Discussion: Functional considerations in aesthetic eyelid surgery.

1171 T his comprehensive review covers many of the important functional considerations in aesthetic eyelid surgery. It is clear, concise, and practical. I would like to add a few more pearls merely based on my substantially longer experience with surgery on this site. When obtaining patient history, in addition to what is discussed in this article, one has to also be cognizant of medications that the patient could be consuming that may cause dryness of the eyes, such as antihistamines and birth control pills. In addition, many patients are not aware that they have dry eyes, and only in-depth probing about the symptoms may unveil the presence of xeroph-thalmia. Furthermore, patients who are tearing during the normal examination or while posing for photography commonly have dry eyes, even though the patient and physician may assume otherwise. These patients cannot go without blinking even for a short period, and what is observed is reflex lacrimation. Failure to detect frontalis muscle compensation for the upper eyelid ptosis is one of the most common blunders that one has to avoid during the assessment of patients for periorbital rejuvenation. One has to use maneuvers that would prevent the frontalis muscle compensation such as asking them to close their eyes forcefully and then open them slowly just enough to view the examiner while resisting elevation of the eyebrows. This process may often have to be repeated several times before the right information is elicited. Also, if the patient is asked to smile, frontalis muscle compensation could be halted because many patients cannot smile and raise their eyebrows at the same time. 1 Another crucial preoperative step is looking for any existing asymmetry, which is extremely common. If the asymmetry is discovered and brought to the patient's attention preoperatively, the problem belongs to the patient. If it goes undetected, it becomes the surgeon's problem. Although sharing the preoperative photographs that prove preexisting asymmetry with the patient who is concerned about this flaw may reduce the patient's anger, it would not diminish the patient's disappointment related to the surgeon's preoper-ative failure to notice or acknowledge this flaw. The authors have referred to excision of a 42-to 45-mm elliptical piece of upper eyelid skin. Although this amount of excision may serve most patients properly, it does vary significantly from patient to patient. Moreover, the amount of skin that is removed during a secondary blepharoplasty is significantly less. A …