SAN DIEGO Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.
Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.
"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."
While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.
Traditional blepharoplasty often results in an agingnot rejuvenationof the periorbital area, as it tends to emphasize hollows that result from the loss of fat.
"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."
In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.
The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."
Several techniques may fill those hollows:
▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."
▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.
With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."
▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.
▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)
The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.
These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."
The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.