Performing blepharoplasty: Knowledge of ocular anatomy, sufficient training essential

October 1, 2009

When performing a procedure like blepharoplasty, it's most important to take into consideration the desires and wishes of the patients.

Edmonton, Alberta, Canada - When performing a procedure like blepharoplasty, it’s most important to take into consideration the desires and wishes of the patients, says a dermatological surgeon.

"Unless I know the procedure will make them look worse, I am in favor of doing what they really want," says Mariusz Sapijaszko, M.D., clinical associate professor, division of dermatology, University of Alberta, Edmonton, Alberta, Canada.

It’s key that the candidate be suitable for blepharoplasty, a cosmetic surgical procedure that reshapes the upper eyelid or lower eyelid through the removal of excess tissues, as well as the reinforcement of the surrounding muscles and tendons, and that ophthalmologists be part of the process to assess the suitability of the candidate, according to Dr. Sapijaszko.

"You need to know if patients have any ophthalmological conditions because that can lead to complications," he says, citing conditions such as cataracts, glaucoma, and pre-existing dry eye as potential conditions that complicate surgery. "This is why the patients should have a consultation with an ophthalmologist prior to blepharoplasty."

With a condition such as dry eye, patients will likely continue to have the dry eye post-operatively, but, fortunately, that can be treated with the administration of eye drops. In addition, in such patients, a more conservative blepharoplasty approach is warranted, Dr. Sapijaszko says.

"Complications of blepharoplasty are infrequent, and most issues that arise are reversible," he says. "I make sure patients know they are to call right away if any complications arise."

Clinicians need to know the anatomy around the eye and have to have sufficient training through fellowships, preceptor ships, and on cadavers before performing blepharoplasty on patients, according to Dr. Sapijaszko.

Although most blepharoplasties are performed for a cosmetic reason, in extreme cases, when there is an advanced amount of upper eyelid skin present, the skin can hang over the eyelashes and be responsible for diminished peripheral vision.

Moreover, there is no age restriction to undergoing blepharoplasty: Dr. Sapijaszko says he has performed the procedure on patients in their 20s and patients in their 80s.

"It’s really an individual decision," Dr. Sapijaszko says. "The impact of the procedure does not last forever, but blepharoplasty is very durable."

Using a "pinch technique," Dr. Sapijaszko judges how much excess skin he will remove when performing blepharoplasty. He makes appropriate markings following the use of the pinch technique. This helps to ensure that the adequate amount of tissue is preserved for optimal functioning of the eye and the eyelids.

The clinician needs to think about the "sacred triangle" of the face and that when people look at the face, they are primarily focused on the eyes and the lips.

Depending on the position of the eyes on the face, taking too much skin from the peri-ocular area will result in eyes looking sunken in the face, Dr. Sapijaszko says.

"Peri-ocular rejuvenation needs to take this sacred triangle into account," he says, noting the position of the eyebrows has to figure into the decision about excess skin removal. "The person’s genetics determine the positioning of the eyes on the face."

Some patients who think they have excessive upper eyelid skin actually have lower eyebrow position. This gives the illusion of the excessive eyelid skin, but the actual cause is lower eyebrow position. In such cases, blepharoplasty alone will not correct the problem.

Ethnic characteristics of the face are also a consideration when performing blepharoplasty, as is age, skin type, and if vision obstruction is present. In terms of ethnic characteristics, Asian eyebrows typically differ in appearance from Caucasian eyebrows, according to Dr. Sapijaszko.

Lower eyelid blepharoplasty can be performed either through the trans-cutaneous or transconjunctival approach. In recent years, the trans-cutaneous approach is used less often as more traumas to the lower eyelid structures can occur.

The transconjunctival approach to lower blepharoplasty is both safe and effective and avoids inflicting trauma on the cutaneous structures. It is critical to avoid the inferior oblique muscle, he says. The transconjunctival approach corrects eyelid puffiness caused by excess fat. The scars following surgical blepharoplasty are barely perceptible, and the time to perform the procedure is typically one to two hours.

Nonsurgical blepharoplasty involves the injection of facial fillers, which are typically administered under the lower eyelid and the cheek. This procedure corrects the appearance of fatigue or dark circles. The procedure is well tolerated and usually does not produce significant bruising.

Blepharoplasty is not the only answer to the full facial rejuvenation, and additional non-surgical therapies are usually helpful. Furthermore, patients need to be informed that they are doing damage to their skin by practicing habits such as smoking or sun bathing and that such damage will likely detract from the final aesthetic result, Dr. Sapijaszko adds. DT