The pre-operative process in blepharoplasty: medical assessment, tests and preparing the patient

The first clinical assessment

The first step in the pre-operative process is the consultation with the plastic surgeon. The purpose of that visit is to determine whether the patient is a good candidate for surgery and to define which technique is the most suitable. The assessment rests on three pillars:

• Anatomical analysis of the eyelid area.
• Review of the patient’s general health.
• Assessment of aesthetic and functional expectations.

During the physical examination the surgeon analyses the amount of skin on the eyelids, the state of the orbicularis muscle, the presence of fat pads, the elasticity of the skin, the tone of the lower eyelid and facial symmetry. He also assesses the position of the brows and the transition between eyelid and cheek, both essential factors in achieving a natural correction.

At this first consultation it is essential that the patient explains clearly their reasons for wanting surgery, their medical history and whether they have had previous operations around the eyes. That information will be key to drawing up an individual surgical plan.

Ophthalmic assessment

Eye health is a critical part of the pre-operative process for blepharoplasty. Although the purpose of surgery may be aesthetic, the structure of the eyelid is closely bound up with how the eye works. When the medical history or the examination points to eye disease, an ophthalmic assessment is requested, which may include:

• Measurement of the visual field where excess skin is obstructing it.
• Assessment of tear production and detection of dry eye.
• Review of eyelid tone and of the function of the levator muscle.
• Inspection of the sclera, conjunctiva and cornea.

The eye examination makes it possible to rule out conditions that could complicate recovery, such as severe dry eye, glaucoma or disorders of the tear film. If a condition is found that needs treating first, surgery has to be postponed until eye health is at its best.

A full medical history

An essential part of preparing for surgery is a thorough review of the patient’s medical history. The aim is to identify factors that could increase surgical risk or interfere with healing. Among the aspects that have to be examined:

• The presence of chronic conditions such as high blood pressure, diabetes or raised cholesterol.
• Clotting disorders or a history of bleeding.
• Known drug allergies.
• Previous surgery on the face or around the eyes.
• Use of anticoagulant, anti-inflammatory or immunosuppressant medication.
• Current smoking or excessive alcohol consumption.

In patients with chronic conditions it is necessary to confirm that these are well controlled. Sometimes other specialists have to be involved in order to get the patient’s health into the best possible state before the operation.

Further tests

Where the operation is carried out under sedation or general anaesthetic, pre-operative tests are requested to confirm that the patient is medically fit. These may include:

• Full blood tests, including clotting.
• An electrocardiogram to assess heart function.
• Specific tests where the patient has a relevant medical history.

Depending on the patient’s age and general condition, these may be supplemented by further tests, such as a chest X-ray or a consultation with the anaesthetist. Safety always comes first.

Preparing the patient in the days before surgery

Once the indication for surgery has been confirmed and the medical assessments completed, the patient is given clear instructions for the days before the operation. These are aimed at reducing risks and making recovery easier.

The most important recommendations include:

• Stopping anticoagulants or non-steroidal anti-inflammatory drugs at least 7 days before surgery, on medical advice.
• Avoiding vitamin E and supplements that can increase bleeding.
• Drinking no alcohol in the preceding 48 hours.
• Giving up smoking for at least four weeks before and after the operation, since it impairs the oxygen supply to the tissues and delays healing.
• Avoiding cosmetics, creams or irritant products around the eyes in the preceding week.
• Keeping to a proper sleep routine and avoiding physical stress in the days beforehand.
• Making sure you are free for the recovery period, which may call for relative rest over 7 to 10 days.

On the day before the operation, if it is to be done under sedation or general anaesthetic, fasting is required from 6 hours beforehand. If the procedure is carried out under local anaesthetic, the surgeon will give specific instructions about eating and drinking, although as a rule fasting is not needed.

Two things that have to be measured separately

The assessment beforehand is not a formality: there are two variables that behave independently of the eyelid and that, unless they are measured separately, shape the result.

The first is the brow. What the patient reads as excess eyelid skin is often in fact a brow that has descended over the years, and they are different things that are resolved in different ways. The important detail is that the brow cannot be deduced by looking at the eyelid: in a series of 125 eyes, the position of the eyelid margin bore no correlation at all to the position of the brow (r = 0.06; p > 0.05). They are two independent parameters. That is why, before deciding anything, one gesture is worth more than any sophisticated measurement: repositioning the brow with a finger and looking at what is left. If lifting it makes the eyelid look normal, the problem was higher up, and the answer may not be a blepharoplasty — or not only that. (That series was of ptosis surgery, not of blepharoplasty: what carries across is the principle that the brow goes its own way, not the figure itself.)

The second is the tear film. It weighs most heavily when deciding how far the surgery should go. In a review of 892 blepharoplasties, 26.5% of patients reported symptoms of dry eye and 26.3% had chemosis; and several of the factors that predict them are visible precisely at this preliminary consultation: scleral show, laxity of the lower eyelid, symptoms of dryness already present and hormone treatment. To these is added one that depends on the planning: operating on the upper and the lower eyelid in the same sitting.

It should be said at once that both settle on their own in the great majority of cases: they are phases of recovery, not lasting damage. Picking them up beforehand is not a way of ruling anybody out, but of adjusting the plan — sometimes splitting into two sittings what was to be done in one — and of being able to warn what the first few weeks will be like.

Individual surgical planning

Before surgery, surgeon and patient go through the surgical plan together. Points to be settled include:

• The type of blepharoplasty to be carried out: upper, lower, transconjunctival or combined.
• Any additional technique, should a canthopexy, fat transfer or laser be required.
• The type of anaesthetic: local with sedation, or general, according to the case.
• The estimated length of the operation and of the immediate recovery.
• Follow-up protocols and post-surgical visits.

The patient is also told about the possible complications, uncommon though they are, and every question is answered so that the day of surgery can be faced calmly and with confidence.

Informed consent

Signing the informed consent form is an obligatory and essential step. The document sets out the benefits, risks, alternatives and limitations of the procedure. It is not a mere legal formality but a tool for communication between doctor and patient.

Consent that has been properly understood ensures that the patient:

• Knows the realistic goals of the surgery.
• Accepts the risks inherent in the procedure.
• Understands the stages of recovery.
• Is aware that results can vary from one individual to another.

At the Instituto de Cirugía Plástica del Mediterráneo, as much time as necessary is given to this step, explaining the document in detail and answering any concern.

The pre-operative process in blepharoplasty is a decisive phase for the success of the operation. It is not limited to checking that the patient is healthy: it sets out to ensure that every anatomical, functional and emotional aspect has been assessed precisely. Only with careful planning can results be lasting, natural and safe.

If you are considering eyelid surgery, the first stage has to be a medical assessment at a specialist clinic. At the Instituto de Cirugía Plástica del Mediterráneo you will find a professional team applying rigorous clinical criteria, focused on your health, your safety and aesthetic excellence. The quality of the result begins long before the day of surgery.