Evaluation begins with a simple observation when talking with the patient. The position of the eyebrows on the moving face and at rest is noted. A patient with low-lying eyebrows often raises them during conversation, creating deep horizontal folds on the forehead. In women, the medial and lateral ends of the eyebrows should ideally be higher than the upper edge of the orbit. If the ends of the eyebrows are on the edge of the eye socket or below it, you should suggest an eyebrow lift operation. The plasticity of the upper eyelids, performed in patients whose eyebrows are located below the edge of the orbit, will undoubtedly shift the eyebrows even lower. Particularly interesting are the patients with the lowering of one eyebrow. These patients perceive the problem as a one-sided excess of upper eyelid skin and believe that it is necessary to surgically remove more skin from one century than from another. This can be understood, because patients with one-sided lowering of the eyebrows under normal conditions perceive this as their natural appearance in the mirror and in photographs. These patients need to be explained that the problem is not in the eyelid, but in the lowered eyebrow that can be corrected with the help of a one-sided eyebrow lift. Patients with a one-sided eyebrow, which is manifested only on a mobile face, are also often found. Such patients should not attempt to raise the lowered eyebrow, as this will only result in asymmetry of the person at rest. After observation, the position of the eyebrows relative to the edge of the orbit is determined by palpation.
The upper eyelid is examined. It should be remembered that the aesthetic tasks of the upper eyelid plasty can be solved by excising excess skin, removing, as necessary, some part of the circular eye muscle and resection of a false fatty hernia. Individual development of middle and central fat is noted. It should also be noted the presence of palpable lacrimal gland and lateral gland of the upper eyelid. The position of the fold of the upper eyelid at the upper edge of the cartilage of the eyelid is determined. For the plastic of the upper eyelid, the type of skin is especially important. Patients with thin skin are usually elderly persons, requiring economical resection of fat in the central zone to prevent a sunken appearance after surgery. It will also require economical muscle resection. In these patients, the appearance of the eyelids should be reduced to the one that existed at least ten years ago. This can be demonstrated to the patient in the mirror, lifting the excess skin to the edge of the orbit with a spatula. Patients with very heavy lateral bumps may need to remove fat from under the circular eye muscle in the lateral part of the eyebrow. This operation can be done together with the plastic of the upper eyelid.
In patients with dense skin and especially in younger patients with thick skin, the folds of the upper eyelid are never noticeable. Surgical creation of the altered age requires the excision of a significant amount of fat, circular muscle of the eye and, possibly, prolongation of the excision of the skin of the eyelid in the lateral direction. It is very important to show these patients how they will look after the surgery, since they have never seen themselves with eyelid folds. They often say: "I never had a century, even in my youth." Patients with thick, dense skin, especially in the outer third of the eyelids, may have scarring during several weeks after the operation. This must also be discussed. Also, when the incision for the plasty of the upper eyelid should cross the lateral edge of the orbit and exit to the skin of the face (that is, if there are significant sidebags), the face of the cutaneous rumen will ripen longer. Symmetry of the eye slits is noted. The upper eyelid should cross the limb immediately above the pupil, symmetrically on both sides. A 2-3 mm uncorrected unilateral omission of the upper eyelid is often not noticed by the patient prior to surgery. It is clear that this can be seen among the excess skin and bulging fat. When blepharoplasty eliminates all the problems of the eyelids, the asymmetry of the eye slits will become noticeable. If the surgeon can not determine this condition and clearly show it to the patient before the operation, it will cause a disagreement between the doctor and the patient after the operation. This will be the first thing that friends will notice. Any post-operative explanation, even with a demonstration of photographs, will look like an excuse. If the asymmetry of the eye gap is indicated before surgery, the patient will think of the surgeon as a neat and perceptive observer.
All concomitant skin lesions are recorded (for example, xanthoma, syringoma, trichoepithelioma, sebaceous gland hypertrophy, skin pigmentation, enlarged veins and telangiectasia). The question of what to do with these lesions should be discussed: to delete them during the operation, later, or not to delete at all.
Preparing for an operation
The decision to perform the plastic surgery of the upper eyelids is based on the positive results of psychological, general medical and ophthalmological research. It is necessary that the patient's expectations are in balance with the possibilities of surgery. The patient should be prepared for the operation by a detailed discussion of pre-operative recommendations, the surgical intervention, the usual course of the postoperative period and possible complications.
Preoperative recommendations contain the exclusion of aspirin, vitamin E, ibuprofen and other non-steroidal anti-inflammatory drugs for 2 weeks. All these drugs are known as anticoagulants. The use of any of them before surgery increases the risk of intraoperative bleeding and, almost certainly, leads to moderate or severe postoperative hemorrhage. Taking alcohol shortly before surgery can lead to swelling; anticoagulant effect of daily wine consumption is harmful before the operation.
The patient should be cautioned against any physical activity, training programs and travel that may adversely affect the immediate postoperative outcome. It is best to assume at the initial consultation that the patient is completely ignorant of these issues.
The patient must fully understand the financial arrangements, so that this does not cause confusion before the operation.
The patient is photographed either in the office or by the photographer. Standard species include full face, proximal frontal (eyes open, eyes up and eyes closed), approximate oblique and approximate lateral.
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