Ten to 20 years ago, says Foad Nahai, M.D., F.A.C.S., "Everyone who underwent a blepharoplasty had removal of skin, muscle and fat. And many of these women who had these procedures done years ago are now coming back for a second operation. Most of them have two sets of problems — one is the fact that they probably have had injudicious or excessive removal of periorbital fat. The second is that now that they're much older, the eyelid has lost its shape."
Dr. Nahai is an American Board of Plastic Surgery-certified plastic surgeon in private practice at Paces Plastic Surgery, Atlanta.Canthopexy To reshape the eye, he says, "at minimum these patients will require a canthopexy or lid tightening procedure. I believe anyone undergoing a secondary blepharoplasty ought to have a lid anchoring procedure."
For most such patients, "a canthopexy or tightening of the lateral canthal ligament is all they need," he says. "But if they have significant lid retraction, then there are several options that one can customize to the patient depending on the degree of retraction. These include a cantholysis and canthoplasty, possible horizontal shortening of the eyelid and the possible use of a spacer."
For restoring volume, Dr. Nahai says the best option would be to bring the descended midface or cheek fat up around the eye to restore the orbit to a fuller appearance. Other options include autologous fat transfer or filler materials such as Restylane (Q-Med/Medicis).
Among volume-restoration procedures, Dr. Nahai's first choice is to move the malar fat pad up closer to the orbit.
"If that's not possible," he says, "I would go with autologous tissue, such as a free dermis or dermis fat graft. My third choice would be autologous fat injections. Another option would be to use a filler material, but if I'm already operating on someone I would rather use their own tissue to restore the volume rather than resort to temporary or semipermanent filler materials."
The choice between a dermis graft or autologous fat injection depends on the amount of volume lost around the eyelid.
"The greater the volume lost," Dr. Nahai says, "the more likely I am to use a dermis graft. If it's a minimal or modest amount (less than 1 cc to 2 cc), then autologous fat injections work fairly well."
Another option Alloplastic implants represent another option for volume replacement.
"One would place an alloplastic implant along the orbital rim through an eyelid incision in exactly the way we would place a dermis graft," Dr. Nahai tells Cosmetic Surgery Times. "Instead of using dermis or fat, this implant is placed right over the bone," he explains.
Dr. Nahai furthermore warns cosmetic surgeons against repeating common secondary blepharoplasty mistakes.
In these procedures, he says, "the most common error is not performing a lid tightening procedure at the same time. In my opinion, all secondary blepharoplasties, by definition, are high-risk blepharoplasties."
Disclosure: Dr. Nahai serves as a consultant for Medicis (but owns no stock in the company).