In blepharoplasty and upper-mid facial surgery, planning is perhaps one of the most important steps of the procedure. Planning begins with an understanding greater than that of anatomy and surgical technique. The surgeon and patient must recognize the specific three-dimensional interrelationships of the normal anatomic structures that, when combined, make up the pattern interpreted by society to represent youth, health, and beauty. This arrangement of structure is significantly different when comparing gender as well as race. Even within one racial group or sex, there are several different combinations of “normal” structural arrangements that society recognizes as youthful. The surgeon should ascertain the distressing characteristics of the patient and determine how to best modify them to produce the most successful outcome.

Many patients inherit anatomic variations that they perceive as not being ideal. This is often overlooked during a consultation and may, in fact, have always been present. Ocular surgery in the young patient primarily involves excisional fat sculpting without skin removal from a heavy lower eyelid. The upper eyelids generally require modest skin, muscle, and fat sculpting, with preservation of the lid crease.

Conversely, blepharoplasty in the mature face often requires restoration of underlying structural integrity of the upper face, including the eyebrows and eyelids. The aging process affects the underlying structural integrity of the eyelid complex, eyebrows, cheek, and jawline, as well as actinic skin changes, fat redistribution, loss of elasticity, and static and dynamic rhytides. The surgical approach must first focus on rebuilding the foundation and then redraping the overlying structures to produce properly positioned eyebrows and eyelids. Failure to recognize and perform eyebrow ptosis surgery, lateral canthal resuspension surgery, and lower eyelid laxity surgery are the leading reasons for complications and dissatisfied patients.

In the older patient population the criterion for functional upper lid blepharoplasty is a roll of skin lying on or bending the eyelashes. Visual fields are subjective and are not reliably indicative of obstruction of vision. If the patient is to have an upper eyelid blepharoplasty, significant eyebrow ptosis must be repaired or it will only be made worse by removing tissue between the eyebrow and the eyelid margin.

Many patients who present requesting blepharoplasty to address heavy upper eyelids actually have significant eyebrow ptosis. The patient may compensate by keeping the eyebrows above the orbital rim, elevating the frontalis muscle. When skin is taken from the eyelid, however, the eyelid margin ptosis may only be slightly improved because the eyebrow falls to a new resting level. It is important to recognize eyebrow problems preoperatively and to discuss with the patient the advisability of eyebrow surgery and the nature of the limitations of surgical results imposed by eyebrow descent if the patient elects to proceed without addressing eyebrow ptosis.

Unlike upper eyelids, lower eyelid blepharoplasty is frequently cosmetic. In the older patient with marked horizontal laxity, the eyelid must be horizontally tightened or the risk of postoperative eyelid retraction and scleral show is quite high. Occasionally, lower eyelid surgery becomes functionally necessary. Diagnoses that warrant noncosmetic surgery include asthenopia, ocular irritation, epiphora, mechanical ptosis, horizontal eyelid laxity with lid margin instability, lacrimal pump dysfunction, lateral canthal dysopia with inferior displacement, and eyebrow ptosis, mechanically obstructing upper eyelid elevation.