Blepharoplasty Controversies

Facial plastic surgery trends towards safer operations leading to a natural appearance without surgical stigmata have been sweeping and continue to question current techniques. Just as other cosmetic procedures, also blepharoplasty enjoyed an evolution over the last decades. Similar to facelift and nose reshaping procedures, not everything new turns out to be better and “abandoned” techniques are suddenly rediscovered. For instance, a laser was promoted as the new and better scalpel just a few years back. Today, probably 99% of incisions are made with a scalpel because surgeons learnt that benefits of a laser scalpel are close to nil and risks are substantial. Interestingly, sometimes dramatically different techniques can produce very comparable outcomes. Learning about a surgeon’s reasons for preferring one technique over the other may help a patient understand the doctor’s philosophy. Sometimes a plastic surgeon does not perform certain procedures simply because he has never mastered them or he has limited experience with the surgical technique required. Still, another expert surgeon may achieve excellent results with this approach.

As demand for facial cosmetic surgery increases, so does the competition among aesthetic surgeons. Some plastic surgeons find it helpful to distinguish themselves from others by promoting their own technique. Sometimes, this very procedure is not unique at all but has been used for many years. Others introduce techniques that are so new that many surgeons take the watchful-waiting approach before incorporating it into their own practices. We believe in a thoughtful philosophy of cutting-edge conservatism for the superior and save service to our patients.

Browlift – Benefit or Pitfall?

Without doubt, the brows descend with aging. In some people, the eyebrow droop is rather significant, in others it is minimal. In general, if the brows are already relatively low in young years, a small move downward may be enough for a stern look. An eyelid lift alone cannot correct this condition but an anatomical restoration of a natural brow position is indicated. Certainly, brows placed too high, are just as unattractive as droopy eyebrows. Therefore, the goal of forehead and brow rejuvenation is not to lift as much as possible but as much as necessary. Most expert aesthetic surgeons would agree that brow lifts represent one of the most frequently overlooked aspects of a balanced rejuvenation. Unfortunately, some surgeons not trained in browlifts may not discuss this procedure with the patient before an eyelid lift. On the other hand, a plastic surgeon overzealous in browlifting may make things look just different, but not necessarily better.

Safety in Blepharoplasty – Inside or Outside Incisions?

When discussing lower blepharoplasty at facial aesthetic specialty conferences, the question of trans-cutaneous or trans-conjunctival approach will always be discussed by experts. The advantages and disadvantages of the two techniques are multifold. Whoever tries to promote one way as the only way, likely represents a biased view or limited inside into the benefits of the alternative procedure.

Today, trans-conjunctival (inside incision) blepharoplasty is promoted by many as the safer operation. Also the lack of outside incisions is promoted as a major advantage. Unfortunately, removal of excess under-eye puffiness (i.e. fat) will automatically result in excess skin and additional wrinkles. In order to prevent this, many surgeons create an outside incision for skin removal in addition to inside opening. Although this results in maintenance of the muscle layer, this certainly does not represent a minimal-invasive alternative to the time-proven skin-muscle flap technique. Interestingly, some surgeons who performed trans-conjunctival blepharoplasties at one point switch to the trans-cutaneous technique.

On the other hand, a procedure is performed with lack of experience, caution or technical expertise, the likelihood of complications increases. The lower lids are no exception. Given their delicate nature, the margin of error is minimal to non-existing. One of the most feared complications is ectropion, a hanging lid with the inside turned out. If trans-cutaneous eyelid surgery is performed on lids that have borderline support to begin with, the possibility of ectropion is higher unless cautionary measures are put in place. Therefore, thorough evaluation of the lower lids before surgery is of utmost importance for a good outcome.

In summary, two technical approaches for lower eyelid rejuvenation exist. In expert hands, both procedural techniques can yield excellent results. If there would be one procedure clearly superior to the other, every facial cosmetic surgeon would be employing the better choice. Experience of the eyelid surgeon is of superior value.

Managing the Lower Eyelid Fat – Remove or Retain?

Over the last years, the under-eye and cheek region has gained much attention. Thorough evaluation of youthful and attractive aesthetics in this region reveals that simple removal of eyelid bags may not be the best treatment of this problem area. Volume enhancement of the cheeks and under-eye hollowness (“dark circles”) represents an important adjunct for best results. Although options of implants, injectables (i.e. Restylane) and fat grafting (fat injection or transfer) exist, the lower eyelid fat is readily available for repositioning into the under-eyelid groove. This advanced eyelid procedure represents a challenging technique for the novice but can be very rewarding in experienced hands.

In a word, modern lower eyelid rejuvenation requires aesthetic attention to the under-eye hollow. Various techniques exist including lower eyelid fat retention and repositioning or fat grafting. Although less frequently used, tear-trough implants and dermal fillers are other options. Talk to your cosmetic surgeon about his approach to volume rejuvenation of the lower eyelid region.

For more information, please contact Dr. Fechner.

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