Surgery requires discipline. Expectations for results are high for both patient and surgeon. Successful outcomes require not only the use of specific surgical techniques but also an understanding of the desires and aesthetics of the patient as mirrored against the potentially achievable and unachievable outcomes. For example, no surgeon, no matter how gifted, can turn an 88-year-old woman into her 28-year-old idealized self. This article will present specific techniques for patient expectation management and then pearls for the surgical techniques used in blepharoplasty.

Expectation Management

1. The preoperative evaluation is critical. An open conversation regarding the desires of the patient as compared to the “world of the possible” is critical for a successful procedure. With a mirror and Q-tip in hand, the likely outcome of a blepharoplasty, cosmetic or functional, is presented. Patients are encouraged to bring old photos and magazine images to the consultation. This serves as a platform to discuss what is probable versus impossible in outcome.

2. The patient is cautioned that more is less successful with respect to this procedure, and that a tight eyelid may lead to closure and dry-eye issues. If the patient refers to the sub-brow tissue as excessive, she should be cautioned that you cannot lift an eyebrow by lifting the eyelid and any attempt to do so will “sew the eyelid to the eyebrow” leading to a nonfunctional and nonaesthetic result.

3. If the patient appears to be unsatisfiable at the time of the consultation, the surgeon does have the ability to say no and decline the opportunity to operate on the patient. Patients that are difficult in the preoperative period do not become easier to manage after surgery when the “honeymoon of good behavior” has ended. Given the damaging power of social media used as a weapon by hostile patients, judgment by the surgeon preoperatively of the appropriateness of the patient for a procedure is critical.

4. Establish an appropriate operating room environment. Our patients not only have high expectations for the procedure, they have high expectations for the process. As such, to the extent possible, a “Four Seasons” experience should be provided to the patient. This may involve private preoperative areas, kind and caring personnel, calming music in the operating suite, warm blankets, organized postoperative instructions, and even a get-well card from the operating room team!

Surgical Procedures

1. Under intravenous sedation a 50:50 mixture of 2% Xylocaine with 1:100,000 epinephrine, 0.5% Marcaine with 1:200,000 epinephrine, NaHCO3 and hyaluronidase is injected into the lateral aspect of each upper lid with a 25 ga. 5/8-inch needle. A single injection point is used with the needle directed laterally. This lateral orientation is critical to patient safety in the event the patient moves her head suddenly. The circulating nurse may gently hold the patient’s head to remind him not to move. Once a bleb of 1 cc is injected, the local solution is wiped across the eyelid from lateral to medial. This single point injection and wipe technique, “digital diffusion,” allows for dissemination of the local solution without tissue distortion and decreases the risk of bruising by limiting the number of times the eyelid is injected.

The enemy of good
is the drive for perfection.

2. The patient is prepped and draped in sterile fashion. The Betadine is wiped from the face to provide a clean surface. The undersurface of the chin is prepped in the event the patient’s chin requires manual elevation during the course of the procedure. The head drape is secured making sure the brows are not elevated or under tension by the drape itself.

3. Attention is directed to lighting, table height and doctor position, ensuring that the illumination is bright and that the surgeon is comfortable without undue stress on her back or neck. The surgical tray is reviewed to ensure all equipment needed is available, additional local anesthetic is placed on the tray, and sutures are selected, opened and preloaded onto the needle holders. For an upper blepharoplasty a 5-0 silk suture on a P-1 and a 6-0 plain gut on a G-1 are used.

4. The patient is then marked with a fine-tip marking pen and caliper. Care is taken to note the position of the natural or desired lid fold crease. The initial marking is placed in the desired crease in the mid-pupillary line. The remainder of the lid crease incision is created by either following the natural and visible lid fold crease or marking the new crease in a gradual taper medially and laterally approximately 1 mm closer to the lid margin at each end point. The lateral aspect of the incision may extend approximately 1 mm less than the maximal lid crease height. Care is taken to provide maximal symmetry.

In a bilateral blepharoplasty, this marking is performed sequentially on the right and left eyelid. 0.5 Castroviejo forceps and Brown Adson forceps are used to delineate the skin to be excised via a pinch technique. Take care to ensure that there is no tension on the eyelid. If the eyelid does not close in the operating room, it will not close in the office. Once the amount of skin to be excised is determined, the marking pen is used to define the incision. Take care to ensure that the arc of the upper lid mark is the same height laterally and centrally. This ensures that the patient does not have residual temporal hooding after the procedure. Once the incisions have been delineated, the surgeon should stand back and compare the two incisions for symmetry. This should include both the extension and angle of the lateral incision as well as a visualization of the tissue that remains behind. The tissue remaining is more important for symmetry than the tissue removed.

5. A 5-0 silk suture on a P-1 needle is positioned in the central portion of the upper lid margin. The lid is placed on downward tension. Using a #15 Bard Parker blade the skin is incised. The cutting mode of cautery on blend and fulgurate at low levels is used to dissect the skin from the orbicularis. The orbicularis is left intact. This insures that the patient will have full blink function and not a skeletonized eyelid postoperatively. Additionally the plane between the skin and orbicularis is a bloodless plane.

6. If the patient requires diminution of the medial or central fat pad, a buttonhole incision is made through the medial preseptal orbicularis. A knuckle of orbital septum is incised. Pressure on the lid will prolapse both the medial and central preaponeurotic fat pads into the surgical field. The fat pads can be differentiated not only by location, but by the white coloration of the medial fat pad and more yellow coloration of the central fat pad. The pads are then trimmed as needed to achieve the desirable cosmetic contour.

7. The skin incisions are then closed with a running 6-0 plain gut or nylon suture. The medial end of the suture is clamped with a curved hemostat. A single, fine skin hook is placed at the lateral edge of the incision and allowed to dangle. This automatically aligns the wound edges and distributes the tension equally across the incision allowing accurate, rapid closure. The ends are tied and cut. A combination corticosteroid/antibiotic ointment is applied. Ice compresses are applied in recovery as they are applied in the operating room as attention is directed from one eyelid to the other. A video of this technique can be seen at:

Additional Considerations

1. Surgical expertise takes experience and practice. It takes a commitment to lifelong learning even when change is uncomfortable. Surgical expertise requires an open mind to change, but also a discerning intellect that keeps its own counsel regarding the viability of new ideas.

2. Blepharoplasty is a contour surgery, not a procedure designed to correct wrinkles.

3. Attempts to dramatically alter someone’s underlying configuration may lead to a surgical appearance, rather than an attractive eyelid.

4. Surgery is subtractive. It does not correct overall deflation and volume loss, which are all signs of aging.

5. Surgical overcorrection may lead to changes that are similar to those of aging—skeletonization, loss of fullness, etc.

6. The enemy of good is the drive for perfection.

7. The best possible surgical outcome results from understanding your patient’s goals and how they compare with realistic outcomes. Understanding the enduring characteristics of beauty and attractiveness and the value of restraint will guide the surgeon in the attempt to achieve optimal results.  REVIEW

Dr. Silkiss is chief of the Division of Ophthalmic Plastic Reconstructive and Orbital Surgery at the California Pacific Medical Center in San Francisco. She is an associate clinical professor of ophthalmology at the University of San Francisco. She has a private practice in San Francisco, Palo Alto and the East Bay. Contact her at 491 30th St. Ste. 103, Oakland, Calif. 94609; phone: (510) 763-0881; fax: (510) 763-0907; email:; or