Blepharoplasty

Blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids. The two world wars laid the foundations of modern reconstructive surgery and simultaneously with it with it the other branch i.e. Cosmetic or to put it correctly Aesthetic Surgery evolved. Blepharoplasty can be both a functional and cosmetic procedure designed to restore a more youthful, bright, and energetic appearance to the eyes. The origin of the word is from Greek; Blepharon meaning eyelids and Plastikos meaning to mould.


Blepharochalasis
Excessive skin on the eyelids due to chronic blepharedema, which physically stretches the skin. Blepharoptosis Drooping of the upper eyelid, which relates to the position of the eyelid margin with respect to the eyeball and visual axis.

Brow Ptosis
Drooping of the eyebrows to such an extent that excess tissue is pushed into the upper eyelid. It is recognized that in some instances the brow ptosis may contribute to significant superior visual field loss. It may coexist with clinically significant dermatochalasis and/ or lid ptosis. Blepharoplasty Surgical removal of redundant skin, muscle and fatty tissue from the eyelids for the purpose of deformity reconstruction, functional improvement of abnormalities or appearance enhancement. Cosmetic blepharoplasty When blepharoplasty is performed to improve a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure is considered cosmetic.

Reconstructive
When blepharoplasty is performed to correct visual impairment blepharoplasty caused by drooping of the eyelids (ptosis); repair defects caused by trauma or tumor-ablative surgery (ectropion/entropion corneal exposure); treat periorbital sequelae of thyroid disease and nerve palsy; or relieve the painful symptoms of blepharospasm, the procedure should be considered reconstructive. This may involve rearrangement or excision of the structures with the eyelids and/or tissues of the cheek, forehead and nasal areas. Occasionally a graft of skin or other distant tissues is transplanted to replace deficient eyelid components. Dermatochalasis Excessive skin on the eyelids as a result of loss of skin elasticity with aging. Pseudoptosis or "false ptosis" Excessive skin overhanging the eyelid margin and creating the appearance of true blepharoptosis, although the eyelid margin is usually in an appropriate position with respect to the eyeball and visual axis.

Guideline
(See also Cosmetic Surgery guideline) The goal of functional or reconstructive surgery is to restore normalcy to a structure that has been altered by trauma, infection, inflammation, degeneration, neoplasia or developmental errors.
Members are eligible for coverage of blepharoplasty procedures and repair of blepharoptosis when performed as functional or reconstructive surgery to correct any of the following (list not meant to be all-inclusive): • Congenital ptosis with risk for amblyopia.
• Symptomatic dermatitis of pretarsal skin caused by redundant upper-lid skin.
• Prosthesis difficulties in an anophthalmia socket.
• Symptomatic redundant skin weighing down upper lashes.
• Visual impairment with near or far vision due to dermatochalasis, blepharochalasis or blepharoptosis.
• To relieve painful symptoms of blepharospasm

• Congenital Lagophthalmos
• Post-traumatic defects of the eyelid Documented patient complaints justifying functional surgery that are commonly found in patients with ptosis, pseudoptosis or dermatochalasis include: • Interference with vision or visual field.
• Difficulty reading or driving due to upper eyelid drooping.
• Looking through the eyelashes or seeing the upper eyelid skin.
• Chronic blepharitis refractory to ≥ 3 months of supervised therapy

Documentation
Documentation must include history and physical with appropriate patient complaints, visual fields and photographs, as described below.

Medical Policy: Blepharoplasty (Commercial)
Photographic evidence: Must be in the form of prints, not slides, imprinted with the patient's name and date of visit. Photographs must be frontal (canthus-to-canthus), with the head perpendicular to the plane of the camera, to demonstrate a skin rash or the position of the true lid margin or the pseudo-lid margin. The photos must be of sufficient clarity to show a light reflex on the cornea. If redundant skin coexists with true lid ptosis, additional photos must be taken with the upper lid skin retracted to show the actual position of the true lid margin.
Oblique photos are only needed to demonstrate redundant skin weighing down upper eyelashes when this is the only indication for surgery.
Photographs must demonstrate ≥ 1 of the following: • The upper eyelid margin rests 2 mm or less above the corneal light reflex.
• The upper eyelid skin rests on the eyelashes.
• The upper eyelid indicates the presence of dermatitis.
• The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket.
Visual fields: Must be recorded using either the Goldmann Perimeter (III 4-E test object; perimeter not accepted if hand-drawn) or a programmable perimeter (i.e., Humphrey or other computerized visualfield test equivalent to a screening field with a single-intensity strategy using a 10db stimulus) to test a superior (vertical) extent of 50-60 degrees above fixation, with targets presented at a minimum 4degree vertical separation, starting at fixation, while using no wider than a 10-degree horizontal separation. Preferred programs on the Humphrey perimeter include the 36-point screening test and the 120-point, full-field screening test. Each eye should be tested with the upper eyelid at rest and repeated with the elevated eyelid to demonstrate an expected surgical improvement that meets or exceeds the criteria. The superior visual with the upper eyelid at rest should be restricted to within 30 degrees of fixation and there should be a minimum of 12 degrees of improvement in the superior visual field (vertical extent) with the upper eyelids taped.

Limitations/Exclusions
The Plan does not consider blepharoplasty procedures performed solely for cosmetic reasons to be medically necessary. Blepharoplasty, blepharoptosis repair, or brow lift and lower lid blepharoplasty is considered cosmetic and not medically necessary when performed to improve an individual's appearance in the absence of any signs or symptoms of functional abnormalities.