A paradigm shift for blepharoplasty

Los Angeles — For years, surgeons have focused on ways to remove tissue during upper eyelid procedures in order to create contours and reverse an aged appearance. But now a paradigm shift is occurring among plastic surgeons.

"The old way meant removing tissue," says Robert Alan Goldberg, M.D., professor of ophthalmology and chief, orbital and ophthalmic plastic surgery division at Jules Stein Eye Institute in Los Angeles. "Surgery is particularly good at (that), so all of the models have been built upon trying to identify problems that can be improved by removing or debulking tissue. The critical paradigm change is to recognize the contours as volume lost ... and that's technically more difficult than treating volume excess."

The change requires a good sense for the three-dimensional contours of the periorbital area and an understanding of the various options for replacing volume loss.

"Any patient who is unhappy with the periorbital area is a natural candidate for this kind of problem-solving, individualized approach," says Dr. Goldberg, "not just on removing tissue, but on trying to understand the hollows and having flexible ways of trying to fill those to recreate the full, inflated contours of youth."

Careful customization A customized diagnosis for each patient requires a careful study of the many different boney and soft tissue factors. Based on this surgical plan, each patient gets an entirely different procedure. "It really becomes a question of periorbital rejuvenation that has to be a flexible continuum," Dr. Goldberg says. "Every patient needs an individualized plan."

Recently, Dr. Goldberg has seen increasing numbers of patients who are unhappy after blepharoplasty — some for aesthetic reasons, others because of functional vision problems, also most commonly caused by collapse or loss of volume.

"The common thread is hollow orbit syndrome," he says. "In fact, we've been describing that for 15 years now." Rethinking the process of blepharoplasty and what it should actually accomplish has led him to believe that today, it's less about removing tissue and more about restoring the volume to reverse the collapse.

"I think this paradigm change opens the door for a completely different model of analyzing problems," Dr. Goldberg says. "It's a paradigm where we examine which areas are relatively hollow and which need more volume."

In this way, treatments often don't involve surgery, but use synthetic fillers or fat injections instead. Instead of just removing fat and muscle and skin, surgeons can focus more on repositioning or filling the hollow areas using some of the existing fat muscle and skin.

"I find that if I analyze the orbital area to look for areas of volume deficit, I am able to focus not as much on removing tissue as in filling and expanding the deflated tissues. I find that this method really opens new vistas for rehabilitation in a much better, more natural way."

This is particularly true, according to Dr. Goldberg, when patients that have had a lot of tissue removed are tracked over time. "With additional age, loss of tissue and other changes, these patients actually age faster. When I look at my results from 10 years ago, I realize that I wasn't looking at the right thing."

The paradigm change in creating contours in the upper eyelids has significantly affected patients' decisions about blepharoplasty, according to Dr. Goldberg. Today, a much smaller number of patients are choosing surgery after considering all the options.

Dr. Goldberg's goal is to help other surgeons develop a more open-minded approach to interpreting the changes that patients associate with aging.