Getting Good Results in Cosmetic Blepharoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Accurately diagnose the cosmetic deformity and thoroughly understand the periorbital surface topography. 2. Develop a preoperative plan and pick the right operation. 3. Master technical tips. 4. Rejuvenate the lateral orbital area. 5. Manage complications. SUMMARY: Getting good results in blepharoplasty requires understanding ideal surface topography, accurate diagnosis of the cosmetic deformity, thorough knowledge of anatomy, and careful technique to change the anatomy. Several approaches have been described; however, the procedure continues to have its shortcomings and share of complications that have both functional and cosmetic consequences. This continuing medical education article focuses on getting good results and maximizing success in upper and lower blepharoplasty through the discussion of five major components: diagnosis and understanding of the cosmetic deformity; preoperative planning; technical tips; rejuvenation of the lateral orbital area; and management of complications.

Patient-reported outcome measurement in upper blepharoplasty: How to measure what the patient sees.

BACKGROUND: Blepharochalasis is very common and affects not only appearance but also visual function. Upper blepharoplasty is therefore the most frequently performed facial cosmetic procedure worldwide. It is generally seen as a small procedure with good patient acceptance and postoperative satisfaction. Research concerning the outcome of this procedure in terms of satisfaction and quality of life is lacking, as well as a recommendation on which assessment tools to use in this patient group. METHOD: A prospective study was performed on patients who underwent blepharoplasty. They were requested to complete a questionnaire preoperatively and at 3-6 months postoperatively. The Blepharoplasty Outcome Evaluation (BOE) and the Derriford Appearance Scale (DAS59) were used preoperatively and postoperatively. Visual analog scales (VAS) were also used preoperatively and postoperatively to measure visual impairment and aesthetic aspects of the eyelids. The Glasgow Benefit Inventory (GBI) was used postoperatively. SUBJECTS: Thirty-six patients completed all questionnaires. They had a mean age of 55 years (range 25-73 years) and 31 were female. MAIN FINDINGS: Reliability of all questionnaires was moderate to good. Both satisfaction with the eyes and self-esteem improved significantly. Patients reported significant benefits afterwards. All scales showed significant correlations with the exception of several DAS59 subscales. CONCLUSIONS: Upper blepharoplasty can result in great improvement in patient satisfaction, self-consciousness of appearance and benefit in daily life. Only the general subscale of the DAS59 seems relevant to use in this patient group. The BOE and GBI are brief but excellent tools to use in patients who underwent blepharoplasty to measure satisfaction and benefit in daily life.

Functional benefits and patient satisfaction with upper blepharoplasty - evaluated by objective and subjective outcome measures.

PURPOSE: To investigate the functional benefits and patient satisfaction with upper blepharoplasty in patients meeting the Danish visitation guidelines for upper blepharoplasty from the Danish Health and Medicines Authority (Sundhedsstyrelsen). METHODS: Before and 3 months after upper blepharoplasty, the following investigations were made: (i) a standard eye examination, (ii) photographic documentation with a normal camera and the infrared camera of a Spectralis Optical Coherence Tomograph and (iii) measurements of the upper visual fields using the blepharoptosis test of Octopus 900. Along with the pre- and postoperative examinations, the patients completed a questionnaire concerning the functional and psychosocial impact of their eyelids. RESULTS: Ninety eyelids of 45 patients were studied, 34 females and 11 males. The mean age was 56.9 years (SD: 12.8). The mean change in the distance between the upper eyelid skin fold and the visual axis or the marginal reflex distance (MRD), depending on which was lowest, was 1.6 mm (SD: 0.8 mm) for the right eyelids and 1.2 (SD: 0.9 mm) for the left eyelids. The mean improvement in the upper visual field was 31.3% points for the right eyelids (SD: 21.4% points) and 28.3% points for the left eyelids (SD: 24.9% points). A statistically significant correlation between the preoperative distance from skin fold to visual axis/MRD and the pre- and postoperative visual field was found. The patients reported an improvement in their symptoms postoperatively. All subjects were satisfied with the postoperative result and would undergo the surgery again if they had to make the choice again. CONCLUSION: Patients meeting the Danish visitation guidelines for upper blepharoplasty experience a measurable improvement in function and alleviation of symptoms after blepharoplasty.

The plastic surgery postcode lottery in England.

INTRODUCTION AND AIM: The National Health Service (NHS) provides treatment free at the point of delivery to patients. Elective medical procedures in England are funded by 149 independent Primary Care Trusts (PCTs), which are each responsible for patients within a defined geographical area. There is wide variation of availability for many treatments, leading to a "postcode lottery" for healthcare provision in England. The aims were to review funding policies for cosmetic procedures, to evaluate the criteria used to decide eligibility against national guidelines, and to evaluate the extent of any postcode lottery for cosmetic surgery on the National Health Service. This study is the first comprehensive review of funding policies for cosmetic surgery in England. MATERIALS AND METHODS: All PCTs in England were asked for their funding policies for cosmetic procedures including breast reduction & augmentation, removal of implants, mastopexy, abdominoplasty, facelift, blepharoplasty, rhinoplasty, pinnaplasty, body lifting, surgery for gynaecomastia and tattoo removal. RESULTS: Details of policies were received from 124/149 PCTs (83%). Guidelines varied widely; some refuse all procedures, whilst others allow a full range. Different and sometimes contradictory rules governing symptoms, body mass indices, breast sizes, weights, heights, and other criteria are used to assess patients for funding. Nationally produced guidelines were only followed by nine PCTs. DISCUSSION: A "postcode lottery" exists in the UK for plastic surgery procedures, despite national guidelines. Some of the more interesting findings are highlighted.

British Oculoplastic Surgery Society (BOPSS) National Ptosis Survey.

AIM: To assess the results of primary aponeurotic ptosis surgery among UK ophthalmic oculoplastic surgeons, from both the surgeon's and patient's perspective; also to inform and encourage good clinical practice by generating outcomes for individual surgeons, units and for benchmarking purposes. METHODS: A prospective, web-based, non-comparative, interventional study was conducted over a period of 1 year commencing January 2005 and ending December 2005. The data-entry sheet for the preoperative, operative and postoperative data was completed and submitted online via the British Oculoplastic Surgery Society website. Surgical results were assessed objectively (by the surgeon) by measuring the upper lid margin reflex distance (uMRD) and the interlid difference in: MRD, lid show, skin crease and lid contour with the outcome graded as: success, partial success or failed. Surgical results were also assessed subjectively (by the patient) with the outcome graded as: completely satisfied, significantly improved, no change or worse than before the operation. RESULTS: Three hundred and sixty-five patients undergoing primary aponeurotic ptosis repair, from 40 different consultant-led teams with a declared oculoplastic interest and expertise, originating from 27 units across the UK were entered into the study. Using objective criteria, success was achieved in 128/223 (57%) cases, with significantly greater degrees of success seen in patients with mild ptosis and for surgeons who performed ptosis surgery more frequently. Using subjective criteria, 184/282 (65%) of patients were completely satisfied, with a further 89/282 (32%) judging themselves significantly improved. The patients' assessment of the surgery was less critical than that of the surgeons: 46/138 (33%) of patients who were completely satisfied and 37/72 (51%) of those who were significantly improved did not meet the criteria for a successful surgical outcome. The re-operation rate was 8/313 (2.6%). CONCLUSIONS: The authors have generated a valid series of surgical outcomes both for individuals, units and the UK as a whole, expressed in both objective and subjective terms for what we regard as the signature procedure for an oculoplastic surgeon: aponeurotic ptosis surgery. Individual results have been communicated to our members, which will allow them to compare their results with true peer-group-generated figures and will aid appraisal and ultimately revalidation.

Preventing complications in facial plastic surgery.

PURPOSE OF REVIEW: The demand for cosmetic procedures has increased dramatically over the past few years, in part fueled by the prevalence of cosmetic 'makeover shows', increased media coverage on television and easy accessibility to the Internet. This growing social acceptance of aesthetic surgery has caused an increasing number of women and men to undergo elective noninvasive and invasive procedures to enhance their appearance. As the number of patients interested in cosmetic surgery increases and the number of physicians performing these procedures increases, the risk of complications invariably also rises. An article focusing on the prevention of complications in facial plastic surgery, therefore, is clearly appropriate in the current era. RECENT FINDINGS: One of the recurring themes in the literature is preventing complications before they occur. Proper patient selection, a thorough understanding of the anatomy and adhering to proper techniques are some of the methods mentioned to avoid unfavorable outcomes. SUMMARY: The literature is replete with articles that focus on the newest techniques for facial rejuvenation. Only through careful analysis of the pitfalls of cosmetic procedures, however, can the facial plastic surgeon adopt principles to help prevent complications.

Combined arcus marginalis release, preseptal orbicularis muscle sling, and SOOF plication for midfacial rejuvenation.

Improvements have been made throughout the history of medicine, causing physicians to abandon a technique or medications clearly shown to be suboptimal. Unfortunately, this has not happened with rejuvenative surgery. Conventional lower eyelid procedures continue to include removal of orbital fat in most cases, and facelift procedures remain primarily a lateral vector pull. The unfortunate results of these traditional procedures are becoming easy to recognize. Optimal rejuvenation of the lower eyelid complex should be based on the principle that the contour changes characterizing aging involve not only prolapse of orbital fat, but also descent of the cheek tissues, resulting in accentuation of the orbital rim and tear trough groove. Although the necessity of preserving fat and repositioning the soft tissues of the midface has been widely accepted, there still is wide disagreement among authors as to the best approach and surgical technique. This report describes a surgical technique for lower lid midfacial rejuvenation that is a composite of several previously published approaches with some modifications, particularly in the way the Sub-Superficial Musculo Aponeurotic System (SMAS) fat pad is plicated and the midfacial tissues suspended. The technique is simple and safe, resulting in a pleasing natural midface contour.

Current concepts in aesthetic upper blepharoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss nomenclature and anatomy associated with upper blepharoplasty. 2. Perform preoperative assessment, decision-making, and counseling of patients. 3. Describe current surgical planning, eyelid marking, and various techniques used in upper blepharoplasty, including lasers. 4. Recognize and treat postoperative complications from blepharoplasty. Traditional blepharoplasty has often involved the excision of both lax skin and muscle and excessive removal of fat, leaving patients long term with a hollow orbit and a harsh, operated appearance that accelerates the aging process. Current methods of periorbital rejuvenation are more conservative, are based on concise preoperative evaluation, and involve the limited resection of the coveted soft tissue from the eye to restore a youthful appearance. The authors describe anatomy, preoperative assessment, decision-making and counseling of patients, surgical planning, eyelid marking, and various techniques, including lasers, along with postoperative complications associated with current concepts in aesthetic upper blepharoplasty.

Subperiosteal midface lifting: a simplified approach.

A simplified approach to subperiosteal midface lifting with suspension is described, which has been performed on 75 patients since 1986. In comparison with standard facelifting, this technique results in long-lasting vertical resuspension of ptotic midfacial tissues. To date there has been a high rate of patient satisfaction with no cases of nerve injury or hematoma. There is a rare incidence of minor complications.

Nonincisional blepharoplasty using the debulking method.

As more women work outside home, a growing number of women who want to have a natural-looking double eyelid choose the method with a short healing time and less pain. Thus blepharoplasty by the nonincisional method is performed frequently. This technique uses 7-0 nylon for simple triple ring-shaped or center doubled triple ring-shaped suture, with removal of subcutaneous fat, pretarsal muscle, and orbital septum through small incisions. This prevents the possibility that the folds will be loosened. By creation of a scar adhesion between the wider portion of the dermis and the tarsal plate after debulking of the soft tissue, the nonincisional method can be applied to a very thin eyelid without any difficulty.A retrospective review of the data for 327 patients who underwent nonincisional blepharoplasty using the debulking method from November 24, 2000 through March 9, 2003 is presented. Except for four cases, the procedures were successful. Two complications of conjunctivitis occurred, requiring removal of the buried suture, and two patients reported a mild scar.

Outcomes instruments in facial plastic surgery.

The accurate measurement of patient-related outcomes of facial plastic surgery procedures relies upon the development, standardization, and use of validated, procedure-specific quality of life instruments. Although other fields of medicine and surgery have embraced the use of such instruments for the quantification and measurement of otherwise subjective or qualitative aspects of patient satisfaction, in the fields of both general and facial plastic surgery, little has been done in this realm. The study of outcomes research and the application of outcomes research to facial plastic surgery have already been discussed in this issue. Outcomes research is founded upon the ability to measure in some fashion those aspects of patient satisfaction that have hitherto been ignored or at best poorly quantified in the assessment of the results of a medical or surgical intervention. In facial plastic surgery, particularly cosmetic facial plastic surgery, the overwhelming majority of results are subjective in nature, be they patient related or based upon the surgeon's own personal assessment of outcome. For this reason, the use of validated instruments to quantify and measure these results is of particular importance in facial plastic surgery compared with other fields of medicine where many outcomes are objectively determined, such as mortality. This article outlines the background of the use of quality of life instruments in the field of outcomes research to provide a basic understanding for the application of such tools to the work of facial plastic surgery. Specific instruments that have already been developed and validated are described as well. Finally, future directions are highlighted that may allow the improved measurement of patient satisfaction as the field of outcomes research in facial plastic surgery continues to evolve.

Outcomes of facial cosmetic procedures.

Facial cosmetic procedures lend themselves to outcomes studies in ways that traditional reconstructive procedures may not. The most important measures of outcome in facial cosmetic surgery are quality of life and patient satisfaction, in contrast to other, more objective measures such as complications or mortality rates. For this reason, outcomes research in facial cosmetic surgery deserves a special focus of attention. In this article, we review outcomes studies for the more common facial cosmetic procedures, discuss in depth what aspects of patient-related satisfaction have been quantified by these existing studies, and highlight the direction that future outcomes research projects may wish to follow. There exists an abundance of potential interesting areas of study in facial cosmetic surgery, and the application of outcomes research methodology to these realms may allow the facial plastic surgeon to better define the success or failure of each individual facial cosmetic surgery procedure.

Laser blepharoplasty: is it safe?

The complications of the "traditional" blepharoplasty have been well outlined; however, very little can be found on the safety of lasers when used for blepharoplasty. In this article, 20 consecutive patients undergoing laser blepharoplasty are examined preoperatively and postoperatively for eye function and ocular injury by an independent ophthalmologist. Follow-up examinations were performed at random times after surgery ranging from 4 to 60 days, with the majority of patients (17 of 20) seen between 4 and 17 days after surgery. Any changes from the preoperative examinations were recorded. Results demonstrated no complications associated with the use of lasers during blepharoplasty. Safety precautions and surgical procedures are outlined. An attempt is made to separate those hazards specific to the laser technique from the "traditional" blepharoplasty procedure.

Blefaroplastía transconjuntival y Laser resurfacing / Transconjuntival Blepharoplasty and Laser Resurfacing

Treinta y ocho pacientes (treinta y siete mujeres y un hombre) se sometieron a una blefaroplastía transconjuntival con láser resurfacing. El objetivo era evaluar la eficacia y seguridad del láser resurfacing en los tipos de piel III y IV. Métodos: Se utilizó láser flashscanner (Sharplan) en posición 5 a 7 w; 0,2 seg; con punto de 4 a 12 mm. Se les indicó a todos pacientes usar crema (tretinoim) al 0,025 por ciento, Hidroquinona al 3 y ácido glicólico al 6 por ciento. Se presentó hiperpigmentación postinflamatoria en casi el 40 por ciento de los pacientes a pesar de los rigurosos consejos postoperatorios sobre la no exposición al sol y el uso de cremas protectoras. La hiperpigmentación comenzó durante la segunda o tercera semana y desapareció al segundo o tercer mes. Ningún paciente ha tenido hiperpigmentación que haya durado más de seis meses. El camuflaje es muy importante para estos pacientes. Generalmente se reanuda el tratamiento prelaser después de la tercera semana postoperatoria. Conclusión: el skin resurfacing se puede usar para tratar ritidectomías periorbitales en tipos de piel (phototype) III y IV cuando se implementa un buen manejo pre y postoperatorio. El láser de CO2 produce remoción de arrugas junto con contracción del colágeno. Estos mecanismos otorgan a la piel del párpado una mejoría excelente

Blefaroplastía transconjuntival y Laser resurfacing / Transconjuntival Blepharoplasty and Laser Resurfacing

Treinta y ocho pacientes (treinta y siete mujeres y un hombre) se sometieron a una blefaroplastía transconjuntival con láser resurfacing. El objetivo era evaluar la eficacia y seguridad del láser resurfacing en los tipos de piel III y IV. Métodos: Se utilizó láser flashscanner (Sharplan) en posición 5 a 7 w; 0,2 seg; con punto de 4 a 12 mm. Se les indicó a todos pacientes usar crema (tretinoim) al 0,025 por ciento, Hidroquinona al 3 y ácido glicólico al 6 por ciento. Se presentó hiperpigmentación postinflamatoria en casi el 40 por ciento de los pacientes a pesar de los rigurosos consejos postoperatorios sobre la no exposición al sol y el uso de cremas protectoras. La hiperpigmentación comenzó durante la segunda o tercera semana y desapareció al segundo o tercer mes. Ningún paciente ha tenido hiperpigmentación que haya durado más de seis meses. El camuflaje es muy importante para estos pacientes. Generalmente se reanuda el tratamiento prelaser después de la tercera semana postoperatoria. Conclusión: el skin resurfacing se puede usar para tratar ritidectomías periorbitales en tipos de piel (phototype) III y IV cuando se implementa un buen manejo pre y postoperatorio. El láser de CO2 produce remoción de arrugas junto con contracción del colágeno. Estos mecanismos otorgan a la piel del párpado una mejoría excelente