I read with great interest the article entitled “Simplifying Blepharoplasty” by Dr. Zoumalan and Dr. Roostaeian.1 The article is focused on the most important aspects of the blepharoplasty, and it could be considered an important tool for surgeons who are approaching this surgical procedure.
The eye is one of the main targets of facial aesthetics, and blepharoplasty can play an important positive role in the perception of aging. I would like to discuss upper eyelid blepharoplasty, and try to add some details that I hope can be helpful.
Upper blepharoplasty is considered a relatively simple operation with a high benefit-to-tradeoff ratio for patients and consequently a high grade of satisfaction for the surgeon. It can be performed using local anesthesia with a day hospital regimen for recovery, and the patients could benefit from a short postoperative period with a rapid return to everyday life.
However, it is not so rare to find asymmetry in the postoperative period, and for this reason, we want to focus on the importance of the preoperative patient evaluation. A complete ophthalmologic examination should be performed to document preoperative decreased visual acuity or limited visual fields. Other physical examinations should include evaluation of the brow position and the presence of eyelid ptosis.
The meaning of these preoperative evaluations is to identify asymmetries so that the surgeon can correct them simultaneously with blepharoplasty. It is important to evaluate the degree of eyebrow compensation, because all patients have some degree of frontalis resting tone, which is used to keep the eyebrow and eyelid skin out of the visual axis. Blepharoplasty or ptosis surgery decreases the frontalis compensatory drive and may allow the eyebrow to descend,2 so in the case of a preoperative condition of brow ptosis, after surgery, the brow position can be more altered.
Regarding the presence of eyelid ptosis on preoperative evaluation, in our experience, especially in patients older than 45 to 50 years, it is quite common to find even minimal blepharoptosis (usually because of dehiscence of the aponeurosis of the elevator muscle) combined with dermatochalasis. In these cases, both aspects should be corrected to obtain the best cosmetic and functional outcome.
Most cases of ptosis appear unilaterally; however, a condition of hidden bilateral ptosis may exist. In those cases, unilateral correction could determine the postoperative presence of the blepharoptosis on the contralateral side. This is because, according to Hering’s law, when one eyelid is ptotic, the compensatory drive to elevate the eyelid is directed toward both sides.3 If we elevate the more ptotic eyelid, the compensatory drive to both sides is reduced so that the opposite eyelid may become ptotic.4 Actually, in cases of unilateral blepharoptosis, it is mandatory to evaluate the contralateral eyelid to identify a hidden ptosis that, if not treated, could result in asymmetry.
In conclusion, I think that, behind its appearance of simplicity of execution, upper blepharoplasty can mask some insidious aspects that could result in embarrassing asymmetry in the postoperative period. A detailed preoperative examination of patients and knowledge of the balanced system of all muscles implicated (i.e., frontalis, elevator of upper eyelid, Müller, and orbicularis oculi) help to avoid complications.
The author has no financial interest to declare in relation to the content of this communication.
Francesco Idone, M.D.
Jalisco Plastic and Reconstructive Institute
University of Guadalajara
Avenida Federalismo Norte, Suite 2022
Guadalajara, Jalisco, México
1. Zoumalan C, Roostaeian J. Simplifying blepharoplasty. Plast Reconstr Surg. 2016;137:196e213e.
2. Teske SA, Kersten RC, Devoto MH, Kulwin DR. Hering’s law and eyebrow position. Ophthal Plast Reconstr Surg. 1998;14:105106.
3. Lew H, Goldberg RA. Maximizing symmetry in upper blepharoplasty: The role of microptosis surgery. Plast Reconstr Surg. 2016;137:296e304e.
4. Wladis EJ, Gausas RE. Transient descent of the contralateral eyelid in unilateral ptosis surgery. Ophthal Plast Reconstr Surg. 2008;24:348351.
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