Secondary blepharoplasty: definitions vary

The secondary blepharoplasty is a procedure that's not uncommon in the practices of aesthetic plastic surgeons across the country. Interestingly, the term "secondary blepharoplasty" can mean one thing to one surgeon and something else to another.

"Secondary blepharoplasty can simply refer to individuals who are presenting for their second surgery after a prior surgery, regardless of whether they were satisfied with the first or not," says Steven Fagien, M.D., an aesthetic eyelid plastic surgeon with a practice in Boca Raton, Fla. "It can also refer to correction of problems from a primary, or first time, blepharoplasty."

No matter how it is defined, however, Dr. Fagien sees the secondary blepharoplasty as being indicative of — or a reminder of — a problem he sees over and over again.

Too often, he says, surgeons who perform primary blepharoplasties don't take into account what problems might result from particular maneuvers that at the time, or on the surface, seemed like a good idea — or even what the patient's eyes will look like years into the future.

"Many surgeons go for the quick fix to please the patient and hasten recovery — some of these patients even look good at one or two months," Dr. Fagien tells Cosmetic Surgery Times. "Laser skin resurfacing to the periorbita was classic for this, and so is 'trans-conjunctival' fat removal. Certainly the patients might look better in the short term; after all, their 'bags' are diminished and their skin looks tighter. But is this really reversing the aging process? Is this the best that can be done? And how long-lasting is this improved appearance? Shortly after, they return to their surgeon, unhappy with their result — and what does the surgeon do then? These patients present for secondary blepharoplasty to fix these problems; however, if a more comprehensive and thoughtful approach had been applied initially, they might not require or desire additional surgery."

Volume loss

Dr. Fagien says that, with aging, comes a loss of youthful volume — the cushion of fat, elastic skin — of the entire face, including the periorbita and the lower eyelid. The periorbita often is the most visibly obvious area to patients, he says, and many present for rejuvenation.

"They want the perioribita 'fixed,' but are not fully appreciative of the complexity of the problem and the deficiencies of traditional or even newer methods," Dr. Fagien says.

A procedure that has become popular in recent years has been to correct this lower-eyelid problem by taking the thicker skin of the cheek and pulling it up and over to cover or replace that fatty cushion that's been lost to the aging process.

"The procedure can work well in the short run and at times even long-term if it's executed with perfection in the appropriate patient," Dr. Fagien explains, "The problem lies with the patient who has been inappropriately selected, or when the procedure is not properly executed. In many of these patients, the lower eyelid is left to support the cheek and midface and over time — sometimes even soon after surgery — if fixation is inadequate, the lower eyelid will be distracted from its supportive and aesthetic position. This can result in mild lower eyelid retraction to severe lower eyelid ectropion," Dr. Fagien says.

In these extreme cases the condition is, at best, very difficult to fix, Dr. Fagien says, recalling one of many patients whose blepharoplasty/cheek lift, performed by another surgeon, pulled her eyelids down to the extent that they were turned completely inside out.

"This poor woman was a virtual recluse for several years before she came in for corrective surgery," Dr. Fagien says. "Once a significant event like this occurs that needs to be fixed, you have to attack it aggressively, usually to the point of requiring skin replacement, and often by recruiting skin from someplace else, like the upper lid, for use in the lower lid.