Periorbital aesthetic surgery is the second-most challenging plastic surgery procedure next to rhinoplasty because the eyes are the most dominant and unforgiving features of the face, according to Bahman Guyuron, M.D., of the Zeeba Clinic, Lyndhurst, Ohio.
“Any flaw is going to be visible and prodigiously consequential,” he says.
Dr. Guyuron was a panelist during the “Periorbital rejuvenation—Point/counterpoint” presentation at the at the American Society for Aesthetic Plastic Surgery’s The Aesthetic Meeting 2017 in San Diego, Calif. He tells Cosmetic Surgery Times that, although rare, potential complications of blindness are one of the top three most serious complications of any surgery.
“For these reasons, no education, analysis or debate on this topic is too much. Although the procedures are all effective, their indications could be controversial,” says Dr. Guyuron, who is editor-in-chief of the Aesthetic Plastic Surgery Journal and professor emeritus, plastic surgery, Case Western University School of Medicine, Cleveland, Ohio.
The plastic surgeon recommends careful analysis of periorbital imperfections — whether those imperfections are related to aging or genetic disposition. These may disclose conditions that are directly related to the periorbital region or caused indirectly by changes in the surrounding structures, such as the forehead or malar area.
“When the forehead becomes ptotic, the eyebrows migrate caudally, engendering varying degrees of crowding in the periorbital region. Caudal disposition of the malar tissues produce the tear trough. Thus, myopic focus on the eyelids only may leave the real cause of displeasing periorbital appearance out of view and result in suboptimal outcomes,” he says.
Even after surgeons detect the imperfections, their choice of a corrective procedure is going to vary depending on the associated conditions. This, he says, is where most controversy lies. Although some techniques seem similar, they are not interchangeable.
For example, when the eyebrows are ptotic, depending on the size of the forehead, hypertrophy of the corrugator muscle group, presence or absence of proptosis/exophthalmos, the surgeon’s choice for elevation of the eyebrows are going to be different.
“For a patient who has a long forehead and ptotic eyebrows, the ideal choice is a pretricheal incision with forehead shortening and lift at the same time. If the patient declines a pretricheal incision or has proptosis or exophthalmos, whereby, elevation of the eyebrows should be conservative to prevent exaggeration of the proptosis or exophthalmos, the choice is transpalpebral corrugator resection with endoscopic temple and lateral brow lift. An endoscopic forehead lift is optimal for someone who has ideal or borderline forehead length,” Dr. Guyuron says.
A patient might have redundant skin, protruding fat bags, discoloration, lid lag, fine wrinkles or malar bags in the lower eyelids in a variety of combinations. The selected procedure should correct all flaws. There is no single procedure that would do all of this, and a combination of maneuvers are often needed to deliver a gratifying outcome, according to Dr. Guyuron.
In the past we created too many hollowed eyelids, both upper and lower lids, he says.
“Whether it is upper or lower eyelid surgery, we almost never do blepharoplasty without fat injection anymore. This restores the lost volume and, because of the contained stem cells, it also improves the skin color and elasticity and returns the natural glow to the lids that we could not re-establish,” Dr. Guyuron says.
Years ago, almost all conventional blepharoplasty patients had slight lid malposition, according to the plastic surgeon.
“Although it could be considered controversial, most of us have been able to avoid and, in most cases, correct the pre-existing lid lag or loss of tone by adding canthopexy to our lower eyelid procedures,” he says.
Aesthetic surgeons often can improve dyschromia with fat injection, alone. Adding laser or chemical peel, however, can help to further eliminate lower lid discoloration more effectively.
“Removal of skin, with or without removal of some orbicularis muscle, deals with the redundant skin or muscle roll; however, it is not necessary on every patient,” he says. “Finally, patients need to understand that festoons or malar bags require different measures, such as orbicularis suspension, and will not be eliminated by conventional blepharoplasty.”
Disclosure: Dr. Guyuron reports no relevant disclosures.