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Assessing entire forehead, eye, eyelid complex key to choosing appropriate treatment


Dr. Fincher
Los Angeles — Traditional blepharoplasty is still the most effective approach to recreating a youthful eye. However, brow lifts can replace upper lid excisions for some patients, and a transconjunctival rather than transcutaneous approach to the lower lid has almost eliminated the potential hazards of lower lid repair.

"Nothing's come up that offers a substitute for blepharoplasty, although the lower lid is a little more risky," says Edgar Fincher, M.D., Ph.D., clinical instructor, The David Geffen School of Medicine, University of California, Los Angeles. "Thermage®, CO2 lasers, and the new plasma machines tighten upper eyelid skin a little bit, but not to the degree that blepharoplasty can."

Assessing need

Extra folds of loose skin indicate a need for upper eyelid repair. Palpating the skin and pushing upward against the globe can suggest whether skin alone or skin plus underlying muscle or fat should be addressed. When assessing a full lateral upper eyelid, it's important to rule out a ptotic lacrimal gland, which would require suture pexy to be repositioned within the bony orbit, according to Dr. Fincher.

"Many patients come in asking for upper lid blepharoplasty when what they really need is a brow lift," Dr. Fincher tells Cosmetic Surgery Times. "With age, the brow often drops down from its elevation high above the bony orbit, causing the appearance of redundant skin on the upper lid."

With his fingers, Dr. Fincher repositions the eyebrow to its original position. This pulls the brow and upper lid up, flattening out the excess skin. If excess skin remains on the lid in this position, he performs a combination procedure of lid resection and brow lift.

If the brow hasn't descended, Dr. Fincher resects a minimum of excess skin from the lid, which restores a sharp eyelid crease and smooth upper eyelid contour. Removing too much tissue will leave the patient with a hollow, more aged appearance.

He advises paying attention to the shape and position of the eyelid crease. In a Caucasian woman, the goal is a curved crease that roughly parallels the eyelid margin and ends with a slight upward curvature laterally.

If a ptotic brow is ignored, performing an upper eyelid blepharoplasty will simply draw the eyebrow further into the orbit, reducing the eyelash-to-eyelid width without providing the desired result. Worse, if the need for forehead correction is only recognized after performing blepharoplasty, the subsequent brow lift may result in lagophthalmos.

Traditional meaning

Lower lid blepharoplasty traditionally meant excision of skin, muscle and orbital fat. When excess skin was removed, the shortened lid often retracted, drooped and became more rounded, altering the eye's natural shape. Excision often overexposed sclera laterally in direct relation to the amount of skin resected and inhibited normal tear flow, leading to dry eye.

Now surgeons recognize that the main indication for the procedure is not loose skin, but fat that protrudes from fat pockets around the eye. Instead of excising outer lid skin transcutaneously, surgeons usually take a transconjunctival approach, placing incisions on the inner surface of the eyelid to access fat pockets and remove fat. No scars or incision lines are visible.

"It's a fairly straightforward procedure that avoids the dangers of contractions and ectropion — the eyelid actually turned out and down. Patients heal quickly and are pleased with the result," he says.

If extra skin remains, laser resurfacing performed simultaneously with transconjunctival blepharoplasty will often tighten the skin adequately, he says. However, elderly patients with loose eyelids may still require some transcutaneous surgery. In such cases, Dr. Fincher advises removing a minimal amount of skin just underneath the eyelid and performing canthopexy, attaching the lateral canthus in an elevated position onto or within the eye's bony orbital rim. This tightens and supports the lower lid without diminishing the length of the aperture and reduces the amount of excision required, he explains.


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