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Better blepharoplasty outcomes depend on appreciation of asymmetry

Article-Better blepharoplasty outcomes depend on appreciation of asymmetry

Key iconKey Points

  • Pre-existing asymmetry often is only partially addressed, surgeon says
  • Assessment of soft tissue asymmetry is done by measuring tarsal platform show and brow fat span
  • Cosmetic ptosis surgery differs from surgery to treat ptosis causing a functional problem, surgeon says

Dr. Goldberg
The ability to recognize pre-existing asymmetry and address it with an asymmetric approach to surgery is important for achieving satisfaction in patients presenting for cosmetic upper eyelid blepharoplasty, says Robert A. Goldberg, M.D.

Speaking at the 2012 meeting of the American Academy of Cosmetic Surgery, Dr. Goldberg discussed detection and management of subtle asymmetry in upper blepharoplasty.

"Most people are not aware of differences between one side of their face and the other, even though facial asymmetry is ubiquitous. However, patients are likely to spot unevenness after cosmetic surgery, particularly as they concentrate on their appearance in a magnifying mirror and partly because a procedure that removes skin, fat and soft tissue can unveil pre-existing deep asymmetry," says Dr. Goldberg, chief, orbital and ophthalmic plastic surgery, Jules Stein Eye Institute, and Karen and Frank Dabby Professor of Ophthalmology, David Geffen School of Medicine, University of California, Los Angeles.

Brow Fat Span (BFS) and Tarsal Platform Show (TPS) are key measurements of eyelid symmetry. (All photos credit: Robert Goldberg, M.D.)
"In my referral practice, I commonly see patients who are very unhappy because of asymmetry after upper blepharoplasty and who are convinced it is the fault of the surgeon," Dr. Goldberg says. "This information underscores that it is incumbent on surgeons venturing into procedures addressing the aesthetics of the periorbital area to be able to understand the nuances of asymmetry existing around the eyes and to discuss the preoperative findings so that the patient understands the situation. Then, unless the patient chooses against it, surgeons must be prepared to surgically treat the asymmetry, which usually requires operating more on one side than the other."

A 40-year-old woman with bony and soft tissue asymmetry; following left upper eyelid microptosis surgery and asymmetric blepharoplasty, symmetry is improved.
Dr. Goldberg adds that in undertaking asymmetric surgery to optimize the cosmetic outcome, surgeons and patients must recognize what he calls the "Goldberg Principle," which cautions that pre-existing asymmetry is usually only partially addressed.

"In my experience, pre-existing asymmetry can usually be improved when it is approached based on careful preoperative analysis, surgical planning and surgical technique. However, even with purposely asymmetric surgery, perfection is rarely achieved. Asymmetry in nature is so powerful, it is difficult to overcome," he explains.

A 64-year-old woman with asymmetric ptosis and eyebrow compensation left more than right (top); following posterior approach ptosis surgery left more than right, eyebrow compensation relaxes and symmetry improves.
EVALUATING THE EYES The preoperative evaluation takes into account that there are multiple sources of upper eyelid asymmetry. It may be bony in origin, arise from differences in soft tissue or be the consequence of a dynamic element. Although bony asymmetry is not something that will be addressed in cosmetic blepharoplasty, it is possible to mask some of the discrepancy between the two eyes by doing asymmetric surgery manipulating the skin, fat and soft tissue, Dr. Goldberg says.

Assessment of soft tissue asymmetry is done by measuring two parameters — tarsal platform show (TPS) and brow fat span (BFS), represented as the distance from the top of the tarsus to the eyebrow. Between the two parameters, achieving symmetry in the TPS should be the main target of surgery, Dr. Goldberg says.

A 32-year-old woman with bony asymmetry and volume collapse of the superior sulcus right more than left (top); hyaluronic acid gel is used asymmetrically (right more than left) to fill the eyebrow fat pad and superior sulcus, combined with botulinum toxin to the right frontalis and left eyebrow depressors.
Dr. Goldberg says his preference for focusing on the TPS is based on the finding that small differences between eyes in the TPS were more noticeable to lay people than small amounts of asymmetry in the BFS.

"In our study where lay people were shown different facial configurations, we found they were able to detect 1 to 2 mm of TPS asymmetry, whereas such small amounts of BFS asymmetry were less noticeable," he explains. "For this reason, I recommend the surgical goal should be to make the TPS as symmetric as possible, especially if there are limitations and compromises that need to be made because of bony asymmetry. Even if the bony asymmetry remains, the outcome of the surgery will still appear fairly symmetric to the patient and other lay people if the TPS is similar for both eyes."

UPPER EYELID PTOSIS Subtle upper eyelid ptosis, identified preoperatively by measuring the distance from the eyelashes to the center of the cornea, is another cause of upper eyelid asymmetry, and it has a powerful effect because it creates a dynamic component, Dr. Goldberg says. For example, drooping of the eyelid margin results in a compensatory muscle drive that raises the eyebrow on the ptotic side. Correction of subtle eyelid ptosis is one of the most important maneuvers performed to address upper eyelid asymmetry, but this feature is often overlooked by inexperienced surgeons, he says.

EXPERIENCE REQUIRED Dr. Goldberg notes that when planning to address ptosis, surgeons must recognize that cosmetic ptosis surgery is different than surgery to treat ptosis causing a functional problem, and they must either be skilled in the minimally invasive techniques used for cosmetic ptosis surgery or be able to work with a colleague who is adept at methods for achieving subtle cosmetic changes in eyelid position.

To address subtle ptosis in cosmetic blepharoplasty, Dr. Goldberg says posterior surgical approaches are preferred because they do not involve any skin incision and are more reliable than anterior surgery for treating small amounts of ptosis in a predictable fashion.

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