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PREOPERATIVE PLANNING
PREOPERATIVE PLANNING
Blepharoplasty is an elective procedure, and is performed on patients who are healthy or only have mild systemic disease. It may be performed using different anesthesia modalities, depending on patient and surgeon preference, as well as the length of planned surgery if additional aesthetic procedures are planned. In the cooperative patient, blepharoplasty can be performed under local anesthesia without sedation in a minor procedure room. Many patients and surgeons prefer to work in a dedicated operating room with IV sedation or general anesthesia.
The timing of surgery needs to be discussed with patients who are taking anticoagulant medications. Anticoagulant and antiplatelet medications should be stopped at least 2 weeks prior to surgery and held for 1 week postoperatively.26,36 If there are comorbidities that do not allow for the safe cessation of these medications, then the patient should consult with their cardiologist or hematologist to make other arrangements, such as using a short-acting anticoagulant to bridge the perioperative period (e.g., Lovenox). If this is not possible because of serious pre-existing medical conditions, blepharoplasty, a truly elective procedure, should be potentially avoided. There are other unique situations where blepharoplasty may be unwise, such as for monocular patients, those with body dysmorphic disorder, or those who have had multiple previous elective eyelid surgeries and maintain unrealistic goals for their appearance.
Ultimately, the surgeonโs experience, the individual patient findings, and the particular expectations for surgery will dictate which approach is best for the aging eyelid.16 Surgical planning for upper lid blepharoplasty should be based on whether
there is only excess skin or also associated brow ptosis, eyelid ptosis, steatoblepharon, and lacrimal gland prolapse. If there is concomitant brow ptosis, this should be addressed with a combined brow lift. If the patient does not want brow surgery, they should be made aware that the degree of brow ptosis could worsen after isolated blepharoplasty, creating the appearance of excess upper lid skin from the descended brow. They may feel that the surgeon performed an inadequate skin excision, when the real issue is that the ptosis of the lateral brow fat pad was not addressed. These patients tend to be dissatisfied with their postoperative result unless they are duly warned preoperatively. If there is associated eyelid ptosis, referral to an ophthalmologist should be pursued. Lacrimal gland prolapse can be addressed with resuspension.
The algorithm for lower lid blepharoplasty is more complicated.16 Fat pads that have prolapsed beyond the orbital rim should be addressed surgically with either debulking or repositioning, depending on the amount of fat present and volume loss at the lidโ cheek junction. At times, there is minimal fat prolapse or excess skin, but prominent nasojugal and/or palpebromalar grooves, and volume augmentation with synthetic fillers or fat grafting alone may be sufficient.37,38 However, if there is concomitant orbital fat pad herniation that would remain after volume augmentation, lower lid blepharoplasty is recommended.
Patients with prominent globes and a negative vector are at higher risk for lower lid malposition following lower lid blepharoplasty. In this population, transconjunctival blepharoplasty is recommended with preservation of lower eyelid volume, possibly in conjunction with midfacial augmentation, and, if necessary, lateral canthal suspension.
If there is lower lid skin excess, it can be removed, either with a skin pinch subciliary approach, with laser resurfacing, or a combination of both. Ablative laser resurfacing may be used to improve lower lid rhytides in transconjunctival blepharoplasty. Because of the increased risk of pigmentary changes in more heavily pigmented skin types, ablative procedures are usually reserved for patients with Fitzpatrick skin type III or below. Skin condition may be electively optimized preoperatively with a 4- to 6-week course of topical nightly tretinoin (0.05โ0.1%) and bleaching agents until approximately 2 weeks before treatment. Laser resurfacing is usually performed with a CO2 or Er:YAG laser.39 Both traditional or fractionated laser platforms can be effective, but fractionated laser treatments result in less erythema, edema, and faster healing times.40
In the case of redundant or hypertrophic orbicularis muscle, a skin-muscle flap can be performed to resuspend the lower lid orbicularis and provide better support to the lid.41 Orbicularis thermoplasty can be performed using cautery to treat an overriding orbicularis.42 Among patients who have excess skin, herniated fat, and a prominent groove along the infraorbital rim, volume preservation transconjunctival blepharoplasty can be performed with fat repositioning. If there is still mild excess skin (<2โ3 mm),
ablative skin resurfacing can be used. If there is moderate remaining excess skin, a skin pinch excision can be performed in appropriate cases.43
Lid laxity and tone should be evaluated in all patients. Most elderly individuals will have some degree of laxity. When there is a poor snap-back test or increased lid distraction, excessive skin excision should be avoided because of an increased risk of eyelid malposition. In cases of mild to moderate lid laxity, lid tightening with lateral canthopexy should be performed, especially when skin is being removed.44 Canthopexy procedures do not shorten the lower lid. Instead, a lateral tarsal strip canthoplasty, which is a lid shortening procedure, should be reserved for severe cases of associated lid laxity and/or preoperative ectropion.45,46
Approaches to the lower lid lengthening seen in the aging face24 vary, but include effacement of the tear trough using fillers, fat transfer, release of the orbital retaining ligament, laser resurfacing, and midface lifting. Lower lid festoons, or malar mounds, can be addressed with ablative laser treatments, direct excision, skin-muscle flap blepharoplasty, midface lift, and orbitomalar ligament release.33