Dr Chen’s viewpoint
Cosmetic blepharoplasty is one of the most popular forms of aesthetic surgery of the face. The surgical outcome is intimately related to the interaction of the upper eyelids with the forehead and brows, as well as the lower eyelids, lateral canthi, and the midface and cheek’s topography. Therefore, in any discussion and examination of a patient concerning this form of surgery, an astute clinician should consider the entire face, and not confine attention to only the superficial upper and lower eyelid skin layers. This awareness of surrounding as well as deeper structures will ultimately yield much better surgical outcome and a happier patient.
In my initial office consultation with a new patient, I first listen to his or her complaints, and mentally classify these into relative orders (or wish list) of which include those that can be improved upon, versus transient improvement or no improvement at all. I then assess from the patient’s personality and temperament the degree of enthusiasm or tolerance he or she possesses towards surgery. Ultimately, the surgeon and the patient need to mutually agree on what is comfortable, beneficial, and worthwhile for the patient to undertake. This may include time commitment as to postoperative healing course, financial matters, as well as overall general medical conditions that may have a bearing on the type of surgery and anesthesia recommended.
I always try to encourage patients to speak their mind, even if they may be embarrassed, and I try to facilitate this in an environment free of stress. Very often, patients may be overly self-conscious about an issue that matters very little to anyone they interact with, or the surgeon may need to point out an extreme condition that requires correction before the aesthetic outcome can be achieved, such as involutional ptosis in conjunction with upper eyelid hooding. It is important to customize individual aspects of your particular technique for that patient. For example, I have not performed two exactly identical procedures among any of my patients who have come to me to have Asian blepharoplasty.
After an adequate prioritization of goals with the patient, I then explain what the procedure involves, before, during, and after the surgery, and what is expected of the patient. This includes the mandatory preoperative cessation of aspirin products, non-steroidal anti-inflammatory drugs, as well as anticoagulants like coumadin and heparin.
The patients need to be quizzed as to whether they are taking any herbal formulas, ginseng compounds, or herbal teas, which frequently may contain therapeutics with anticoagulative properties (‘circulatory-promoting, blood-flow-promoting’ ingredients in traditional Chinese medicine).
The patient is given a detailed written list of preoperative and postoperative instructions with regard to bed rest during the first day, use of ice compresses as well as antibiotic ointments, what to expect, and instructions to call me should there be any unexpected outcome or medical emergency. The office staff are trained to make a follow-up telephone call to the patient the day after surgery, both to verify that the patient is stable and to confirm a return date for suture removal.
In the patient chart, I record particular aspects of his or her facial structure (ptosis, ectropion, entropion, lateral canthal dehiscence, thinning of levator and aponeurosis, forehead brow overaction, prominent sulcus) ( Fig. 1.1 ), what was mentioned to the patient (for example, one upper lid margin is half a millimeter lower than the other, one eye is more sunken and shows a more prominent sulcus), the patient’s response and preferences (high crease, low crease, shape of crease line selected), as well as skin texture and pre-existent thinning of lower lid skin and telangiectatic blood vessels observed, plus what I tell patients as to whether their stated preferences could be achieved ( Fig. 1.2 ). If a patient has thick dry skin, or oily complexion, superficial furuncles, or rosacea, these are all noted on my plan of management for this patient ( Fig. 1.3 ).
