Thorough preoperative evaluation with meticulous surgical planning to achieve facial aesthetic balance between the forehead, eyelids, and midface is imperative to avoid or decrease potential functional and/or cosmetic complications in cosmetic periocular surgery. Before performing surgery, the physician should be aware of the patient’s history of dry eyes, previous facial trauma, previous injection of Botox Cosmetic, history of previous laser-assisted in situ keratomileusis, and past facial surgery. A full evaluation should be performed on the upper eyelid/brow region to assess for the presence of brow ptosis, brow/eyelid asymmetry, dermatochalasis/pseudodermatochalasis, eyelid ptosis, and deep superior sulcus. On the lower eyelid/cheek examination, special attention should be directed to the diagnosis of underlying negative vector, dry eyes, prominent eyes, lower lid retraction, ectropion, lateral canthal dystopia, lower eyelid laxity, scleral show, and lagophthalmos, with a rejuvenation goal that focuses on obtaining a youthful fullness through repositioning and reinforcing efforts to avoid the negative effects of hollowness. Intraoperative and postoperative medical and surgical management of cosmetic periocular surgery complications focus on decreasing the risk of postoperative ptosis, lagophthalmos, lid retraction, and lid asymmetry, with special attention to limiting the risk of visual loss secondary to orbital hemorrhage.
The ultimate rejuvenation goal of cosmetic periocular surgery is to achieve an aesthetic balance between the forehead, periocular area, and midface. As patients who seek cosmetic surgery are focused on achieving their ultimate aesthetic result, it is imperative that cosmetic surgeons take the time to focus on the importance of educating patients regarding realistic outcomes and possible complications that may result from the planned procedure. This discussion should emphasize the aging changes that occur in the periocular region, including facial volume loss (deflation), volume shifting (descent), and skin, ligament, muscle, and bone changes, which lead to baggy lids, suborbicularis oculi fat descent, subcutaneous fat loss, and other age-related changes. Cosmetic surgeons should strive to restore fullness with avoidance of procedures/surgeries that result in hollowing and skeletonization. This goal can be achieved by efforts to reposition and reinforce, with an individualized surgical plan for each patient to achieve facial aesthetic balance with a youthful, refreshed appearance.
Because blepharoplasty ranks as one of the most popular cosmetic procedures in the United States, with more than 221,000 cases performed in 2008, thorough preoperative evaluation with meticulous surgical planning is imperative to decrease or even avoid the risk of potential complications (cosmetic and functional) that can occur with facial cosmetic surgery in the periocular region. Possible functional issues following periocular surgery include keratopathy/dry eyes, infection, tearing/ocular irritation, lagophthalmos, hemorrhage/hematoma, diplopia, loss of vision, and/or blindness ( Box 1 ). Postoperative cosmetic problems include asymmetry, deep superior sulcus, periorbital hollowing, lateral canthal dystopia, and unnatural appearance. Complications with functional and cosmetic implications include eyelid malposition, retraction, and ptosis ( Box 2 ). It is imperative that the cosmetic surgeon does not focus on the amount of tissue removed in periocular surgery; instead, the surgical goals should focus on the importance of preservation of tissue to retain a youthful symmetric fullness through repositioning and reinforcing to achieve optimal aesthetic results.
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