

  • All current medical conditions must be discussed.

  • Whether cosmetic or functional, upper lid blepharoplasty is an elective procedure, and underlying medical conditions must be evaluated and treated prior to elective surgery.

  • Patients with thyroid eye disease should exhibit 12 months of stability in their orbitopathy before elective cosmetic surgery.

  • A history of keloid scar formation or dry eyes is concerning but not a contraindication for upper lid blepharoplasty.

  • Abnormal coagulation and actively inflamed blepharitis should be addressed prior to surgery.

  • Specific questions should be asked about Graves disease, other thyroid abnormalities, autoimmune and inflammatory diseases, dry eye syndrome, chronic blepharitis, previous refractive surgery such as laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK), and other conditions that may alter the natural recovery process after blepharoplasty.

  • A history of allergic reactions is obtained in order to avoid complications from medications used before or after the procedure.

Current medications, including vitamins, herbs, nonsteroidal anti-inflammatory medications, and aspirin, need to be documented. To avoid a postoperative hemorrhage, preoperative clearance must be obtained to stop all medications that cause platelet dysfunction and tendencies for increased bleeding.

The evaluation should include a thorough ophthalmologic evaluation that includes visual acuity, ocular motility, visual field testing, and basic tear secretion testing such as the Schirmer test. The Schirmer test is performed by placing a strip of test paper over the temporal palpebral conjunctiva and measuring the wetting on the strip after 5 minutes. If the measurement is less then 10 mm (reference range is >10 mm), the patient may have difficulty producing tears, which may be a contraindication to blepharoplasty. The value of the Schirmer test in predicting postoperative dry-eye problems is controversial.

Examination of the patient should include an evaluation of specific landmarks, including palpebral fissure distance; margin reflex distance-1 (MRD1), which is the distance between the center of the pupil in primary position and the central margin of the upper eyelid; margin reflex distance-2 (MRD2), which is the distance between the center of the pupil in primary position and the central margin of the lower eyelid; margin fold distance; and eyelid crease position, as depicted in the image below. Ptosis of the upper eyelid should be suspected when the palpebral distance is less than 10 mm (reference range is 10 mm) and MRD1 is less than 4 mm (reference range is 4-4.5 mm).

Clinical photograph of the complete face used to e Clinical photograph of the complete face used to evaluate specific landmarks such as brow position, palpebral fissure, margin reflex distance-1 (MRD1), margin reflex distance-2 (MRD2), margin fold distance, and eyelid crease position.

The individual components of the periorbital region are thoroughly assessed prior to surgery.

  • The surgeon assesses the relationship of the brow position to the upper lid and makes an early decision as to whether isolated upper lid blepharoplasty is sufficient or whether brow position adjustment is necessary to achieve the desired results. The patient should be reminded that the tail of the brow may be further pulled downward following isolated upper eyelid blepharoplasty.

  • Manual elevation of the brow to the desired position allows the patient and surgeon to assess the role the brows play in the appearance of the upper eyelid. In males, the brow is positioned along the supraorbital rim. In females, the brow is elevated to a position at or up to 1 cm above the supraorbital rim. This is done with the patient in an upright position and with the patient looking in a mirror to help judge how brow position affects the upper eyelid.

  • Repositioning of the brow, the brow fat pad, and the skin between the lid crease plays a profound role in the appearance of the upper eyelid. Do not let the patient underestimate its relevance to the upper eyelid appearance.

Once brow position has been determined, the surgeon assesses the components of excess skin, skin laxity, and fat herniation in the upper lid. Upper eyelid aging changes are typically a combination of excess skin or skin laxity, causing redundancy of the tissues. Excess or herniated fat causes a protrusion or convex contour of the upper eyelid. The medial or nasal fat pad, the middle fat pad, and the lacrimal gland in the temporal upper eyelid influence the overhang of the upper lid fold. The sub-brow fat may also descend into the superior sulcus, altering the indentation between the lid fold and the brow. The position and protrusion of these tissues are amenable to surgical modification.

Photographs are taken to document the clinical findings in each patient, as depicted in the image below. Traditional views include full face and a close up of the eyes in primary, upward, and downward gaze. Additional views may include right and left oblique views and a lateral view to document the globe position relative to the inferior orbital rim.

Clinical photograph showing a male patient with ag Clinical photograph showing a male patient with aging changes that include brow ptosis, dermatochalasis, and steatoblepharon in the upper and lower lids.