EVALUATION OF UPPER BLEPHAROPLASTY OUTCOME-OBJECTIVE MEASUREMENTS AND PATIENTS` SATISFACTION

Background/Aim. Upper blepharoplasty is one of the most often performed aesthetic operations and is indicated for periorbital rejuvenation or for correction of some functional problems. Goal of this study was to evaluate outcome of this procedure and to assess patients’ satisfaction and possibilities of objective measurement of results. Methods. A two year prospective, observational study was conducted among 50 patients who had upper blepharoplasty done by same surgeon. Data were collected from medical documentation, questionnaire and objective measurements conducted via standardized digital photographs that were taken before and two months after surgery by same surgeon. Tarsal platform show (TPS) and brow fat span (BFS) were measured in three points before and two months after the surgery. Questionnaire that was conducted before surgery and two months after included general complaints considering upper eyelids (visual field narrowing, fallen eyelids, sensation of heavy eyelids, raising head backward in order to enhance vision, headache), patients assessment of eyelid asymmetry and after surgery questions for surgeon and patient concerning satisfaction with outcome. Results. This study involved 50 patients between 33 and 67 years (49.98±8.6). There is statistically significant difference in all points for TPS and BFS before and after operation. No significant asymmetries were notices between eyes neither before, nor after surgery. There is statistically significant difference in operation success between 3 age categories in TPS-P1 (chi square=13.089, df=2, p=0.001) and TPS-P2 (chi square=8.386, df=2, p=0.015) with best results achieved in older patient (>55).There is strong positive and statistically significant correlation between patients’ and surgeons’ satisfaction (r=0.704, p=0.002), and also between patients’ satisfaction and age of the patient (r=0.704, p=0.002). Conclusion. Realistic expectations, adequate information about surgery and possible complication, are essential to a satisfied patient. Objective measurements correlate with patient satisfaction and together with photographs can be useful tool in communication with patient.

This procedure has high rate of patient satisfaction, but in light of social media pressure expectations can be unrealistic and patient can be unsatisfied with result as with any other aesthetic procedure. 3 Sometimes surgeons' satisfaction with outcome does not correlate with patients' satisfaction therefore, objective measurements could be useful tool in explaining to patient what have we achieved with surgery. Also, objective measurements and standardized scales could allow comparison of different techniques or establishing criteria for exclusion of patient that could not benefit much from surgery.
Key measurements when we analyze upper eyelids are tarsal platform show (TPS) and brow fat span (BFS). Changes in those parameters can simply illustrate what we have achieved with surgery. Besides these features every patient has different orbital bone structure, sometimes prominent eyebrow ridge, sometimes fatty periorbital region prone to edema. All these factors have to be analyzed as they will influence final result and sometimes limit possibilities of surgery. Preexisting asymmetries have to be noticed and discussed with patients as they are sometimes unaware of them. Surgeon is trying to reach balanced appearance that will ultimately please the patient. Usually that's not obliterated tarsal platform, but also not unnaturally elongated, less fluffy eyelid appearance, nor hollow old looking eye.

Study protocol
This research was designed as prospective, observational study that included 50 Data were collected from medical documentation, questionnaire and objective measurement conducted via standardized digital photographs that were taken before surgery and 2 months after surgery during standard follow up procedure. All photographs were taken with patient in upright position, primary gaze, frontal and lateral view, with frontal muscle fully relaxed. All measurements were conducted with photo size calibrated to 11,5 mm cornea diameter. All photographs, computer calibrations and measurements were done by the same person. We measured tarsal platform show (TPS) and brow fat span (BFS) in three points. TPF was defined as distance between upper eyelid margin and palpebral crease and BFS as distance between upper margin of the brow to palpebral crease with the patient gazing in the primary position. TPS and BFS were measured along the vertical meridian at three points (the center of the pupil-P1, lateral corneal limbus-P2, eyelid lateral canthus-P3) before and two months after surgery ( Figure 1). Patient survey was conducted using two questionnaires: one before operation considering eyelid asymmetry, problems and symptoms that bother patient and are connected to upper eyelids; and two months after surgery, considering patients' and surgeons' satisfaction with overall outcome, improvement in symptoms, perceived difference in eyelid symmetry.
Overall result concerning patients' and surgeons' satisfaction was graded by Lickerts' scale were 0 was aesthetically poor/completely unsatisfied and 5 was aesthetically excellent/completely satisfied.

Surgical Technique
All blepharoplasties were done by single surgeon in local anesthesia as one day surgery procedure. A marking pen was used to mark planned skin resection. After that local anesthetic was infiltrated in this area and redundant skin was resected. If there was redundant orbicular muscle narrow strip of muscle was separately resected. Orbital septum was opened in order to expose both restroseptal fat pads (nasal and central), which were evaluated and trimmed with cauterization if needed. Wound edges were closed with continuous nonabsorbable suture (nylon 6.0.) that involved skin-muscle-skin in order to better define supratarsal fold. Muscle was not sutured separately from the skin. Adhesive tapes were applied and patient was advised to cool upper eyelids during first 48hours with cold pads, to protect eyes with sunglasses, clean the face with running water as usual and to use artificial tear eye drops if needed. The skin sutures were taken off after one week. After that they were advised to use silicone gel with SPF 50 for scar treatment and to avoid exposure to sun. They were scheduled for another control in two months.

Statistical Analyses
Statistical analysis was performed with the software SPSS 20.Kolmogorov-Smirnov test was used to examine whether variables follow normal distribution. Descriptive statistics was shown using mean, standard deviation, minimum and maximum values. Wilcoxon test was used to determine existence of statistically significant differences between the two dependent samples for variables that doesn't follow normal distribution. Man-Whitney Independent samples t-test was used to determine existence of statistically significant differences between the two independent groups for variables that doesn't follow normal distribution. Kruskal-Wallis test is used as non-parametric tool to discover statistically significant differences in more than 3 independent groups. Spearman correlation was used to measure the strength and direction of association between two ranked variables. All tests were performed on 0.05 significance level.
According to the results of the normality test for TPS and BFS measured before and two months after the operation all variables display deviation from normal distribution. As consequence, non-parametric test was used in the remaining analysis. Descriptive statistics of all TPS points measured before and after operation is shown in Table 1. The results of testing difference in TPS and BFS for all three points between before and after the operation is shown in Table 2. According to the results there is statistically significant difference in all points before and after the operation. Table 2 Wilcoxon test: Difference in TPS points before and after operation .000 .000 .000 .000 .000 .000 Furthermore on we assessed whether there were significant asymmetry comparing left and right eye before and after the surgery. According to the results of the normality test for all points measured before and after operation by left and right eyes, non-parametric test was used in the further analysis. Descriptive statistics of all TPS points before and after the operation by left and right eye is shown in Table 3. Results of testing statistical difference in points between left and right eyes before and after operation are given in Tables 4 and 5. According to the results there was no difference between left and right eyes both before and after the operation.  Table 5 Difference Besides objective measurements presented in Table 4 and 5 patients were also asked about their perception of upper eyelid asymmetry before and after surgery. Their answers are presented in Figure 2 Table 6. Table 6 Difference between points before and after operation by age groups  Major complains considering upper eyelids before and after surgery are presented in Figure   4 and 5.   We have calculated the absolute differences between pre and post measurement in TPS in all points. Then we calculated the mean value of these differences for each patient. With this quantity we wanted to measure the objective achievement and to compare it with subjective satisfaction of the patients.
There is positive and statistically significant correlation between patients' subjective satisfaction and objective operation results (r= 0.498, p=0.000). Similarly, there is positive and statistically significant correlation between surgeons subjective satisfaction and objective operation results (r= 0.600, p=0.000). We don't believe in wide resection of orbicular muscle and radical excision of fat pads in every patient as preservation of muscle and some amount of fat pads should give fullness to eyelid end youthful appearance. "Hollow eyes" are one of the stigmas of blepharoplasty and sigh of radical fat resection. These days with better understanding of aging process and after detailed analyzes of volume changes in aging face we are more oriented to volume preservation and restoration, than resection and forced tightening as it was done previously.

Discussion
If there is obvious redundant muscle, we resect just a small strip of muscle in order to avoid muscle fold formation. Similar practice is found in many other studies in literature. 6,7,8,9,10  On the other hand, some authors are in favor of wide muscle resection as they consider skin and muscle as a single unit. According to them redundancy in skin reflects redundancy in muscle also. 13,14,15 When arguing about aesthetic achievements that are related to muscle resection we have to keep in mind influence of muscle resection to brow position as all these components are closely connected. Widgerow AD and authors advocate that the resection of orbicular muscle is supposed to allow the frontal muscle advantage over antagonistic orbicular muscle and thus produce elevation of eyebrow. 16 This hypothesis gives new prospective to importance of muscle resection in rejuvenations of periorbital region. In this study all patients had statistically significant improvement after surgery and this improvement was verified by change in TPS and BFS (Table 1 and 2). This improvement was greatest in older population (Table 6). Aesthetically significant difference in operation success was measured for TPS-P1 (chi square= 13.089, df= 2, p=0.001) and TPS-P2 (chi square= 8.386, df=2, p=0.015) for older than 55 (Table 6). We expected to get such a result as in older population skin excess is more pronounced so change in appearance and benefit from surgery is greatest. Those patients were also most satisfied with result. Strong positive correlation between patients' satisfaction and age of the patient (r= 0.704, p=0.002) was noticed after questionnaire analyzes. Besides objective measurement and more evident change after surgery in older population these patients are traditionally more objective and realistic in expectations. They approach surgery with "real" problem, have many complains that are pronounced so they feel significant relief after correction of eyelids. For them skin excess is not just aesthetical problem, but also often impairs their everyday functioning and diminishes quality of life.
We also wanted to evaluate if we managed to correct asymmetries in eyelids with surgery. However results of testing statistical difference in all points between left and right eyes before the operation didn't show any significant difference so we couldn't expect to be able to measure improvement later on (Table 4 and 5). This correlate with results of questionnaire where 58% of patient didn't perceive eyelid asymmetry and 24% noticed insignificant asymmetry before the operation (Figure 2). Most of those who noticed asymmetry had from moderate to significant improvement after the surgery (Figure 3).
Considering preoperative complaints, most often patient complained about sensation of fallen eyelids, increased eyelid weight and narrowing of visual field (Figure 4). Those symptoms were marked as "significantly improved" or "absent" after surgery ( Figure 5). In our study, as in most studies in literature, upper blepharoplasty had high rate of patient satisfaction. 18,19 This satisfaction also correlates with surgeons' satisfaction of final outcome ( Figure 6).
As there is positive and statistically significant correlation between patients' subjective satisfaction and objective operation results (r= 0.498, p=0.000) our measurement proved to be reliable and simple tool for estimation of final result. One more interesting role of objective measurements in eyelid surgery is implementation of measurement criteria that could allow health insurance companies to limit falsification of medical necessity for upper blepharoplasty which if often seen in practice. 20 Thus it would be easy to separate patients that has clearly just aesthetic problem from those that are entitled to health insurance coverage as they have some functional disability or important visual field narrowing caused by change in upper eyelids.

Conclusion
Objective measurements (TPF and BFS), as before/after photos, can be a useful mean in approaching the patient after eyelid surgery, when we argue about achieved results. We are not seeking for standardizes single solution for periorbital rejuvenation and we do not try to reach some imaginary goal, but rather look on this as a constant journey of improving ourselves as a surgeons in order to be able to offer more and to have satisfied patient in the end.