Answer:
Any deficiency in examination or in careful preoperative planning fosters suboptimal or even dismal surgical results, including dropped brows with exaggerated frown, increased scleral show, altered aperture contour, persisting fat throughout or in isolated locations, hollowed-out areas from excessive removal, and lack of control of brow position. In addition to fat and skin quantification, planning should include brow elevation, frown ablation, ptosis repair, alteration in the lateral and/or medial canthus, modification of orbital bony encirclement, suborbital malar enhancement, and consideration of dynamic changes and relationship alteration as a result of excision or repositioning of tissues. When a patient is positioned supine in the operating room, relationships change, making it imperative to lay out the precise surgical assignment while still vertical. Preoperative examination and planning, done in the vertical position, is the key to an accurate result.
It is essential that the examination and planning take place with the patient in the vertical position, under good lighting, with complete facial relaxation. It should include a visual acuity test, a Schirmer’s test, and a fundoscopic examination. These three tests, together with an accurate eye history, are essential. Visual field determination to document interference with vision from the lid and brow provides additional meaningful information.
To examine the upper orbit:
1. Establish eye level contact with the patient, whose head is in a neutral and erect position.
2. Have the patient fully relax the face and brow. Examine the brows for symmetry and the lids for ptosis, and look for lid hollowing.
3. If the brow tends to overhang, elevate it manually to an aesthetically desirable level and once again inspect the eyes. Does elevating the brows expose undesirably hollow lids, upper lid retraction, or tiny apertures? With the brow manually elevated, measure the skin between the lashes and the lower margin of the eyebrow with the eyes closed. Record it. This step becomes immensely important with a history of a previous upper blepharoplasty. Less than 30 mm of vertical lid length signals altered function when the brow is in normal position. Excessive skin removal effectively prevents deep crisp lid invagination.
4. While still maintaining manual brow elevation to an optimal level, determine whether the eyes close completely. If they fail to do so, brow lifting must be limited, and forehead tightening should be mostly in the lateral direction.
5. With the eyes closed, elevate the lids and carefully inspect for Bell’s phenomenon. A patient whose globe fails to rotate cephalad with the eyes closed (absent Bell’s phenomenon) is at increased risk for postoperative cornea exposure after periorbital aesthetic repair, especially in the first few weeks after surgery.
6. Diagnose compensated brow ptosis. Have the patient close the eyes and relax the forehead completely. Determine the amount of accentuation of the corrugator frown with eyes closed and brow relaxed. This is what will happen to the corrugator frown with frontalis muscle relaxation after blepharoplasty without brow tightening and corrugator excision. Next have the patient open the eyes, and measure the extent of automatic elevation of the central brow. That amount of elevation is the amount of compensated brow ptosis.
7. Have the patient close the eyes once more and totally relax the forehead. Press both thumbs inward against the brow to obstruct elevation of the brows by the frontalis muscle. Ask the patient to open the eyes. This is the resting brow posture and is the level to which the brow will drop if blepharoplasty is performed without elevating and fixing the brow into a higher position. Then, with the eyes open and the frontalis at rest, note the interbrow frown caused by the corrugator muscle. If the brow remains in satisfactory position with frontalis muscle relaxation and there is no compensated brow ptosis, the procedure of choice may be a simple upper lid blepharoplasty. If there is more than 1 or 2 mm of compensated ptosis, one may expect postoperative drop of the brow, which will render the countenance less bright and less attractive—except in young patients with East Asian type lids, whose brow is usually high. Brow elevation can convert many “baggy lids” to clean and aesthetically pleasing ones without any eyelid surgery. With the brow manually secured in the most desirable position believed to be surgically obtainable on a long-term basis, the eyes are opened and the lid tissue assessed.
8. The surgeon now decides whether the upper lid procedure will be a simple excision of tissues (which is feasible if there is no brow ptosis) or a lid invagination procedure. If the procedure is a simple excision, the surgeon marks the desired location of the caudal lid overhang at various points along the lid.
In a similar fashion, when a lid invagination procedure is planned, a contoured wire paper clip is used to invaginate the skin to the upper margin of the tarsus (or to a lower level if a more caudal tarsal insertion is elected—with a smaller visualized pretarsal segment). Usually in persons of European extraction, this point is 10 mm above the lash line, and the amount of undesirable overhang noted. An accurate measurement of this sort may require an assistant to invaginate the contralateral eyelid. By so clearing the obstructing overhang bilaterally, one can coax the frontalis muscle into relaxation and gain a realistic appreciation of postoperative brow drop.
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To examine the lower orbit:
1. With the patient seated directly before you, assess lower lid tone. Pull downward on the lower lid using gentle digital pressure. Allow the lid to restore itself to its resting position. The normal lower lid will “snap” back. As tone decreases, the lid’s return slows. If severe, it returns only after the patient blinks.
2. Assess lid posture, the amount of scleral show, the medial-to-lateral tilt of the eye, and the presence of grooves near the junction of the lower lids and cheek skin (nasojugal grooves or tear trough deformities).
3. Only after accurately assessing lid tone and posture, examine the lids for length. If lower lid tone is still lax after manually elevating the lateral canthus to its correct position, a lid shortening procedure may be required. (This is usually necessary only with gaping ectropion and in patients with severely stretched lower lids.)
4. Manually elevate the lower lid to its correct position and assess the lids for excess skin, fat, and muscle. Often, with the tone and position restored, little (if any) skin and muscle need resection. With a partial smile, there always appears to be redundant or hypertrophic muscle and excess skin. With total facial relaxation, however, the examiner may find it startling how the perceived “excess” either disappears completely or reduces tremendously. Don’t be tricked and over-resect precious lower lid skin and muscle.