First, we now have a better understanding (although we all do not necessarily agree) of how the face and periorbita ages, and methods have evolved that incorporate the surgeon's vision of reversal of this process. Volume loss and shifts obviously occur and there are changes of the periorbital retaining ligaments, skin, muscle and even the bony orbital framework. Right or wrong, many procedures have been derived as a solution to these perceptions. Second, we, as well as our patients (who bring in magazines or old photos of themselves showing what they desire to look like), have a better idea of where they would like to be after the procedure. This has changed dramatically from the altering, volume depleting and "hollowing" procedures of the 70s and 80s to a more subtle "refreshing" look that patients presently demand. Finally, no one wants problems or complications with their patients so procedures have been modified or changed entirely to avoid these. While "simpler" approaches have their advantages with regard to avoiding untoward events many of these are inadequate in aesthetic enhancement.For example, the trans-conjunctival access for fat removal has become extremely popular as a method to improve the appearance of the lower eyelid due to its "minimally invasive" approach. Laser skin resurfacing, too, also avoids a skin incision. However, what are we expecting or promising our patients with these approaches? By avoiding a skin incision do we compromise the result? And what other steps in a procedure could be performed to make incisional surgery more effective and aesthetic? In this issue we have a spectrum of approaches from various surgeons who have their vision of periorbital rejuvenation. What is clear is the diversity of techniques that vary more than their common goals. On the surface, this usually suggests that no one particular method or technique is perfect for every situation. On the other hand, I believe it is more due to the complexity of facial aging that mandates a more comprehensive approach that may require a combination of excision, repositioning, reinforcement and soft tissue augmentation that delivers a powerful result — yet is undetectable.
Steven Fagien, M.D.
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