Since each one of these represents an area of expertise almost within itself, we must be prepared to utilize the newest and best techniques when we decide to undertake some or all of these.
Tools and techniqueConsider the use of Botox. When its usage began, it was for functional treatment of blepharospasm. Thanks to observant clinicians and an excellent drug, Botox finally evolved into one of the most efficient tools that we have against wrinkles around the periorbital and facial areas. Most of us started using Botox for crow's feet and glabellar creases, and soon found that we could functionally raise the lateral brow, reduce periorbital creases, and improve upper and lower lid rhytids. Botox has established itself as one of the most useful drugs in the armamentarium of cosmetic surgeons, and we should all take advantage of the information available to us to learn the specific techniques relating to more sophisticated use of Botox.
Fillers have a long history beginning with collagen and evolving through fat grafts, Restylane (Medicis) and others. We initially saw complications from fat injection, including beading, lumping and irregular contour. Collagen was easier to use and somewhat more forgiving, and held some potential to improve the hollow areas of the nasojugal groove and the lateral tear trough area. I have personally found CosmoDerm (Allergan) and Restylane to be invaluable in filling in defects that I cannot surgically correct in this area. Several years ago, I began using fat grafting in a different manner to correct the nasojugal groove deformity and found that, by releasing the fascial layer on the underside of the orbicularis muscle near the arcus marginalis, I could free up the sharp nasojugal crease and allow fat to be injected by needle into the muscle. This has pretty much solved the problem of eliminating the nasojugal crease and has allowed me more versatility in filling out or improving the hollowing of that area. Although it is more problematic to release that fascia in the lateral area for fear of damaging some of the fine nerve fibers, the combination of fillers such as Restylane along with fat grafting to the medial nasojugal groove area can overcome the problem of hollowing very well. This can be done without the more extensive technique of using a mid-facelift, which is much more invasive.
I think that we need to always think about the problem of dry eyes in our patients, both for the present and for the evolution of problems that can be caused by eyelid surgery in patients who are destined to have dry eyes. We know that 60 percent to 70 percent of postmenopausal women develop some symptoms of dry eyes, and some of these have this problem to a severe degree. Often, women come for eyelid surgery in their 40s and may have a marginal or even normal Shirmer test. However, if blepharoplasty surgery is done on these patients, and the healed lids are stiff and don't close well, this can be a setup for dry eye symptoms in the future. For this reason, every blepharoplasty that is performed in my clinic is accompanied by upward massage to keep the lower lid supple and easily able to close, both when awake and in the sleeping state. Since eyelid closure during sleep involves the upper lid coming down and the lower lid coming up one to two millimeters to meet the upper, it is best to keep this mechanism intact. If the lower lid is stiff from scarring or excessive removal of fat, then the patient sleeps with a one to three millimeter open palpebral fissure and experiences dry eye symptoms. In my experience, it's always best to teach the patient the massage technique and to check this each time they have a follow-up visit.