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Orbital analysis guides approach


Traditional blepharoplasty techniques, removing skin muscle and fat, can result in hollowness, an aged look, and scleral show with poor eyelid closure.
Las Vegas — The actual incising and suturing involved with an upper eyelid blepharoplasty has not changed significantly, yet advances in how a surgeon judges problems in the upper eyelid are allowing more accurate anatomic diagnoses and, ultimately, customized procedures, according to Robert Alan Goldberg, M.D., who spoke here at the Facial Aesthetic Excellence meeting.

"There are many who are rethinking traditional blepharoplasty because of how they view their patients," says Dr. Goldberg, professor of ophthalmology and chief, Orbital and Ophthalmic Plastic Surgery Division at Jules Stein Eye Institute in Los Angeles. "The most important factor is the detail in pre-operative analysis," he says.

While the advances in upper eyelid blepharoplasty may be much more conceptual in nature, the discerned structural differences among patients is literally shaping today's approach — one that includes both non-incisional surgery and non-surgical options.

"From a functional standpoint, the eyelids need a significant amount of tissue for comfortable closure — the older (blepharoplasty) techniques often violated or crossed the line of safety, resulting in problems with closure and function," says Dr. Goldberg, who is also director, Orbital Disease Center, and co-director, Aesthetic Center at Jules Stein Eye Institute. "My referral practice comes from unhappy patients with eyelid problems after (an initial) blepharoplasty — their complications motivate me very strongly."

Eye-opening optionsBefore engaging in any type of upper eyelid procedure, the surgeon should survey the various physical attributes that can help determine the correct procedure.

An example is bony asymmetry that may be significant enough that the surgeon may have to change the position of the globe relative to the orbit before effectively and safely performing blepharoplasty, according to Dr. Goldberg.

"The eyebrow fat pads are also critically important. If you look at MR scans, the roof fat pads are a powerful participant in creating the eyelid contour," Dr. Goldberg says. "Learning how to recognize the contour of the eyebrow fat pads and to differentiate this from other contours is absolutely critical for surgery. If you mistake an eyebrow fat pad fullness or deflation for an orbital change, you may do the wrong procedure. Eyebrow fat pad surgery may involve reinflating it with Restylane or fat, three-dimensional reshaping, or it may involve an upper facelift."

While the surgical process of an upper eyelid blepharoplasty has only seen recent minor modifications, Dr. Goldberg has fine-tuned his approach. For example, he performs the lateral fixation of the arcus marginalis, or "eyebrow brassiere," to design and reshape the lateral eyebrow. His practice also offers non-incisional surgery options — including the closed crease-forming surgery, an approach used for many decades by aestheticians in Asia — that avoid the need to remove fat, skin and muscle.

Transitory transformationA paradigm shift occurring among plastic surgeons is contributing to the non-traditional approach to the eyelid, one where success is no longer measured by the length of time a procedure lasts, according to Dr. Goldberg.

"Something that is permanent might be right for now, but it could be different in 10 years. For example, the excision of fat may help the 40-year-old look 32, but when she's 60 and she's missing a lot of volume it's very hard to replace," Dr. Goldberg says. "Permanence is not really what we're looking for, and the patient is very receptive to the idea of maintenance."

"Nowadays, I do far fewer blepharoplasty surgeries; rather, I'm more inclined to offer non-incisional options such as Botox, Restylane and closed suturing techniques — using to my advantage the fact that they're not permanent," Dr. Goldberg says.

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