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Deciphering a patient's real needs

Las Vegas — Traditional lower lid blepharoplasty is based on an incomplete formula that initially derived its success from the removal of fat and skin. While this approach has been modified through attempts to restore the skin by reshaping deep tissue, doctors have become much more focused on the non-surgical approach aided by customized diagnosis, according to Robert A. Goldberg, M.D., who spoke here at the Facial Aesthetic Excellence meeting.

"Patients don't want lower lid blepharoplasty, even though they may at first request this procedure," says Dr. Goldberg, professor of ophthalmology and chief, orbital and ophthalmic plastic surgerydivision, at Jules Stein Eye Institute in Los Angeles.

"In my practice, I may see many patients who say they want lower lid blepharoplasty, yet what they want is to look less tired and have less sagging skin," he says.

Addressing an underlying need A surgeon can determine why a patient is unhappy with the appearance of the lower eyelids by addressing six different causes, including: orbital fat prominence, eyelid fluid, periorbital hollows, obicularis prominence, loss of skin elasticity and malar fluid festoon, according to Dr. Goldberg, who is also director, orbital disease center, and co-director, aesthetic center, at Jules Stein Eye Institute.

"Understanding the anatomic basis helps to customize a treatment plan. Although it may include traditional blepharoplasty, more often there are going to be other treatments that are recommended," Dr. Goldberg says.

When looking at 114 consecutive patients who had lower eyelid concerns, Dr. Goldberg and his colleagues noted that some 10 different procedures were recommended in various combinations to customize an approach that best suited different anatomic features.

"When looking at the whole group of patients, only a small minority would benefit from lower lid blepharoplasty," Dr. Goldberg says. "Most often, patients would benefit from other procedures, such as skin resurfacing or radiofrequency eyelid sponge thermoplasty, where we use radiofrequency energy to dry up excess fluid — a procedure completed under topical anesthesia."

Foregoing the traditional Other examples of in-office procedures used as alternatives to lower lid blepharoplasty include Restylane used for three-dimensional filling of the various peri-orbital hollows, and Botox used to sculpt the obicularis.

"The obicularis is a very complex muscle that can change the dynamic aesthetic shape of the eyelid," Dr. Goldberg says. "When analyzed, we realize that this is often the most significant problem for the patient. Blepharoplasty, with or without fat repositioning, is offered among these other therapies, yet the minority of my patients end up having blepharoplasty after considering the other therapies that are offered. This is the biggest difference I've seen in the last five years. ...

"You will be increasingly successful the broader your palate of minimally invasive approaches ," Dr. Goldberg says.

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