What is the correct technique when measuring the upper eyelid before surgery? (photos)

Thanks for your question. I share your concern and feel that you could have had additional skin removed from your upper lids. A far as your question, there is no specific way or correct technique to measure how much upper lid skin to remove. there are some "ideal" measurements that you will hear about but the best way to know is to actually view the patient in the sitting position looking straight ahead. IMHO the pre-op markings need to be done way before the patient is taken into the OR. Intra-operaively I do a pinch test.A comparison is made. Since symmetry in the human being does not exist, you will often find that one eyelid has more redundant skin than the other. Therefore, the markings will vary. Pre-op markings are extremely important. There are cases where too much skin has been removed and the patient is unable to close their eyes. In your case, if you ever wanted to have your upper lids re-done, it could be done safely. Be patient and if you are still not happy then you should get a second opinion.Always seek out the opinion of a surgeon certified by the American Board of Plastic Surgery with years of experience in eyelid surgery. Remember this is your face....can't cover it up! Furthermore request to see before and after photos of previous patients by that doctor....not a clinic or surgery center. Do your homework......research and verify the doctor's credentials. Have they had problems with the Board of Medicine, disciplinary or otherwise. Any law suits? How about the center, clinic or facility? Are they accredited by a national organization or do they just have State approval. Understand that at the current time, there are three nationally recognized organizations responsible for the highest levels of patient safety, AAAASF, AAACH and JCHO. You owe it to yourself to position yourself for the best possible results but under the most stringent safety regulations, If you have kids, even more so.How about anesthesia? Will you have a medical doctor certified by the American Board of Anesthesiology or a certified nurse anesthetist (CRNA)? Understand that there is no substitute for research. Cosmetic surgery, no matter how simple it may be to the patients, are invasive procedures and as such carry certain risks and complications.In our office we use TouchMD which is a web based program in which patients have the ability to load their picture unto the program. We accomodate patinets from as far away as California. I then evaluate them and can actually draw on the picture to show a potential patient where the incisions would be located and how the procedure is to be realized. It's all done to comply with HIPPA which is the federal law that protects the patient's medical information. Look them up.Give yourself the highest percentage of a sucssesful operation. Good luck 

You're way too early in the postoperative period to make an assessment regarding skin excess.  As the swelling resolves and the skin retracts, the appearance of both fullness and excess will improve.  Remember, you have to have enough skin to allow the eyes to close in order to protect them.  As for marking, there is no absolute technique of marking the amount of skin to remove.  Each patient's anatomy is different,  so variations in the design of the skin excision are never exactly the same.  Rest assured, if indeed you desire additional skin excision and it is possible, this is an easy fix.  Taking too much skin is a far greater problem.

It looks like you can stand to have more skin removed from your upper lids.  The way I measure the skin is that I plan to remove as much skin as possible while leaving enough skin to allow you to close your eyes comfortably.  Makes sense, doesn't it?

You are still quite early in the post-op period, so some of the swelling should still resolve.  As it does, there should be less skin as it will settle back into the orbit.  If you do have some excess skin still after about 6 months, you can have some more removed.  Most surgeons will mark the patient lying down.  A lid crease is drawn from 8-10 mm above the lid margin, or the patient's lid crease can be used.  Excess skin is then determined by pinching up the eyelid skin above this with an instrument.   At least 10 mm of skin is left above the crease.    

does occur.  But to really critique it, you must be healed and your swelling gone.  This could take 2-3 months more.  Once you are healed, you should be able to review your results with your surgeon and if the asymmetry is easily appreciated, revisions can be done to help improve that.  Know what your surgeon's revision policy is as you may need to use it later.

I see a very very conservative upper eyelid skin excision in the posted photos. Allow 3 months healing and determine if additional excision is needed... 

You are still early in the recovery period and are likely still pretty swollen. Give it 4-6 months to heal.

Although at this early date there is still a lot of swelling it would appear that there is still an excess of skin.  More should be taken out and that might be done under local anesthesia.  A couple of other pertinent points - you have a mild brow ptosis and that cannot be corrected by a simple blepharoplasty, and in fact that leads to a conservative skin resection.  Ideally the patient should be upright when the skin is marked.  I suggest that you continue elevation of the head and massage for a couple more weeks and then return to your surgeon and ask if he/she would consider removing more skin.

There are a couple of techniques for measuring the amount of skin that needs to be removed and a surgeon's technique may vary somewhat depending on how they were trained to perform the surgery.  Please keep in mind that you are only about 2.5 weeks out from your surgery so a good deal of what you are seeing at this point is still swelling.  The eyelids are very sensitive to any intervention (i.e. surgery, injections, etc.) and the swelling may take weeks to months to completely resolve.  You can help yourself by doing some lymphatic massage, cold compresses, and keeping your head propped up. Additionally, avoid eating salty foods and aggressive exercise at first.  Be patient and wait for your body to heal before you worry about the results. The swelling sometimes resolves at different rates from side to side so they may look different until you are completely healed.  Finally, the risk of any eyelid surgery is removing too much skin. It is much easier to have a touch-up procedure under local anesthesia to remove a little more skin and improve symmetry than to deal with the problems that come from removing too much skin at once--trouble closing the eyes, corneal exposure, etc.  Continue to follow up with your surgeon and relay your concerns.  Good luck!

In order to remove the ideal amount of upper lid skin, fine measurements are taken before and during surgery with a caliper so that 8-10 mm can be preserved above the lashes at the highest part of the eyeshadow space. The upper incision is measured from the lower part of the brow and ranges from 10 - 15 mm. This ensures that enough skin is removed and equal amounts of skin, especially in patients that have more skin on one side. 1.McCord,
CD and MA Codner. Eyelid Surgery: Principles and Techniques.
Philadelphia: Lippincott-Raven, 1995.

2.Codner, MA, Ed., McCord, CD. Eyelid & Periorbital Surgery., Vol 1
& 2, St. Louis: Quality Medical Publishing. 2008Mark Codner, MD mcodner@markcodnermd.com