Boca Raton, Fla. — Blepharoplasty techniques have evolved from those that sought to remove and resurface tissue to those that comprehensively address underlying problems.
"Many of the newer techniques of the perceived problems that occur with aging of the periorbita," says Steven Fagien, M.D., a cosmetic oculoplastic surgeon in Boca Raton, Fla. "It started as a procedure of taking out skin, muscle and fat when blepharoplasty first became popular here in the United States, in part because we saw that we could achieve a sort of cause and effect despite lacking a full appreciation of the ingredients of aging and the characteristics of youth. Someone presented to the surgeon with apparently excess skin and puffiness, and the procedures were based on excision. Patients would even see a big difference after surgery.
"But as time went on and we got a better handle on what happened as the periorbita aged, and what things really looked like in youth, some of the procedures of excision became less acceptable and created more of a change or distortion in the patient's appearance rather than true rejuvenation," he says.Over the past several years, surgeons have seen many newer approaches to cosmetic blepharoplasty that were both a response to patient dissatisfaction and potential solutions to problems related to surgery.
"Problems with lower lid malposition occurred frequently, because no attention was given to the canthus to support the lid to enable procedures to be performed that would be rejuvenative," says Dr. Fagien. "Conversely, surgeons would oftentimes avoid the lower lids or approach the area very conservatively, often removing fat only through a transconjunctival approach, and found those procedures still were not optimal.
Age of lasers "Then the age of lasers came along, and many blepharoplasty surgeons said, 'Now we have a way to make the skin look better.' So fat removal was combined with laser abrasion.
quot;But after all of us went through the phase — in my opinion, a fad — where we were using lasers to improve skin, we shortly realized that not only were the results at times unacceptable or not long-lasting, but this approach also did not rejuvenate in most patients."
At the turn of the millennium, studies began taking an even closer look at how the periorbital area ages.
"It became obvious that it wasn't that things fell, or that we somehow develop excessive soft tissue," he says. "It had a lot to do with reduced elasticity and thinning of the skin, shifts in volume and volume loss, and a loss of adherence of the many soft-tissue layers and the skeletal attachments, and we essentially exhibited what some call 'radial expansion.' Good anatomic studies suggested that if you could address these issues, you may be heading toward true rejuvenation," he says.
New surgical methods To meet this goal, Dr. Fagien pioneered surgical methods for returning the upper eyelid to a more youthful appearance by retaining rather than removing volume, and procedures that rejuvenated the lower eyelid with simple and predictable methods to shape the contours as well as maintain and improve lower eyelid position.
In the latter area, he says, "You need to bolster the support of the lower lid, first and foremost, in order to do the type of rejuvenative procedures — including muscle and skin tightening — necessary to avoid lid malposition. The approach I call 'component blepharoplasty' actually surgically addresses as many of the aging features as possible in order to achieve true rejuvenation.