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Reply: Refinements in Upper Blepharoplasty: The Five-Step Technique

Rohrich, Rod J. M.D.; Villanueva, Nathaniel L. M.D.; Afrooz, Paul N. M.D.

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 435e
doi: 10.1097/PRS.0000000000005228

Dallas Plastic Surgery Institute

Department of Plastic Surgery, University of Texas Southwestern Medical Center

Dallas Plastic Surgery Institute, Dallas, Texas

Correspondence to Dr. Rohrich, Dallas Plastic Surgery Institute, 9101 North Central Expressway, Suite 600, Dallas, Texas 75231,, Twitter: @DrRodRohrich, Instagram: @Rod.Rohrich, DrNVPlasticSurgery (for Dr. Villanueva)

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Thank you for your interest in our article, “Refinements in Upper Blepharoplasty: The Five-Step Technique.”1 We appreciate that the Asian blepharoplasty is a different procedure and the goals of the procedure vary among the different Asian cultures. Although the authors mentioned that we did not show how to mark the incision on the video, the markings we used are clearly represented at second 35 of the video. Also, the extent of the excision was explained. The amount to be excised is determined preoperatively using a skin pinch technique, which is approximately 7 mm from the lash line in women and 10 mm from the brow at a point on the brow directly vertical from the lateral limbus. The shape of the excision depends on skin laxity but varies from lenticular to trapezoidal. Skin pinch and assessments are performed with the patient in the upright position.

In the technique, the authors describe a “cut-as-you-go” or tailor-tacking technique to verify the shape of the upper lid, which is a good alternative approach. However, using the technique of the senior author (R.J.R.), the amount of skin excision planned also leads to appropriate upper lid shape and is very efficient.

We agree with the discussants that the overall length of the incision laterally is also an important consideration, and we limit this as much as possible to prevent scarring on the lateral orbital region. We also agree that the length of this incision is critical in patient populations that are prone to poor scar formation.

We find the technique described interesting and applicable to the Asian patient population. However, we disagree with the authors’ point number 3 on the benefits of the infraeyebrow blepharoplasty. During any blepharoplasty procedure, whether upper lid versus infraeyebrow blepharoplasty, the notion that you can pull brow skin onto the upper lid is a fallacy. There are retaining ligaments that prevent that, and the thickness of the dermis in the brow has greater recoil properties than the thin eyelid skin, further preventing the pulling of the brow skin onto the eyelid as the authors have described. We also agree with the authors that the procedure they described may not be applicable for non-Asian patients.

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Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing. He is a clinical and research study expert for Allergan, Inc., Galderma, and MTF Biologics, and the owner of Medical Seminars of Texas, LLC. The remaining authors have no financial interests to disclose. No funding was received for this communication.

Rod J. Rohrich, M.D.
Dallas Plastic Surgery Institute

Nathaniel L. Villanueva, M.D.
Department of Plastic Surgery
University of Texas Southwestern Medical Center

Paul N. Afrooz, M.D.
Dallas Plastic Surgery Institute
Dallas, Texas

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1. Rohrich RJ, Villanueva NL, Afrooz PN. Refinements in upper blepharoplasty: The five-step technique. Plast Reconstr Surg. 2018;141:1144–1146.
Copyright © 2018 by the American Society of Plastic Surgeons