Improving blepharoplasty results with careful observation

Baltimore-Surgical results for patients requesting a blepharoplasty can be improved if the surgeon carefully examines individuals for coexisting diagnoses, pre-existing asymmetries, brow position, and lower eyelid malposition, explained Shannath L. Merbs, MD, PhD, FACS.

It is important to be aware of coexisting diagnoses in the potential patient, so that the appropriate procedures are performed to correct the problems. Some co-existing diagnoses that need attention are ptosis and thyroid eye disease, noted Dr. Merbs, assistant professor of ophthalmology, oculoplastics, The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.

Unrecognized ptosis can be problematic if it is not addressed at the time of blepharoplasty, she said. Dr. Merbs was referred a patient who was unhappy with a four-lid cosmetic blepharoplasty because upper lid ptosis remained. In this case, the ptosis should have been treated as well, she said.

"The surgeon can address this problem by making a lower incision than normal (about 5 or 6 mm), opening the orbital septum, and tacking each skin closure bite up to the levator tendon to roll out the lid margin," she said.

In another referral case, the patient had undergone blepharoplasty with a very high incision. The patient had dermatochalasis of the pretarsal area and noted a foreign body sensation of the lid crease. The woman had undergone skin cancer surgery and when the cancerous lesion was removed, she experienced exposure. To correct the problems, Dr. Merbs fixed the lid crease by opening up the orbital septum and tacking the inferior edge of the levator tendon.

Oculoplastic surgeons should also be aware of patients who want the insurance company to pay for the blepharoplasty by trying to "create" ptosis. In one case, a patient tried to squint while talking and during the photography session to document her condition.

"Most patients cannot maintain that voluntary closure," Dr. Merbs added. "When she was talking, she did open her eyes. Surgeons need to convince these [patients] that we are on their side. She actually had dermatochalasis that qualified for insurance coverage. Be careful to watch the patient carefully during the history taking."

Patients with lower or upper eyelid retraction or atypical puffiness may have thyroid eye disease. Dr. Merbs shared several cases of undiagnosed thyroid eye disease. In one individual, there was significant left lower eyelid swelling after Mohs' surgery. Instead of operating, Dr. Merbs waited 6 months for the swelling to subside.

In another patient with no history of thyroid disease, Dr. Merbs performed a bilateral lower eyelid tarsal strip procedure. After 1 week postoperatively, the patient's upper eyelids were swollen. Dr. Merbs had not recognized the patient's thyroid eye disease.

"The reason that you want to know if they have thyroid eye disease is that you can improve the situation by getting their thyroid-stimulating hormone (TSH) levels normalized," she said.

Dr. Merbs showed a case of patient with puffy eyelids and a TSH level of 13 mIU/l. Within 8 months, the thyroid function test is in the normal range and the eyelids were no longer puffy.

"You want patients to have normalized TSH levels before surgery," she said. "You can do surgery, but patients must be told that they will heal more slowly than the average patient."

A patient with long-standing thyroid eye disease that had stabilized had ptosis repair but was displeased with prolapsed fat inferiorly. Dr. Merbs performed a transconjunctival lower lid blepharoplasty to handle the problem.

Pre-existing asymmetries

Patient complaints after blepharoplasty can stem from pre-existing asymmetries. A patient with uveitis who had undergone left upper eyelid ptosis repair was displeased with the lid fold asymmetry after the surgery. By examining the preoperative photos, Dr. Merbs noted pre-existing asymmetry that the patient attributed to the surgery.