Initial Consultation with Dr. Polly McKinstry
Dr. McKinstry has a certain approach...
"I like to observe my patient. First, I look at the forehead and the eyebrows, noting the position of the eyebrows relative to the superior or bony orbital rim. Different people have different tastes as to where the eyebrows look the best. The patient's opinion of where they want their eyebrows to be is very important to me."
When assessing the forehead, Dr. McKinstry notes if the hairline is high or low. Next, she looks at the wrinkles, the frown lines between the eyebrows, and the horizontal forehead creases.
Then, she looks at the upper eyelids. She wants to see where the eyelashes lie relative to the pupil and cornea. The ideal upper eyelid margin is anywhere between the top of the cornea (or over the colored portion of the eye) to 2 mm below. She also assesses if there is excess upper eyelid skin and fat. She asks the patient to close their eyes to see if the eyes close completely.
Next, the Dr. McKinstry looks at the lower eyelids. The ideal lower eyelid position is at the lower edge of the cornea and colored iris. She tests the tension in the lower eyelid. It should have good tension and snap back.
Sometimes the margin can be pulled downward so it rests a millimeter or several millimeters below the cornea leaving a white exposed area or "scleral show". This can follow previous lower eyelid surgery, either occurring soon after surgery if too much skin was excised, or years later when the eyelid loosens with age and the eyelid level drops down. It can result in drying of the surface of the lower eye because the eyelid margin can no longer hold the tear film near the cornea. The patient can then be left with burning, discomfort and tearing.
Also with aging, the eyelid support structures may become weak, allowing the eyelid to turn in so that the eyelashes scratch on the eyeball (a term called entropion) or turn outward away from the eyeball leaving a pink edge (called ectropion).
Dr. McKinstry also checks for eyelid puffiness. The eyelids puff out when the normal fat cushioning the eye bulges forward, because the membrane or septum that usually holds it back has become weak.
Dr. McKinstry also looks at the position of the cheek fat. The cheek fat may have fallen creating a hollow between the lower eyelid and the cheek. Sometimes it bunches over the malar bone or cheekbone as it drops from its former position. Next comes the skin. Is there excess skin in the lower eyelids or just fine wrinkling?
Finally, Dr. McKinstry examines the skin of the entire face - noting if there are brown aging spots, growths such as keratoses or moles, or just flat, pigmented age spots. She notes the wrinkles and skin texture.
Once she has made her assessment, Dr. McKinstry asks the patient about his or her desires and goals and what bothers them the most that they would like changed. She then discusses with the patient what she sees, what can be changed, and what results can realistically be expected from surgery.
Dr. McKinstry will sometimes offer suggestions about additional procedures that might be done for the patient. At this time they can discuss some of the risks with some of the procedures. Dr. McKinstry will offer the patient what is the minimum she thinks this patient could do to improve his or her problems. She will also suggest other procedures that would give the patient the best results.
Of course, before discussing all of the surgical options with the patient, the doctor will have performed a medical examination of the eyes to expose and assess any particular risks. She tests the vision, the integrity of the cornea and conjunctiva, or white of the eye, and tear production. To see well, a patient's cornea must have a regular amount of moisture or tear film. A good tear film requires properly positioned eyelids that blink regularly, a normal amount of tear production, and open tear drainage passageways.