Ask the patient to demonstrate what he/she is unhappy with and/or would like changed either in a mirror or with photographs. It is essential to note whether these concerns are appropriate and more importantly whether the expectations with regard to surgery realistic.
Examine the whole face for asymmetry, scarring etc. before examining specific areas of the face. It is important to remember that there are certain differences in facial structure between the female and male, such as brow and upper eyelid configuration, as well as racial variations. Surgery must always be planned with these variations in mind.
Examine the eyebrow configuration, position and symmetry. The male brow has a "T" shape configuration whilst that in the female is "Y" shaped. Assess the eyebrows for ptosis and symmetry, remembering that a patient may initially complain of eyelid ptosis when in fact the underlying problem is one of brow ptosis. The correct operation in this situation is a brow lift rather than blepharoplasty since the latter will if anything further accentuate the patient's problem. Brow ptosis and excess upper eyelid skin often co-exist; surgery should correct each of these components (Figures 8.1 and 8.2).
Examine the eyelids paying particular attention to the upper lid skin crease, lid contour and position, levator function, presence or absence of lagophthalmos and Bell's phenomenon. Assess the eyelids for
symmetry, excess lid tissue, i.e. is the problem one of dermatochalasis or blepharochalasis, and fat prolapse. Specifically examine for lower lid eyelid laxity. If this is present to any significant degree and lower lid blepharoplasty is contemplated then a lower lid tightening procedure may well be necessary. The lower lid skin is assessed for excess tissue, skin wrinkles and altered skin texture. If the latter is the case then periocular laser resurfacing may provide a better result with less risk of complications than skin excision. Is the patient suffering from festoons of excess lower lid skin? If so a variation in the surgical approach from conventional blepharoplasty may be needed.
Examine the rest of the face with particular attention to any scars, wrinkles and skin folds and generalised skin texture changes. It is important to document the patient's skin colouring and type which is best assessed using Fitzpatrick's classification. (Fitzpatrick described six skin types with types 1 and 2 representing a fair skin complexion, susceptible to sunburn, types 3 and 4 dark Mediterranean/Asian type of complexion, whilst 5 and 6 are deeply pigmented Afro-Caribbean skin types.)
Detailed ophthalmic examination must be undertaken. General ophthalmic examination should include best corrected visual acuity, assessment of ocular motility and slit lamp examination, the latter paying particular attention to the cornea and any evidence of dry eye syndrome, such as punctate corneal staining, a reduced tear film or break up time or an abnormal Schirmer's tear test.
Visual fields and any further specific tests are undertaken as necessary. Pre- and post operative photography is essential.
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