Finally, a history of dry eye symptoms, use of artificial tears and other topical emollients for the eye surface, as well as the use of contact lenses should be elicited that may give you more information than can be obtained by didactic measurements.^1,² For instance, if a patient states that they have intermittent dry eye symptoms of irritation, pain, light sensitivity, and decreased vision, an elaboration of these questions may reveal that the patient infrequently uses tear supplements and by increasing their usage of the topical agents dramatically reduces and even eliminates symptoms. These patients must be approached (i.e. for surgical candidacy) with great caution and the procedures may be modified to reduce the chance of increased ocular exposure symptoms. Similarly, if the patient states that their dry eyes are ‘terrible’ but also denies the use of tear supplements, or that they are able to tolerate contact lenses for days and weeks at a time without symptoms of dryness or irritation, they can do very well after surgery with regard to the concerns of potentially worsening dry eye symptoms. To the contrary, if a patient denies a history of dry eye symptoms but after further questioning reveals a complete intolerance to the use of contact lenses (due to pain and discomfort), can’t tolerate a fan or air-conditioning (i.e. in a car or plane) blowing near them due to enhanced ocular foreign body sensation, they may pose significant risk when proceeding with any eyelid surgery. Finally, women that are nearing menopause, immediately pre-, or postmenopause, should be warned that their incidence of dry eye symptoms can be worsened even when surgery is performed very well. As this is a common age for women to have cosmetic blepharoplasty, their increased symptomatology is often blamed on the surgery. Appropriate preoperative counseling lets them know that their worsening of symptoms may be expected and fortunately, is temporary in most situations. Finally, those individuals who have had keratorefractive surgery (i.e. LASIK and related procedures), clearly exhibit a greater risk and incidence of dry eye symptomatology after surgery, and this should be discussed beforehand, so that the choice to proceed with cosmetic blepharoplasty, understanding the risks, becomes theirs.

After an accurate history followed by a discussion regarding much of the data obtained, an accurate physical examination is then performed. Any data obtained during the history or examination that suggests an instability or concern regarding the patient’s general medical condition indicates that, prior to surgery, a preoperative clearance by their primary care physician or specialist may be warranted. Often these physicians can aid in medical care that might be required after surgery, for whatever reason, and are more likely to be helpful if they had been made fully aware of the upcoming surgery and contributed in the preparation of this mutual patient. Also, if there is any concern regarding the ocular status before proceeding with surgery, it might be prudent to have the patient consult his/her personal eye care professional for guidance prior to surgery. This can be helpful if the patient develops even temporary symptomatology after surgery, whereby eye care is perceived as a shared effort that is seen in a more favorable light.

The physical examination

The first part of the physical examination begins during the history taking process. I commonly will simply observe a patient while they are speaking, and simultaneously evaluate them for animation and effects that may relate to either their complaints or possibly recommendations and treatment options. Asymmetries are commonly noted, especially with regard to the position of the eyebrow(s), as well as the size of the horizontal and vertical palpebral apertures (Fig. 4-1). At times during this discussion, even subtle facial weakness or dyskinesis can be identified which must be considered while entertaining surgical options, as well as documentation of its presence as it may only become obvious to the patient after surgery. A prelude to the patient’s personality can also at times be detected by their habits and mannerisms. Those who are shy or even untruthful will not as frequently maintain eye contact. Those who continuously question or even argue every statement or recommendation negatively, may cause trouble after surgery even if it is performed at or near perfection. Those patients who have been unhappy with all prior experiences and speak unfavorably about many or all prior treating physicians are also likely to be dissatisfied with your efforts. So the history portion of the consultation is not simply performed to obtain routine historical data, but the treating surgeon should be keenly observant of facial expression as well as personality and mannerism traits of the individual which will lead to the best possible treatment recommendations, that might include no treatment at all.

Figure 4-1 (Left) This patient presented for periorbital rejuvenation surgery. She was unhappy with the aging appearance which she described as hanging skin of the upper eyelids on her right side more than her left, and the lower eyelid dark circles. (Right) After upper and lower blepharoplasty with particular attention to her presurgical crease and fold asymmetry. A brow lift was not performed, but differential surgery was performed on her upper eyelids. Canthal surgery was also performed with her lower blepharoplasty and was carried out so as not to exaggerate her pre-existing canthal asymmetry.

General upper facial assessment

Once the general assessment and more casual observation (during the history-taking portion) of the patient’s situation has been obtained, a more detailed evaluation should follow, including more formal measurements and notations (see Chapter 3) of the eyebrow position and asymmetry. There should be careful evaluation of forehead and periorbital lines and furrows, which will often indicate chronic and habitual animation (Figs 4-2 to 4-5). I do not believe that formal or precise brow measurements will dictate whether or not to perform brow surgery (Fig. 4-6); however it will serve as a basis for discussion of the possible options. For instance, I will often request to review old photographs of the patient to determine their opinion on their brow position in the past and present, and then will discuss the reality of actual brow descent. Photographs are generally helpful for many aspects of periorbital surgery (see Chapter 2), especially in lieu of asymmetry and general aesthetic appearance and ultimately the goal for our rejuvenative efforts (Fig. 4-7). Nonetheless, useful didactic measurements including the vertical and horizontal palpebral fissures, margin to reflex distance (MRD₁) and lower lid position with regard to shape, retraction, canthal position and lower eyelid laxity should be determined (see Chapter 3). I have not found reliance on snap-back or lower eyelid distraction maneuvers particularly useful as a screening tool for the necessity (or not) for canthpexy/plasty, especially in lieu of my philosophy that most lower lid surgical procedures (except in the very young) require routine, varying degrees of canthal support⁵ (see Chapter 15). These maneuvers, however, may simply confirm the necessity for lower eyelid/canthal re-enforcement procedures, and vectors for commissure support or repositioning (Fig. 4-8). They may also serve as an illustration (to the patient) of the need for particular ancillary procedures at the surgical setting.