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 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, 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 (MRD|) and lower lid position with regard to shape, retraction, canthal position and lower eyelid laxity should be determined. 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 support. 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.

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.

Figure 4-2 This patient presented several years after having undergone upper and lower blepharoplasty and facelift elsewhere. She noted significant facial asymmetry, especially in photographs, but was not aware of the cause. The evaluation detected brow asymmetry that was in part due to her upper eyelid ptosis, left greater than right with a compensatory elevation of her left eyebrow.

    Although I have not found absolute brow position to be a qualifier for the suggestion of browplasty, this observation as well as the amount of brow laxity can often be helpful in determining whether further brow descent will be likely after upper blepharoplasty alone. The brow shape and contour should also be considered. An assessment of relative globe prominence should be made, especially in lieu of lid position anomalies or asymmetries. Globe prominence is not always related to orbital pathology (such as thyroid exophthalmos or other orbital processes including lesions/tumors and old fractures) and may be due to a host of situations including (but not limited to), maxillary hypoplasia (Fig. 4-9), axial myopia (Fig. 4-10), or prior surgery (Fig. 4-11). Formal measurements including Hertel exophthalmometry are usually not required, but may be used for confirmation of the general assessment. The globe prominence will significantly impact both the selected surgical procedures and the modification of ancillary steps (including

Figure 4-3 (Left) This 35-year-old female presented for periorbital rejuvenation. She was aware of a significant difference and asymmetry in the appearance of her eyes. She strongly preferred the appearance of her right ('larger') eye. The evaluation detected a significant difference in the horizontal and vertical palpebral apertures and increased orbicularis oculi muscle tone of the left lower eyelid. (Right) After lower blepharoplasty, including orbicularis muscle trimming of the left lower eyelid and differential canthal refixation.

Figure 4-4 This patient presented for upper blepharoplasty. She had undergone lower blepharoplasty several years prior and always noticed a difference in her 'eye size.' The higher lid fold on her left side was in part due to a mild relative left upper eyelid ptosis and compensatory elevation of the left eyebrow. If the patient is not interested in upper eyelid ptosis repair, an upper blepharoplasty must be performed differentially to improve the symmetry of the upper eyelid folds.

Figure 4-5 (Left) This patient presented for periorbital rejuvenation and felt that a surgical procedure might improve her situation. She was unhappy with the periorbital lines and felt she had 'small eyes.' The evaluation revealed mostly lateral canthal and lower eyelid dynamic lines with hyperkinetic lower eyelid orbicularis oculi. (Right) After Botox treatments to the lateral canthus and lower eyelids. It was explained to her that her situation was not well suited for surgery.

Figure 4-6 (Left) This patient presented for upper periorbital rejuvenation. She had consulted with many surgeons who felt that she would need a brow lift that she was not interested in having. (Right) After volume enhancing upper blepharoplasty without a brow lift.

Figure 4-7 (Left) Patient in her early 20s. Note the position of the eyebrow and upper eyelid fold in youth. Also note the smooth convex contours of her lower eyelids and mild lateral canthal dystopia left greater than right. (Right) Same patient in her 60s. Note the deflationary changes of the upper eyelids and brow and the convexity of the cephalad components of the lower eyelid that resides above the deflationary changes at the lower eyelid/cheek junction. Surgical remedies should consider the appearance of youth.

Figure 4-8 Lower eyelid and canthal surgery must be titrated and is dependent on several factors including the anterior projection of the globe relative to the lower orbital rim/maxillary component (left), the distance of the lateral commissure to the lateral orbital rim (top right), and the vertical displacement of the lateral commissure (bottom right).

Figure 4-9 (Left) This young male presented for correction of lower eyelid bags. The evaluation was significant for lower eyelid bags contributed to by maxillary hypoplasia. (Right) After lower blepharoplasty with lateral retinacular suspension, canthoplasty was performed in a way that protected against lower eyelid malposition while maintaining normal lower eyelid shape.

Figure 4-10 (Left) This patient presented for upper and lower blepharoplasty. Note the anterior globe projection that in his situation was due to high axial myopia. (Right) After upper and lower blepharoplasty with lateral retinacular and orbicularis muscle suspension.

Figure 4-11 (Left) This patient presented with unhappiness with the appearance of her eyelids after undergoing upper and lower blepharoplasty/cheek-lift elsewhere without canthopexy/plasty. (Right) After lower eyelid reconstructive surgery that included transconjunctival lower eyelid retractor release, placement of acellular dermal matrix grafts to the lower eyelids and lateral retinacular suspension canthoplasty.