Doctors of aesthetic medicine often "pull to the last" patients who have long been indicated for blepharoplasty or facelift. In turn, plastic surgeons often do not take the methods of cosmetologists seriously (remember the old, good movie: "...Cut! Without waiting for peritonitis"?).
The prejudice of cosmetologists, in my opinion, is based on the fear of an "irreversible result" of plastic surgery. Therefore, in this article, I would like to build a kind of connecting bridge between cosmetology and plastic surgery, to convey to aesthetic doctors the essence and principles of blepharoplasty as an operation, to justify why I use a comprehensive method for periorbital correction, namely surgery, volumization and peeling - the combination of procedures that gives the most significant and long-lasting result.
It should be noted that cosmetologists have some prejudice against blepharoplasty due to a number of possible complications of this procedure: the most severe ones manifest as the symptoms of "burning eye", "dry lake", etc. In this article, I will try to briefly explain the principles of the operation and demonstrate why certain undesirable effects occur and how we can prevent or mitigate them to the best of our ability.
SOME FEATURES OF BLEPHAROPLASTY
The principles of suturing in classical lower blepharoplasty in any case lead to a certain "rounding" of the eye due to the reduction of the cosmetic scar along the suture line, which gives the undesirable effect of a "rounded lower eyelid." The planar vertical contraction of the scar tissue after returning the lower eyelid flap to its place sometimes leads to such significant undesirable results of the operation as prolapse of the lower eyelid (symptoms of "standing lake", "dry eye", etc.), and therefore, as long as it is possible to postpone the classic lower blepharoplasty, I try not to resort to it.
Blepharoplasty of the upper eyelid (spindle flap, suture in the fold of the upper eyelid) never gives similar symptoms and is therefore safer.
The maximum negative outcome of upper blepharoplasty is the possibility of some drooping of the eyebrow due to shortening the distance to the lash line, so I often supplement the procedure with an endoscopic upper zone lift.
What is the alternative to the classic lower blepharoplasty - with or without excess skin, with or without fatty hernias? My answer is: lower blepharoplasty with a transconjunctival approach with a one-step median peel of the suborbital zone and possible volumetric compensation of this zone with autofat or hyaluronic acid (HA) filler in the delayed postoperative period.
AN ALTERNATIVE VISION OF CLASSICAL BLEPHAROPLASTY
Thus, transconjunctival blepharoplasty is not so much intended to remove fatty hernias of the lower eyelid (which may not be present) as to compensate for the eyelid-cheek transition, which becomes really obvious with age and is a serious aesthetic defect. It is impossible to compensate for this defect with fillers, since the ligament that runs from the zygomatic bone to the skin that forms this hollow has an extremely rigid, stiff texture and does not stretch when fillers are injected. The use of "camouflage" techniques in this area is fraught with severe swelling and other manifestations of lymphostasis.
In fact, during transconjunctival blepharoplasty, the plastic surgeon separates the pretarsal ligament from the bone with a wet tupfer, which allows the lifting portion of the circular muscle of the eye to lift the weakened and overgrown edge of the lower eyelid tissue.
Commentary for fellow surgeons: I separate the tissues no further than 3 mm from the edge of the orbit in order not to injure the second inferior ligament. This caution can be explained by the fact that I very often combine lower blepharoplasty with middle third volumization. During the volumizing procedure (autofat or Teosyal Deep Line in the delayed period), we perform a fan-shaped filling of the middle third from the most prominent point of the zygomatic bone towards the orbit, forming a supraosseous compartment. The fat does not penetrate into the transconjunctival incision, as it is limited by this inferior ligament, and the volume of fat injected is located supraperiosteal, below the second ligament (nasolacrimal ligament).
If we perform the intervention incompletely, with significant soft tissue trauma, we combine a simple transconjunctival separation of the ligament from the bone and at the same time superficial postoperative peeling. Phenol peeling is not recommended in this situation due to the unpredictable response of injured tissues.
I usually perform TCA Skin Tech of various concentrations as the most effective (which in the case of peels is often synonymous with "aggressive") and at the same time highly controlled, and therefore safe peeling.
The presence of a demarcation line quickly becomes invisible if you use the scalloped method of applying the Philippe Despres peeling composition. During exfoliation, skin retraction occurs, as a result of which the smooth edge of the peeling application will become a real skin drop, and the scalloped edge will not give such a drop during skin contraction (Fig. 3).
So, after separating the upper ligament from the bone, as soon as we go under the circular muscle of the eye, we get a hole into which a section of the fatty compartment - the central fat - immediately penetrates. If we perform the operation with a laser, we can evaporate the excess subbulbar fatty tissue, if we work with a scalpel, we remove exactly as much as has penetrated the wound channel. After aligning the first central fat pack under the edge of the orbit, we proceed to align the medial one.
A common surgeon's mistake is that they mistake the medial part of the central fat pack for the true medial fat pack (a visual sign of the medial fat pack is a lighter color). After aligning the inner fat pack, we align the outer fat pack (also under the edge of the orbit). Once again, I emphasize that the surgeon removes only the fat that protrudes from the wound opening. In no case is it allowed to press the eyeball from above, as this is likely to lead to excessive removal of subbulbar fat and, as a result, to such an unpleasant symptom of "droopy eye" and skeletalization of the lower edge of the orbit.
As I mentioned, I often combine surgery with middle third volumetry.
In parallel with the volumetry of the suborbital zone, we can perform volumetry of the upper orbital margin. We work with a cannula without fear of damaging the supraorbital and supraorbital nerves, because they are located in anatomical notches and are protected from injury with this technique. The cannulas are injected from the upper outer corner of the orbit, the cannula passes in the supraorbital space, forming the edge of the orbit, adding volume to the upper edge. We use soft, low-hydrophilic fillers.
Let me remind you that the peeling stage is performed immediately during the operation: I use 15% Skin Tech TCA Pain Control or even Skin Tech Easy Phen Light. It should be borne in mind that too much white frosting should not be allowed, as tissue permeability is much higher during surgery.
I specifically do not dwell on such subtleties as eyelid lift reversal, layer-by-layer movement, etc., since the purpose of the article is to familiarize cosmetologists with the features of transconjunctival blepharoplasty, not a detailed analysis of the surgical intervention.