Laser Blepharoplasty evaluation and surgery: Blepharoplasty is defined by medical dictionaries as “any operation for the restoration of a defect in the eyelid”.  This is a broad description that could include procedures to repair ptosis, entropion, ectropion, trichiasis or almost any other eyelid defects.  The common term for laser blepharoplasty in society refers to an operation in which a  specialized CO2 laser is used either to assist the surgery or all of the surgery to remove redundant tissues (skin, muscle and fat) from an eyelid.Much has been written over the past 25 years about blepharoplasties and more recently laser blepharoplasty; however there is very little in print to help the inexperienced laser surgeon understand that blepharoplasties are far from a science and each patient much be treated individually. A laser blepharoplasty surgeon must combine art, science, experience, common sense and the patient’s objective to obtain a great cosmetic result.   Hopefully this brief review of evaluation and technique will enhance the laser surgeon’s ability to create positive end results.   Blepharoplasty, whether traditional or laser blepharoplasty, is not eyelid surgery but orbital surgery.  This should never be misconstruded as a simple procedure.  This misconception has led to a number of unfortunate results that are difficult to correct.  Those who have failed to understand the orbital intricacies and negative effect that it can have on the life of a patient usually will have challenges beyond what they anticipated. (1)

The periorbital region is one of the most important aesthetic complexes of the face.  It is this area that genetics, aging, smoking, accumulated sun damage will show up first.  Tissue elastosis, muscle hypertrophy and genetic tendency for fat prolapse and tissue distortion leaves the face with the appearance of agitation, tiredness, grumpiness.  These projected impressions can create a negative effect for patients and those that they relate to.  The most important feature of an attractive orbital region is a high degree of symmetry. (1)

Unacceptable results after Blepharoplasty are often the inevitable consequence of poor preoperative planning.  It is important that planning take place in the vertical position under good lighting, with complete facial relaxation, and before preoperative sedation has been administered.  (2)

THE BAGGY EYELID
There are many causes of baggy eyelids and only rarely will a patient just have one  condition.  The maturing process and genetics creates a combination of causes for baggy eyelids.  Patients satisfaction depends on the surgeon correcting all components responsible for the deformity.  The more common causes of baggy eyelids include, dermatochalasis, blepharochalasis, hypertrophic orbicularis muscle which may involve upper and lower eyelids.  Protrusion of intraorbital fat giving a fat prolapse in the central and central upper eyelid areas and in three locations in the lower eyelids.  Brow ptosis causes hooding of the upper eyelids and lateral fullness of the upper eyelid. Festoons of the orbicularis oculli muscle gives loose muscle hammocks in the lower eyelids extending to the cheeks.

BLEPHAROPLASTY: PATIENT SELECTION AND EVALUATION
The proper selection of a blepharoplasty patient may be more important than the level of technical and artistic ability of the laser surgeon.  Even intelligent patients do not fully realize that it is their baggy eyelids caused by dermatochalasis and fat prolapse that is causing them to look tired and more mature than they need to. To ensure the patient is happy and satisfied with the end result, the laser blepharoplasty surgeon must be willing to spend the time that is necessary to select and evaluate patients thoroughly before the blepharoplasty procedure is undertaken. Patient selection and evaluation is not a simple task.  Several authors have addressed this issue over the past few years (4,5,6,7,).

The laser surgeon must not make assumptions what the patient means when they are trying to describe their wants and desires. Most cosmetic blepharoplasty patients present with a non specific complaint such as:

Table 2

IMPORTANT PERIORBITAL RELATIONSHIPS

During the consultation observations and measurements are included.  This is either done right at the consultation and partially recorded but must be done prior to the surgery and prior to sedation.  (See Table 3 for appropriate observations and measurements to record in patient’s records).

The most common eyelid and periorbital conditions that may be improved by blepharoplasty include dermatochalasis, blepharochalasis, and protrusion of intraorbital fat (fat prolapse). Contraindications are noted on the enclosed table.  (Table 4)

Table 4

Several conditions predispose a patient to “dry eye syndrome” after blepharoplasty.

• (e) Proptosis (protruding of the eye and eyelids - orbital tissue)
• (f) Exophthalmos
• (g) Laxity of the lower eyelid (Hypotonia)
• (h) Maxillary Hypoplasia (very flat cheek bones)
• (i) Inferior scleral show. (In the normal eye the lower eyelid just touches the inferior corneal limbus.)