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Preservation blepharoplasty, the new paradigm.

By Dr. José Villamarín.

Today we are going to talk about eyelid surgery or preservation blepharoplasty, focused from minimal invasion to achieve natural results.

Facial rejuvenation includes the recovery of lost shapes in the eyelids and the middle third of the face. This is possibly the most important area in facial recognition and expressiveness, and the one that plays the greatest role in defining the beauty of the face. Unfortunately, it is one of the first areas to age, and its impact on the deterioration of personal image is crucial.

East Coast vs. West Coast

Years ago, operating face and neck rejuvenation hand in hand with a surgeon from the United States, specifically Los Angeles, California, I noticed his tendency to perform procedures with greater length, depth, and dissection area than mine, especially in blepharoplasties and in face and neck lifts.

At the end of the surgical day, when asked about his reasons, he replied that the West Coast, and particularly Los Angeles, is oriented in cosmetic surgery to Hollywood trends, which often includes a change of varying degree in personal features, and the achievement of more striking results; this frequently requires more invasive procedures and with greater depth or extension of dissection. However, on the East Coast of the United States, the trend is the opposite, and more natural results are sought, with preservation of both the structures to be operated on and personal characteristics, through less invasive procedures.

It is obvious that each surgeon has to decide his style, his artistic path based on his free will and his academic freedom within those four quasi-sacrosanct walls of the operating room. I have decided, from the beginning, to seek an Aristotelian balance between the extremes, to honestly satisfy the demands of each patient, the center of my practice as a surgeon for almost 30 years.

My tendency and recommendation is to pursue natural results without looking for supernatural effects, if I may express myself, that is to say, without changing the personal characteristics of the patient, returning him backwards in the operating room time machine, to rejuvenate him naturally. To do this, I rely whenever I can on minimally invasive surgery and preservation techniques.

Blepharoplasty, an ancient technique in constant changes

Blepharoplasty is an eyelid surgery that is performed for different purposes. It can be reconstructive after injuries or tumors, or it can be purely aesthetic or cosmetic, in otherwise healthy people who want to improve their image or rejuvenate. Aesthetic blepharoplasty has historically gone through many changes in its technique.

The pioneers of aesthetic and reconstructive blepharoplasty have been ophthalmologists, since the eyelids are an inseparable and protective part of the eyes and the sense of vision. For many years, the techniques have been designed by ophthalmologists (possibly the oldest surgical specialty in the history of Medicine), but with the creation of new specialties after the First World War, such as plastic surgery (a general specialty, not focused on an exclusive area of the body), more doctors have signed up to operate on the eyelids.

What is preservation blepharoplasty?

Essentially, preservation blepharoplasty consists of preserving or minimizing the removal of tissue in the operative process. The historical evolution of aesthetic blepharoplasty is very clear. At the beginning, the reconstruction techniques were not very careful with the final aesthetics, due to a different perception or sensibility of society compared to what exists now.

Little by little, they began to care for and refine the details of surgical wound closure, and to design less invasive or extensive procedures to solve wounds or defects after tumor removal. This was transferred to purely aesthetic procedures in healthy people but with aging over the years.

Over time, increasingly ingenious techniques have been devised to reduce surgical steps and dissection. All this has come to be called minimally invasive surgery.

In recent years, a further step has been taken by including the concept of preservation blepharoplasty in procedures, a natural evolution of cosmetic surgery, which also extends to face and neck lifts or rhinoplasty. It consists of drastically reducing the removal of tissues and preserving or transposing them (changing their location) whenever we can.

What are the main techniques in preservation blepharoplasty?

The main tissues to which we apply the concept of preservation blepharoplasty are several. Among these tissues we can include skin, fat, muscle, fascia, cartilage or bone.

On the skin, we reduce the surgical incision and skin removal to the minimum necessary to avoid tension and maintain a natural result, particularly in men and some ethnicities.

On the other hand, with fat we can perform many techniques, which I personalize for each patient. For example, we reduce the volume of fat that we remove, both from the subcutaneous tissue and from the orbital fat pads, we change or transpose some fat volumes in the eyelids and we also sculpt the shape of said fat pads, with the ultimate goal of reducing the possibility of skeletonization or sunken eyes after surgery.

Regarding the muscles, be it the orbicularis oculi, the depressor supercilii, the procerus, the corrugator or others, it is common to act on them to eliminate wrinkles, tractions, scallops, blurred vision or spasms, but we try to avoid extirpations or wide incisions and with the highest efficiency, to achieve the best results and avoid sinking in the form of furrows, permanent tearing, severe dry eye problems, or permanent drooping eyelids.

We try to preserve the fascia, that is, dense tissues that keep other tissues apart or favor movement and sliding of some anatomical areas. We try to minimize the incisions and dissections of these fascias, rebuilding them delicately to avoid unexpected problems.

Sometimes, there are cases of migraines that accompany patients who consult for aging, and that we can try to solve, releasing some condensation of these fascias on nerves that come from the brain and cross the orbit. These condensations on the nerves sometimes cause entrapment and pain, and we free them while performing the blepharoplasty.

Other tissues that we rarely touch are the palpebral cartilage, the canthal ligaments that support the eyelids (canthoplasty, foxy, and cat eyes), the lacrimal gland, the tear excretory circuit that is intimately connected to the eyelids, or the bony edge of the eyelids. the orbit and which also supports the eyelids.

In highly selected cases, we can reposition the sagging gland – otherwise healthy – if it protrudes unsightly, but we avoid partial extirpations, a preservation concept that we also apply to the submandibular gland in neck lift procedures.

Although we almost never modify the bones of the orbital rim and surroundings to preserve it, in extreme cases we can carry out different actions and always for unsightly reasons or to request transformation. These actions are varied, from adding alloplastic implants with the minimum volume and the minimum incision necessary to preserve the rest of the facial structures, to lowering an orbital bone rim using conventional or ultrasonic techniques, but always tending to remove the minimum amount of volume.

The conclusions…

Preserving blepharoplasty is the expected natural trend of evolution in cosmetic surgery, what some call the East Coast philosophy, which seeks to preserve as much tissue volume as possible, to avoid undesirable postoperative effects, be it in blepharoplasty, face or neck lift, rhinoplasty or other procedures.

If you want more information, do not hesitate to contact Dr. José Villamarín requesting an appointment in person or through his online consultation. Thanks.

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