Blepharoplasty approach more comprehensive

National report — Along with combining blepharoplasty with traditional or older procedures such as facelifts or laser resurfacing, cosmetic surgeons are now performing blepharoplasty in conjunction with filler injections and the use of new technologies.

"The whole focus of rejuvenation has been shifting," says Robert A. Goldberg, M.D., professor of ophthalmology and chief of ophthalmic plastic surgery, Jules Stein Eye Institute, University of California Los Angeles, Los Angeles. "A lot of the traditional ideas of blepharoplasty surgery were wrong. We all did what the surgeons before us had done, but I don't believe the results were great. When one looks back at the results of traditional blepharoplasty, even in fairly recent articles, there is certainly a difference between pre- and postoperative pictures, but I don't believe patients look consistently younger or more beautiful."

Over the past 15 years, he says, "My practice has changed dramatically. We understand much better the role of volume loss and loss of skin elasticity in facial aging. And traditional surgery doesn't fundamentally address either problem."

James H. Carraway, M.D., says, "People are very concerned about volume restoration now. There's been an emphasis upon looking at the whole face — not just stretching the skin tight with a facelift, browlift or laser resurfacing — and noting that there's atrophy of the fat pads around the nasojugal groove area." He is professor and chairman, division of plastic surgery, Eastern Virginia Medical School.

"There's a trend toward combining botulinum toxin with blepharoplasty, because one can't take away crow's feet surgically when one performs a blepharoplasty," he adds. "One might improve the corner of the eye a bit, but usually extensive crow's feet must be treated with botulinum toxin."

Youthful appearance

"People are becoming more aware of the fact that if one just treats one area, it produces an incongruous appearance, because the patient's eyes may appear young while their cheeks and brows look old," says Robert M. Dryden, M.D., clinical professor at the University of Arizona, department of ophthalmology, and a trustee of the American Board of Cosmetic Surgery.

Accordingly, he says, the number of facelifts, browlifts and cheek lifts as well as midface and mini facelifts performed in conjunction with blepharoplasty continues to increase.

"I almost always combine my lower-lid blepharoplasties with some form of cheek lift now because it makes the patient look so much better," Dr. Dryden says. "It's important when one sees patients who need blepharoplasties to consider whether or not they have brow ptosis that's exacerbating the dermatochalasis of the upper lid, and in the lower lid, whether or not they have cheek ptosis, and if they could benefit from having the nasolabial fold elevated so they have a less prominent nasolabial crease."

New trends

The number of lower-lid blepharoplasties being performed in conjunction with laser resurfacing also is rising, Dr. Dryden says.

"For example, if one wants to treat steatoblepharon from the back side and do what's called a retro-blepharoplasty, one can either move or remove the preaponeurotic fat. When one moves or removes it, the patient frequently still has a little excess eyelid skin. If that's the case, one can use a CO₂ laser to tighten the skin without doing an excisional procedure," he says.

The retro-blepharoplasty or fornix approach is gaining popularity, Dr. Dryden says, "because it avoids skin removal and decreases the chance of ectropion. And when one uses an anterior approach on patients who have very lax lids, it's important to tighten the lid horizontally. The way I like to do that is to anchor the lateral tarsus to the inner aspect of the orbital rim periosteum."