Less is More

Palm Springs - Removing less fat from the upper and lower eyelids is the modern philosophy to blepharoplasty and, in the long run, will have better aesthetic results for the patient.

Removing less leads to less hollowing or skeletalization of the eyelids, according to one specialist.

"This idea is consistent with the overarching philosophy in terms of facial rejuvenation that you want to increase volume or replace volume, because we lose fat as we age, and the eyelids are no exception," explains Hayes Gladstone, M.D., assistant professor of dermatology at Stanford University School of Medicine and director of dermatologic surgery at Stanford Hospital, Stanford, Calif.

He says patients who undergo blepharoplasty usually have some degree of dermatochalasis, and the surgeon needs to remove this. For a more refined sculpting of the eye, Dr. Gladstone believes removing muscle and leaving the fat can achieve better contour. The modern approach is to take less.

"Previously, surgeons would automatically open up the septum and remove fat from the medial and central fat pad. Today we are not so anxious to do that. If you do, it will lead to skeletalization of the upper eyelid in the future, which looks cadaveric and makes people look worse in the long run," Dr. Gladstone tells Dermatology Times.

Simultaneous browlift

In relation to the upper eyelid, he also likes to do simultaneous browlifts, especially in women.

The reason is that when skin is taken out, the eyebrows will often drop dramatically, leaving them with a frowning look, which aesthetically, they do not want.

Here, Dr. Gladstone performs the lift with threads. To raise the eyebrow, he either does a thread lift, he fixates the brow or he proceeds with a pretrichal approach to raise the brow.

"In women, you want the eyebrow to be approximately 2 mm to 3 mm above the orbital rim. In men, the eyebrow is at the rim, so these procedures are generally not necessary. Therefore, I usually do not do a simultaneous browlift in men," Dr. Gladstone says.

In the lower eyelid, he adds that the concept is the same - less is more. He says that the lower eyelid has three fat pads and, in the past, surgeons used to take out as much fat as possible. This surgical approach has changed very much for modern blepharoplasties. He says the modern approach to a lower lid blepharoplasty is using the transconjunctival technique, as opposed to the now outdated subciliary approach.

Citing a retrospective study that he conducted recently comparing the two techniques, Dr. Gladstone says the aesthetic results were significantly better in the transconjunctival approach and had less complications.

"In the transconjunctival approach, there is less malpositioning of the eyelid. Also, there is no visible scarring because you cross the conjunctiva," Dr. Gladstone says.

Laser follow-up

When performing this procedure, Dr. Gladstone says that he remains fairly judicious when removing the three fat pads.

He adds that most patients will have rhytids and some loose skin, especially after removing the fat. Therefore, he usually follows up with an erbium laser for the periorbital skin. This tightens and smooths out the loose skin resulting from the blepharoplasty.

Dr. Gladstone says older patients that undergo a transconjunctival lower blepharoplasty may sometimes get some scleral show or a very mild ectropion, especially if they had some pre-existing lid laxity.

"To circumvent this complication, I do a prophylactic canthopexy. This is a procedure that basically placates the lateral canthus to tighten it. This will decrease lid laxity and will correct the mild ectropion in those few patients," Dr. Gladstone says.

Final touch-ups with fillers

Dr. Gladstone adds that sometimes patients will have a nasojugal deformity or defect, a hollowing called a teardrop deformity.