Plastic Aesthetic and Laser Surgery, Hygeia hospital, Athens, Greece
KeywordsClassic blepharoplastyRemove or restore tissuesFat pad preservationFullness of the eyelid Heaviness of the eyelidLaser in blepharoplasty
2.1 The Classic Blepharoplasty
Blepharoplasty is one of the most commonly performed procedures in aesthetic plastic surgery. The term comes from the Greek words “blepharo” (eyelid) and “plasso” (to form).
Various techniques and approaches have been advocated through the years, and the literature is replete with published reports. These approaches include variances in skin incisions (cold steel, laser, radiofrequency), the transconjunctival approach, fat excision, fat transposition, lacrimal gland suspension, canthopexy, skin flaps, skin–muscle flaps, additional chemical peels, and laser skin resurfacing. No operation or standard combination of operations meets the needs of every patient. Equipment costs and marketing methods, unfortunately, also play a role in the decisions of surgeons and patients.
Traditional blepharoplasty has often involved the excision of lax skin and muscle, and in the past excessive removal of fat, leaving patients with hollow orbits and an appearance that accelerates the aging process. Modern methods of periorbital rejuvenation are more conservative, involving limited resection of the affected soft tissue from the eye to restore a youthful appearance.
The basic surgical steps in traditional blepharoplasty consist of redundant skin excision of the upper and lower eyelids, excision of orbicularis oculi muscle excess, retroseptal fat excision, and several canthopexy and canthoplasty techniques depending on the patients’ indications.
2.1.1 Quick Literature Review and the Recent Trends in Classic Blepharoplasty
Blepharoplasty was originally described by Karl Ferdinand Von Grafe in 1818 to describe a case of eyelid reconstruction he performed in 1809.
In 1913, American Encyclopedia of Ophthalmology defined blepharoplasty as the reformation, replacement, readjustment, or transplantation of eyelid tissues. The surgeons have recognized cosmetic indications only since twentieth century. This change followed the development of improved operative techniques, better surgical results, and control of sepsis.
In 1920, Suzanne Noel, a Parisian surgeon wrote a book on cosmetic eyelid surgery. She mentioned the importance of preoperative planning using photographs. In 1924, Julian Bourguet was the first to describe the transconjunctival approach for the removal of the restroseptal fat. In 1929, he described the removal of fat from the two separate compartments of the upper eyelid. In the 1950s, Castanares described the detailed anatomy of the eyelids and pointed out the importance of orbicularis resection in blepharoplasty and its contribution to better aesthetic results .
In the past, surgeons were very aggressive with eyelid tissues resection, a fact that contributed to unpleasant results in patients who were followed up after years. The creation of hollow eyes and “amputated eyelids” was very common.
The recent trend in blepharoplasty is the maintenance of “fullness” of the eyelids with concomitant correction of the “heaviness,” which is actually the main concern of the majority of patients. This can be achieved by detailed preoperative clinical examination, conservative tissue dissection and excision, always in discussion with the patients, and explanation of the aesthetic anatomy and expectations.
2.2 Innovations of the Blepharoplasty Technique
Despite the enormous evolution of techniques in aesthetic surgery in the last two decades, the blepharoplasty techniques which are described in the past have not changed excessively, at least regarding the basic steps of the classic operation, as described earlier. The widely accepted fact of the conservative excision of eyelid structures (skin, muscle, fat) is the most important development of the technique in the recent years, together with the evolution of the technology devices that have importantly invaded the field of aesthetic blepharoplasty. The laser technology and other devices (radiofrequency, etc.), if wisely used, contribute to less tissue damage and offer quicker postoperative downtime and minimization of complications.