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1177/0748806817700534The American Journal of Cosmetic SurgeryTroell

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Article
The American Journal of

Peri-orbital Aesthetic Rejuvenation Cosmetic Surgery

111
The Author(s) 2017
Surgical Protocol and Clinical Outcomes Reprints and permissions:
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https://doi.org/10.1177/0748806817700534
DOI: 10.1177/0748806817700534
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Robert J. Troell, MD, FACS1

Abstract
The aim was to examine the validity of a peri-orbital rejuvenation protocol with clinical surgical results evaluating patient
satisfaction and complications. Retrospective patient data and chart review was performed on 367 patients who underwent
a blepharoplasty procedure. Outcome measures were dependent upon direct patient responses on postoperative visits,
photographic documentation, and physical examination findings. The other outcome measure was termed a successful
surgical outcome. This definition included the procedure goal was met, no postoperative complication was observed, there
was no need for a revision, and the patient was satisfied with the outcome. From a cosmetic result standpoint, 99.5% (365
of 367 patients) were satisfied with the outcome. There were a total of 456 blepharoplasty surgeries: 203 upper, 75 lower,
and 89 quad blepharoplasties. The patients defined with a successful outcome totaled 94.0% (345 of 367 patients). There
was a complication incidence of 2.5%. Revision surgery occurred in 3% of upper blepharoplasties and in 1.8% of lower
blepharoplasties. Adjuvant procedures performed either at the same time or as a staged procedure to complete the peri-
orbital rejuvenation protocol were as follows: browlift surgery 24, brow or hairline dermal filler placement 4, facial silastic
implant surgery 9, mid-facelift 16, lateral canthopexy 7, facelift 41, laser skin resurfacing 53, trichloroacetic acid peels 19,
radiofrequency skin treatments 19, lower eyelid fat transposition 10, and facial fat transfer 25. The peri-orbital rejuvenation
surgical protocol, surgical blepharoplasty techniques, and adjuvant procedure techniques performed revealed a high benefit
to risk profile and high patient satisfaction rate.

Keywords
blepharoplasty, peri-orbital area, browlifts, CO2 laser peels, facelift, facial plastic surgery, fat transfer, synthetic implant issues,
transconjunctival techniques, skin filler substances

Introduction[AQ: 1] restoration of youthfulness, each of these anatomical levels

It has been said that the eyes are the window to ones soul.
The facial assessment that we all unconsciously perform
each day conversing with another involves mostly obser-
vation of the eyes, nose, and teeth followed by their skin.
The most common aesthetic procedures performed in the
United States are neuromodulator injections1 with the most
common sites of treatment performed to lessen the wrin-
kles located in the peri-orbital areas: the glabellar, fore-
head, and lateral orbit area, known as the crows feet.
The most requested areas for dermal filler injections for
volume loss in my practice are the peri-orbital area and
lips. Blepharoplasty is the second most common facial
cosmetic surgical procedure performed today.1 These data
illustrate that peri-orbital rejuvenation is on the forefront
of our patients minds. Peri-orbital aesthetics is paramount
to beauty.
The aging process alters the surface of our skin down to
the bony framework of our being.2-4 To optimize the
should be addressed: the facial bones, especially the maxilla
and mandible,2 atrophy with age resulting in facial volume
losses that cause excess skin, ptotic soft tissue, and formation
of deepened creases.3,4
Facial animation muscle contraction creates wrinkles and
furrows. Muscle weakness can cause increased scleral show
and lid retraction abnormalities. Connective tissue loss of
structural integrity results in a weaker orbital septum and fat
herniation of the eyelids. This tissue weakness results in
forehead and midface ptosis. This ptosis results in increased
excess upper eyelid skin, festoon formation, and hollowing
of the tear trough and nasojugal groove areas.4 Acquired skin
1
Beauty by Design, Las Vegas, NV, USA
Corresponding Author:
Robert J. Troell, Beauty by Design, 7975 W Sahara Ave, 104, Las Vegas,
NV 89117, USA.
Email: rjtroell@gmail.com
2 The American Journal of Cosmetic Surgery
damage, especially from solar damage and smoking, creates
inelastic skin with fine and course wrinkles.
Understanding the cause and changes created by the aging
process suggests treatments to restore the youthfulness that
we all seek, and few of us can completely achieve. The peri-
orbital aesthetic protocol was constructed early in my career
from training suggestions, new technological and surgical
developments, and clinical investigation.
Some patients chose to embark on all the recommenda-
tions for their peri-orbital and facial rejuvenation, whereas
others elect only some of the recommendations. This article
is designed to identify the procedures that are impactful with
the identification of blepharoplasty surgical techniques,
caveats, and pitfalls to minimize complications and optimize
aesthetic outcomes.
Material and Methods
Patients
Patients either initially requesting blepharoplasty during their
cosmetic initial consultation or during the facial aesthetic
analysis were recommended to proceed with a blepharoplasty
procedure to yield a positive aesthetic improvement.
Comprehensive Facial Analysis
The comprehensive facial examination started at the fore-
head, proceeds to the eyes, to the midface, lower third of the
face, and finally the neck (Figure 1A-C). The most observed
and appreciated facial anatomical area is the peri-orbital
area, followed by the nose, mouth, and the skin. Understanding
the proportions of the aesthetic face5 and knowledge of the
common anatomical issues detracting from the patients
beauty is essential to achieving the optimal final aesthetic
rejuvenation product.
History and Physical Examination
All patients underwent a complete history and physical
examination by the author, a facial plastic and reconstructive
surgeon. Depending on the patients history and physical
findings, additional clearance was acquired by an ophthal-
mologist, internist, or cardiologist. Patients diagnosed with
upper eyelid ptosis or who admitted to experience moderate
to severe eye dryness during the initial consultation or the
preoperative visit were referred to an ophthalmologist prior
to surgical therapy.
The pertinent history elicited at the initial consultation
and/or at the preoperative consultation was as follows:
1. Any previous ocular procedures, such as Lasix, eye-
lid cosmetic surgery
2. Head and neck surgery history, including dental
extractions (which may suggest bleeding disorders)
Figure 1. (A) Anatomical issues of the aging face. (B) Before:
The initial facial comprehensive analysis is the key to the
patient aesthetic story. It sets the immediate and future goals
and a pathway to achieve a rejuvenated outcome and patient
satisfaction. A 63-year-old Caucasian woman requesting upper
blepharoplasty and facial rejuvenation. She did have strabismus
and although physical findings suggested upper eyelid ptosis,
she was not ultimately diagnosed with this entity. (C) After:
The patient underwent a standard facelift with platysmaplasty,
temporal browlift, upper blepharoplasty, perioral and forehead
carbon dioxide laser skin resurfacing (DEKA), and upper lip
augmentation (Perma Lip). She elected not to proceed with
neuromodulators, full face and neck skin resurfacing after the
facelift healed (>30 days), tattooing or dermal filler placement
along the vermillion border, and lower blepharoplasty.
3. Cardiopulmonary disease
4. Diabetes
5. Medication allergies
6. Presence of dry eyes by history
7. Use of contact lenses or refractive glasses
8. Symptoms or exam findings to rule out thyroid dis-
ease (proptosis, lagophthalmos, diplopia, photopho-
bia, eye pain, corneal dryness, and irritation)
9. Timing of neuromodulator injection related to the
date of surgery.
Pertinent physical examination findings correlating with sur-
gical recommendations (Figure 1) were as follows6:
1. Confirmed upper eyelid dermatochalasia, presence of
medial and central fat excess
2. Presence of lacrimal gland ptosis
3. Brow ptosis temporally or throughout entire brow or
forehead
4. Orbital or eyelid asymmetries
5. Lower eyelid excess skin, presence of pseudo-herni-
ation fat in each of the three pads, scleral show, snap
testing to evaluate eyelid laxity, status of movement
of eye musculature
Troell
6. Facial volume loss, especially to tear trough, nasoju-
gal groove, and infra-brow areas
7. Midface or entire facial ptosis and excess skin
8. Presence of wrinkles on the lower eyelid area
9. Festoons.
Preoperative Protocol
Preoperative recommendations to minimize bleeding and
bruising included the following: (1) no fish oil or aspirin for
2 weeks prior to surgery, (2) avoidance of no non-steroidal
anti-inflammatory drugs medications 5 days preoperatively,
and (3) no alcohol 2 days prior. Smokers were urged to stop
smoking 1 month prior to surgery, because of the carbon
monoxide and nicotine vasoconstrictive effects.
Photographic documentation was performed either dur-
ing the preoperative appointment or on the day of surgery.
Postoperative photographs were taken, starting at the
second or third month visit and at 6 and 12 months
postoperatively.
Laboratory Testing
All patients underwent a complete blood count. Women
with a uterus who had not undergone menopause required
a pregnancy test. If patients had symptoms of thyroid dis-
ease, a free T3, free T4, and possibly thyroid stimulating
hormone were ordered. Other testing was acquired per
clinical indication.
Consent Process
Patients sign a photography consent form, a single-page con-
sent denoting all the specific procedures being performed,
and a long consent form. The long consent forms review
each individual procedure being performed, the alternative
treatments, risks, and possible complications in detail. The
main complication discussed of upper blepharoplasty is post-
treatment dry eyes. The main risk of the lower blepharoplasty
is corneal injury and scleral show. These complications are
always clearly presented to every patient.
Surgical Day Protocol
Nearly all patients undergoing blepharoplasty alone under-
went oral sedation and local anesthesia only. When indicated,
intravenous sedation was performed using midazolam
(Versed) with narcotics added as needed. Nearly all blepha-
roplasty patients received either a methylprednisolone taper
(medrol dose pack) or prednisone taper beginning at 60 mg
over 10 days. Steroids were not prescribed in those with dia-
betes or those older than 65 years of age to prevent signifi-
cant blood glucose elevation, insomnia, confusion, and
agitation postoperatively.
3
Figure 2. A 46-year-old Asian female underwent bilateral upper
blepharoplasty with bilateral transconjunctival lower eyelid
blepharoplasty. (A) Before. (B) After (3 months).
Upper Blepharoplasty
With the patient on the operating table lying in the supine
position, the surgeon asked the patient if he or she had any
dry eye symptoms. In Asian patients without a uni-crease,
maintaining this appearance or alteration of the current upper
eyelid crease anatomy to a uni-crease or Caucasian appear-
ance is confirmed (Figure 2).
Most complications can be avoided by comprehensive
assessment of the patient prior to entering the operating
room.6 Excess skin excision is the most common cause of dry
eyes postoperatively. Conservative skin excision decreases
the incidence of dry eye syndrome, however, it does increase
the incidence of excess upper eyelid skin postoperatively. The
temporal or lateral aspect of the upper eyelid was the most
requested area for revision skin excision.
The procedure begins by using a marking pen to place
small dots along the normal anatomical upper eyelid crease
or fold. A Green forceps grabs the skin above the crease until
the lashes of the upper eyelid start rotating upward and the
marking pen places small dots at this location. Once this step
is completed, the upper eyelid crease dots are grabbed
between the tines of the Green forceps to confirm the amount
of skin to remove, but still allowing full eyelid closure.
In patients who stated they had mild dry eyes, a more con-
servative amount of skin (about 2 mm less skin is excised
than the standard measurement technique) was marked for
excision. Patients with more significant dry eye symptoms
confirmed at the initial consultation or preoperatively are
referred to an ophthalmologist for evaluation and treatment.
It is requested that the ophthalmologist tests for adequate
lacrimal gland tear production and an eyelid examination
for complete musculature closure. In most Caucasians who
have not had a previous upper blepharoplasty procedure,
the amount of skin to be removed is between 8 and 10 mm.
In the Asian population, depending on the specific ethnicity,
the amount of excess skin is less; the typical amount of skin
excision is between 5 and 8 mm (Figure 2).
Local anesthesia is injected using a 10-cc syringe and
27-gauge 1 needle through the skin at the lateral aspect of
the orbit and in the upper eyelid skin as the injection moves
medially. Approximately 3 cc of local anesthesia is injected
4 The American Journal of Cosmetic Surgery
into each upper eyelid. The local anesthesia formulation is 4
cc of 1% lidocaine with 1:100 000 epinephrine, 5 cc of 0.25%
bupivacaine with 1:200 000 epinephrine, and 1 cc of 8.4%
bicarbonate.
Lower Blepharoplasty
Transconjunctival approach. Two drops of tetracaine 4% are
administered to each globe of the eye. The fat pads are
injected with approximated 1 cc of local anesthetic into each
fat pad using a 10-cc syringe and 27-gauge 1 needle
through the skin at the lateral aspect of the orbit. The patient
is asked to open the eyes, the skin of the face is pulled down
with the left hand, and the conjunctival mucosa is injected
with the surgeons dominate right hand.
If a skin pinch is to be performed, Brown Adson forceps
pinch the excess skin between its tines up to the point where
the lower eyelid lashes turn outward.
Subciliary transcutaneous approach. The marking pen places
dots about 2 mm below the lashes from medial to laterally. At
the lateral aspect, there usually is a horizontal wrinkle or
crease extending onto the frontal process of the zygomatic
bone at the lateral orbit. Care has to be taken to minimize the
amount of lateral extension of the incision to minimize a vis-
ible scar. It is best to perform this approach with the patient
in the awake state and is cooperative. The awake state ensures
that the patient can open his or her mouth at the time of the
skin-muscle flap tissue excision to minimize excess tissue
removal. This excess excision would result in either increased
scleral show or ectropion formation. On healing, there is
some scar contraction. Conservative tissue excision is rec-
ommended to take this additional reduction of skin-muscle
coverage into consideration.
Facial Preparation and Draping
Once the local injection is completed, the face is prepped
with chloroxylenol, instead of chlorhexidine (hibiclens), to
reduce the risk of inflammatory conjunctivitis. Once the
preparation solution application is complete, sterile towels
are placed. Surgery is begun at least 10 minutes after the
local anesthetic is injected to optimize the hemostatic effects
of the epinephrine.
Peri-orbital Aesthetic Treatment
Protocol
This comprehensive treatment protocol was formulated
to address all aspects of the peri-orbital aging process. If
excess skin and/or herniated fat to the upper or lower eye-
lids was confirmed by examination and the patient desired
correction, blepharoplasty was performed. During the
examination, if moderate or severe brow ptosis was noted,
the patient was recommended to undergo some surgical
technique of browlift surgery first.7 In 2015, patients were
presented the option of either temporal fossa siliastic
implant surgery or dermal filler placement as alternatives
to browlift surgery. The dermal filler recommendation
was for a polymethylmethacrylate (PMMA; Bellafill) col-
lagen gel placement above the brow hair, in the hairline
and/or into the temporal fossa. If midface ptosis was
noted, the patient was recommended to undergo either a
facelift or mid-facelift. The treatment recommendations
were dependent on the presence of festoons, the presence
of facial volume deficiency, the location and amount of
facial ptosis, and excess skin.
The lower blepharoplasty procedure was performed with
different techniques depending on the patients anatomy. The
technique alternatives included the following: (1) a transcon-
junctival approach for fat herniation with no or mild excess
skin, and (2) a subciliary transcutaneous approach for mod-
erate to severe excess skin with or without pseudo-herniated
fat. The other lower eyelid surgical technique alternatives
were related to the presence of significant lower eyelid weak-
ness with excess skin or midface ptosis. In this instance, the
alternatives included (1) a transconjunctival approach for fat
removal and a skin pinch technique for skin excision, (2)
adding a lateral canthopexy to either the transconjunctival
approach or subciliary approach, and (3) adding a mid-face-
lift for facial ptosis in the midface area.
Those with festoons were treated with a mid-facelift,
dermal fillers above and below the festoon, external radio-
frequency (RF) energy delivery, or a new adaptation of the
VASER ultrasound technology to the festoon itself without
performing liposuction. These procedures either camou-
flage the festoon or cause the inelastic, excess skin to
tighten. The RF and ultrasound energybased procedures
produce skin tightening and scarify the soft tissue space
under the festoon skin. These tissue changes obliterate the
space containing edema, aesthetically improving or com-
pletely resolving the festoon.
Patients who had facial volume loss in the midface area
were also recommended to treat the volume loss with dermal
fillers to optimize the cosmetic result. The most common
areas treated were the tear trough and nasojugal groove. An
alternative option in this patient population was a lower eye-
lid fat transposition into the fat volumedeficient tear trough
(Figure 3). If this fat transposition did not ultimately resolve
the volume deficiency adequately, the patient was offered
additional filler placement. Patients diagnosed with more
significant facial volume loss were given the option of facial
fat transfer with platelet rich plasma or placement of facial
silastic implants (tear trough, cheek, submalar, combined
midface implant, temporal, chin or mandible angle, and
ramus implants).
The surgeon educated the patient on all alternative
options and specific recommendations. However, the ulti-
mate decision to perform a particular procedure rested
with the patient.
Troell
Figure 3. A 48-year-old Hispanic male underwent upper
blepharoplasty with lower transconjunctival blepharoplasty with
fat transposition to the volume-deficient tear trough. (A) Before.
(B) After (3 months postoperatively).
Surgical Techniques
Upper Blepharoplasty
A 15 blade makes an incision along the upper eyelid skin
crease with the incision starting medially and traversing lat-
erally with the skin under tension. The same is done with the
previous superior mark for skin excision of the upper eyelid.
The skin above the orbicularis muscle is excised with a 15
blade alone. An alternative method is to undermine the skin
with scissors followed by skin excision. A 2-mm strip of the
orbicularis oculi muscle is excised from the superior aspect
of the incision. Making this tissue excision at the superior
aspect prevents inadvertent injury to the levator muscle or its
fascia. Hemostasis is performed using a Colorado needle at a
cautery energy level of about 12.
With the assistant holding cotton tip applicators on the
superior and inferior raw eyelid tissue margins in the mid-
line to spread the tissue apart, the orbital septum is elevated
with forceps. The orbital septum is entered using scissors,
opening the septum to allow fat egress or herniation. Earlier
in my career much of the fat of the central fat pad was
excised per my training. I transitioned to allow more central
volume retention from less fat excision to acquire a more
rejuvenated appearance. The entire medial fat pad is com-
pletely excised or cauterized. The visual appearance of the
fatty central pad is less firm and more yellow in color,
whereas the medial fat pad is firmer and white in color. This
anatomy can assist the surgeon in knowing that both fat
pads were addressed. Following these caveats increases the
chance of achieving an excellent cosmetic outcome while
minimizing risks (Figure 4).
A rare patient (n = 2) with lateral upper eyelid fullness
was diagnosed with lacrimal gland ptosis. The lacrimal gland
5
Figure 4. A 50-year-old Caucasian woman underwent upper
blepharoplasty, carbon dioxide laser skin resurfacing, dysport
neuromodulator placement to the forehead, glabellar and crows
feet wrinkles and correction of volume-deficient areas of the
face with dermal filler placement to the tear trough and nasojugal
groove.
ptosis was treated by gently dissecting the gland from the
surrounding soft tissue and tacking the gland at a superior
position at the anterior and posterior aspects of the gland.
To lower complication rates, caution should be taken to
not extend the medial incision onto the thicker adjacent nasal
skin. This may result in either a more obvious scar or a
medial scar band. When there is more excess skin medially,
a more rounded than elliptical skin excision can be per-
formed without extending medially. The same can be per-
formed if there is more skin at the lateral extent of the
incision, as the scar is more noticeable when the incision
extends onto the bony lateral orbit.
Hemostasis is again acquired. The wound is closed with a
5-0 running, subcuticular nylon suture technique. Patients
are cautioned to only place cold compresses on their eyes
when the eyelids are closed to prevent a self-producing cor-
neal injury.
The surgeon must use extreme caution in the amount of
skin excision in the following patients: (1) those greater than
65 years of age; (2) patients stating they have mild dry eyes
prior to surgery; and (3) those with excessively inelastic,
crepey skin. The crepey skin makes it difficult to determine
the amount of skin to be excised. This skin stretches instead
of tightening when the skin is placed under tension. These
patients are the most likely to need revision; however, they
are also the patients at highest risk of postoperative dry eye
symptoms.
Lower Eyelid Blepharoplasty
Transconjunctival approach. A Yeager eye shield containing
lacrilube protects the cornea. The mucosal incision is made
with a Colorado needle on the blended cutting mode at an
energy level of 12 immediately below the tarsal plate or
about two-thirds the distance from the lash line to the fornix
of the globe. A 2-prong skin hook is placed into the incision
and pulled inferiorly by the surgical assistant. Thereafter, the
Yeager eye shield is removed. A 5-0 nylon suture is placed
through the superior aspect of this incision and pulls the con-
junctiva over the globe for corneal protection, immobilizing
the suture to the head drape.
6 The American Journal of Cosmetic Surgery
A Green retractor is substituted for the 2-prong skin hook
for retraction to minimize risk of a sharp object injuring the
globe. The medial lower eyelid fat pad is opened with a scis-
sors and separated from the central fat pad with cotton tip
applicators. Dissection identifies the inferior oblique muscle.
This muscle may be very close and adherent to both of the
medial and central fat pads. During the dissection, if the
patient experiences increased discomfort, it is a sign that you
are close to the muscle. The fat pads are grabbed with a pair
of forceps and excised using a Colorado needle. Direct
observation of the heart rate during fat pad manipulation is
essential to rule out bradycardia from the oculocardiac reflex.
Hemostasis is attained after applying a cold compress.
Caution is observed not to excise too much fat, especially
the fat located below the inferior orbital bony rim. Excess
fat removal skeletonizes the orbital appearance. After the
amount of fat to be removed is finalized, gentle pressure on
the globe may identify additional fat herniation. This tech-
nique usually lowers the risk of delayed fat herniation post-
operatively. The soft tissue of the lower eyelid is snapped
back into its premorbid anatomic position. No sutures are
placed.
Fat transposition. If a patient has decided on fat transposition
as the tear trough volume deficiency treatment, the transcon-
junctival approach surgery is altered to some degree. This
technique is only recommended in patients with an adequate
amount of lower eyelid herniated fat. Once the 3 fat pads
(medial, central, and temporal) are identified, they are gently
dissected with cotton tip applicators and fine scissors. The
base blood supply and fat attachments are not disturbed to
ensure the fat pads stay viable. However, the fat pads need to
be mobilized adequately to transpose into the tear trough
area. The fat pads are pulled inferiorly into the tear trough
area and sutured with a 5-0 chromic suture. The suture tech-
nique weaves through the skin into the fat pads from medial
to laterally (Figure 2). This method immobilizes each fat pad
in a volume-deficient area of the tear trough space. The
external chromic suture is cut 3 to 5 days postoperatively.
Lower Blepharoplasty
Subciliary transcutaneous approach. A 15 blade makes a 2- to
3-cm length lateral skin incision from the lateral canthus
temporally. A 2-prong skin hook retracts the inferior skin-
muscle flap inferiorly as hemostasis is acquired with elec-
trocautery. A skin-muscle flap is undermined medially. The
incision about 2 mm under the lower eyelid lashes is per-
formed with the scissors. A 5-0 nylon suture is placed at the
superior aspect of the cut orbicularis oculi muscle and
retracts the lower eyelid soft tissue over the globe to prevent
corneal injury. A green retractor and 2-prong skin hook are
used to pull down the skin-muscle flap as hemostasis is
again attained. The fat pads are re-injected with local anes-
thesia. Forceps lift the orbital septum and the 3 fat pads are
identified. A Colorado needle excises the excess fat that is
dissected using cotton tip applicators. A clamp is not used
on the fat pads, as this can increase the risk of blood vessel
rupture postoperatively.
Hemostasis is acquired with electrocautery. The patient is
instructed to open his or her mouth as the amount of the skin-
muscle flap to be excised is determined in a stepwise fashion
from medial to lateral. The surgeon needs to leave more skin
than is measured (about 2 mm) for postoperative scar con-
traction and downward retraction of the eyelid, especially if
there is not adequate skin and/or lower eyelid support. If
examination suggests additional support is required, a lateral
canthopexy or lid shortening procedure is performed to opti-
mize lower eyelid strength. The need for this procedure is
nearly always determined during the preoperative eyelid
examination or, less commonly, at the time of the skin-mus-
cle flap excess excision. These maneuvers are designed to
prevent scleral show or ectropion formation postoperatively.
A tacking suture is placed at the location of the L transition
of the incision, located at the vertical line dropped down
from the lateral canthal tendon insertion. The wound is
closed in a running subcuticular 5-0 nylon suture technique,
placing a loop with the suture tied to itself on either end,
which allows uncomplicated suture removal.
Lateral canthopexy. When the lower eyelid is determined to
have inadequate strength diagnosed either visually with
scleral show or has a weak lower eyelid snap test, a lateral
canthopexy is recommended. An incision is made on the
lower eyelid lateral canthal tendon at the apex of the superior
and inferior tendon insertion. Skin is excised containing
lashes for about a 5- to 7-mm length and 3-mm height of skin
excision to isolate the tendon. A permanent suture of either
5-0 or 6-0 polypropylene (Prolene) or nylon (Ethilon) immo-
bilizes the tendon to the lateral orbital periosteum. The goals
of the canthopexy are to make each eye symmetric with the
same height of lower eyelid lateral elevation with the fixa-
tion, avoid blunting the lateral commissure, and to ensure the
lower eyelid tissue rests gently on the globe of the eye. This
later effect occurs when the fixation suture is not placed too
anterior on the lateral orbital periosteum. This position will
pull the eyelid away from the globe, creating both a cosmetic
deficiency and eye dryness.
Outcome Measures
With regard to facial plastic surgery, result analysis is a sub-
jective evaluation by the patient and physician. However,
patient-reported outcome measures (PROMs) attempt to
quantify these qualitative results in an objective manner.
PROM emphasis is on the effectiveness of outcome and satis-
faction, quality of life (physical, emotional, and social func-
tioning), and complications.9 There are several ways in which
surgical benefit can be measured, including clinical scales,
functional ability scales, and global quality-of-life scales.9,10
Troell 7

In an attempt to find a PROM that was the most appropri- Table 1. Patient Data.
ate or accepted as the standard in the industry, several litera-
Patient profile Blepharoplasty profile
ture searches were conducted using a combination of the
following terms and phrases: face/surgery, blepharoplasty, Total patients, 367 Total surgeries, 456
plastic surgery, cosmetic techniques, reconstructive surgical Women, 319 Upper alone, 203
procedures, eyelids/surgery, surveys and questionnaires, Men, 48 Lower alone, 75
patient satisfaction, treatment outcome, quality of life, out- Combined, 89
come assessment (health care), patient outcome assessment,
PROM, PROMs, and patient-reported outcomes. In addi-
tion, filters for English language articles published in the Table 2. Peri-orbital Rejuvenation Protocol Outcomes.
last 10 years were used, but a few older articles that specifi- Patient category No. %
cally mentioned the blepharoplasty outcome evaluation
(BOE) tool were included. Patient subjective satisfaction 365 99.50
The Glasgow Benefit Inventory (GBI)10 and the BOE Surgical success 345 94.00
(BOE)9 are examples of scales assessing the patients general Blepharoplasty complications 9 2.50
perception of well-being, with psychological, social, and Blepharoplasty revisions (total) 13 2.90
Blepharoplasty revisions (upper) 10 3.40
physical subscales.
Blepharoplasty revisions (lower) 3 1.80
One review article examined 442 articles, and identi-
fied 47 PROMs assessing facial appearance after a cos-
metic procedure. 11 Only 9 questionnaires satisfied their
inclusion and exclusion criteria. The researchers con- Results
cluded that a valid, reliable, and responsive instrument
Overall Review
designed to measure patient-reported outcomes follow-
ing surgical and nonsurgical facial rejuvenation is still The patients enrolled in the peri-orbital rejuvenation proto-
lacking.11 col were 87% women (n = 319) and 13% men (n = 48) with
As no researched outcome measure regarding the indica- an age range between 32 and 84 years. There were a total of
tion for surgery of cosmetic blepharoplasty was superior to 203 patients undergoing upper blepharoplasty, with 75
another or has been accepted by practicing physicians as the undergoing a lower blepharoplasty and 89 who had a com-
standard of practice, the author used the following 2 assess- bined upper and lower (quad) blepharoplasty. There was a
ments as an outcome measure. total of 456 total blepharoplasty procedures performed in
To determine that the patients preoperative expectations 367 patients (Table 1).
were achieved, they were specifically questioned regarding From a cosmetic result standpoint, the protocol revealed
cosmetic and functional issues. Relatives, friends, or signifi- that 99.5% (365 of 367 patients) were satisfied with the final
cant other opinions were not taken into consideration in con- blepharoplasty outcome. The patients defined with a suc-
trast to other PROM surveys. The following questions were cessful blepharoplasty outcome totaled 94.0% (345 of 367
presented to each blepharoplasty patient during postopera- patients; Table 2).
tive visits: (1) Do you have dry eyes? (2) Are you happy with Evaluating the amount of measured skin for excision in
the present eye shape? (3) Do you feel you have excess eye- 20 consecutive upper blepharoplasty patients who did not
lid skin? (4) Do you have excess fullness anywhere? (5) Is experience dry eye symptoms postoperatively, the mean
there anything we can do to change the eyelid appearance at width measured vertically above the pupillary line was 9.6
this time? Subjective patient satisfaction responses were mm with a range of 7 to 12 mm. The minimal amount of skin
noted at each postoperative visit, especially at 5 to 6 months excised during the protocol period from upper blepharo-
when the final appearance was most likely. Photographic plasty was 5 mm (Asian woman) and the maximum amount
documentation was performed starting at the second postop- of skin excision was 16 mm (Caucasian man and woman).
erative month.
The other outcome measure, termed a successful out-
Revision Blepharoplasty
come, required the following criteria: (1) the goal of the pro-
cedure was met (eg, removing excess skin and fat), (2) Eighteen patients (6.2%) who presented for upper blepharo-
avoidance of postoperative complications, (3) no need for a plasty had a previous blepharoplasty procedure 8 to 15 years
revision procedure, and (4) the patient was satisfied with the earlier. The amount of skin excision (mean 9.2 mm) was
cosmetic outcome. The successful surgical outcome defini- slightly less than that for a primary upper blepharoplasty
tion satisfied the variables of the PROMs: effectiveness of patient (mean 9.6 mm). Many did not have evidence that the
outcome and patient satisfaction with regard to the quality of fat pads were treated previously as there was absence of scar
life (physical, emotional, and social functioning), and obser- tissue in these areas. The indication to remove fat on revision
vation for complications. cases was its excess presence (Figure 5). In patients with no
8 The American Journal of Cosmetic Surgery
Figure 5. A 48-year-old Middle Eastern female underwent upper
blepharoplasty (revision of previous blepharoplasty) and lower
eyelid transconjunctival blepharoplasty. (A) Before. (B) After
(9 months postoperatively).
observed herniated fat during the preoperative examination,
the fat pads were not addressed.
Ten patients (3.4%) undergoing upper blepharoplasty
desired more skin excision to some part of the incision (2-4
mm of skin excision) compared with 3 patients (1.8%) who
underwent lower eyelid surgery (Table 2). The lower eyelid
revisions were for repeat fat pad excision in 2 patients and 1
who developed mild lateral scleral show. This latter patient
was treated with a dermal filler injection to lift the eyelid
margin.
The upper eyelid revisions were performed under local
anesthesia and involved between one-third and one-half the
total length of the incision. The surgical technique involved
an elliptical skin excision of 2 to 4 mm of excess skin using
a 15 blade and suture closure. Most of the patients requesting
upper eyelid revision had a degree of temporal brow ptosis,
which results in more upper eyelid skin in the sitting or
standing position than was measured in the supine position.
Two patients who underwent a transconjunctival blepha-
roplasty were noted to have a repeat unilateral temporal fat
pad herniation. This was first observed in both patients 4
months postoperatively. The recurrent fat herniation was
treated surgically under local anesthesia with repeat excision
of the single fat pad herniation. The patients requesting revi-
sion blepharoplasty were treated with no additional compli-
cations and complete patient satisfaction.
Proper blepharoplasty surgical technique minimizes
risks.12-14 Patients treated with a methylprednisolone dose
pack or prednisone taper were noted to have much less eyelid
swelling and chemosis.14 Eyelid swelling was considered to
be a normal post-surgical side effect along with bruising and
these were not classified as complications. Three patients
were treated with topical antibiotic and steroid drops
(Tobradex) postoperatively, who had moderate unilateral
chemosis, which resolved within 7 to 10 days. No infections
were observed.
Aesthetic Ancillary Procedures
Ancillary or adjuvant procedures performed either at the
same time or as a staged procedure to complete the peri-orbital
rejuvenation protocol were as follows: browlift surgery, 24;
brow or hairline dermal filler (Bellafill) for a minimally inva-
sive browlift, 4; facial silastic implant surgery, 9; mid-facelift
(combined with a subciliary blepharoplasty and lateral can-
thopexy), 16; isolated lateral canthopexy, 7; mini-facelift and
standard facelift, 41; carbon dioxide laser skin resurfacing,
53; medical grade trichloroacetic acid peels (35% or 50%),
19; RF skin treatments, 19; lower eyelid fat transposition dur-
ing transconjunctival lower blepharoplasty, 10; and facial fat
transfer, 25 (Table 3).
Most patients received neuromodulators (Dysport over
Botox) or dermal fillers. The dermal fillers chosen were
either hyaluronic acid/Restylane lift or PMMA collagen gel/
Bellafill to the midface area. The most common areas for
fillers included the tear trough, nasojugal groove, maxilla,
and nasolabial folds as part of the rejuvenation protocol. Of
the 10 fat transposition patients, 6 (60%) required an addi-
tional filler to completely treat the tear trough volume defi-
ciency. The number of adjuvant procedures totaled 227,
excluding dermal fillers and neuromodulators. Women were
more likely to choose an adjuvant treatment for peri-orbital
rejuvenation and perform a larger number of procedures than
their male counterparts.
Complications
Regarding complications, there were 9 complications noted
on all operated patients, with an incidence of 2.5% (Table 4).
Of the 9 (2.5%) total complications, there were 7 temporary
and 2 permanent complications (dry eye syndrome).
Results related to complications were as follows: 1 patient
who underwent a combined upper and subciliary lower
(quad) blepharoplasty developed a right eye orbital hema-
toma 48 hours postoperatively that resolved with standard
treatment with no visual loss. His cosmetic outcome was
good at 3 months and excellent at 6 months after the revision
procedure and adjuvant procedures with persistent premor-
bid visual acuity (Figure 6).
No patients experienced a cardio-ocular reflex. Two
patients complained of an increase in dry eye symptoms
postoperatively and were treated with wetting drops. Both
of these patients on postoperative physical examination and
photography were noted to have complete closure of the
eyelids.
Two patients had a hypertrophied upper eyelid incision
scar (less than 2-cm length only). These patients requested
surgical scar revision with resultant normal incision appear-
ance. One of these patients had a diagnosis of rheumatoid
arthritis. One patient had a unilateral mild medial upper
eyelid scar band, resolved with 1 triamcinolone (Kenalog
10) injection and adequate time (2 months) for complete
healing.
One patient had scleral show at the lateral aspect of the
lower eyelid from a subciliary approach and mid-facelift;
however, no patient experienced an ectropion. This scleral
Troell
Table 3. Adjuvant Aesthetic Procedures (n = 227).
Volume replacement (43) Brow suspension (28)
Fat transposition, 10 Browlift surgery, 24
Facial fat transfer, 25 Bellafill browlift 4
Midface implants, 9 Lateral canthopexy, 7
Note. Most patients received neuromodulators (Dysport over Botox) or dermal fillers. The dermal fillers chosen were either (hyaluronic acid/Restylane
lift or PMMA collagen gel/Bellafill). RF = radiofrequency; TCA = trichloroacetic acid; PMMA = polymethylmethacrylate.
Table 4. Blepharoplasty Complications (n = 9).
Temporary (n = 7) Permanent (n = 2)
Orbital hematoma, 1 Dry eyes, 2
Scleral show, 1
Hypertrophic scar, 2
Granulation tissue, 2
Medial scar band, 1
Figure 6. A 52-year-old Caucasian male who underwent
upper eyelid blepharoplasty, transconjunctival lower eyelid
blepharoplasty, neck liposuction, and facial carbon dioxide laser
skin resurfacing for acne scarring. This patient had the right-
sided orbital hematoma that occurred on postoperative day
2 necessitating lateral canthotomy and incision opening with
wound exploration. He subsequently underwent incision repair,
canthopexy, and facial fat transfer to correct the resultant scleral
show. The patient has premorbid visual acuity. (A) Before. (B)
After (3 years postoperatively).
show was resolved with dermal filler injection to the lateral
tear trough area. Two patients who underwent transconjunc-
tival blepharoplasty had a unilateral localized growth of a
granulation tissue form within 3 weeks of surgery. The gran-
ulation tissue was removed using a Brown Adson forceps
after the application of topical tetracaine 4% anesthetic
drops. No patients were noted to have or informed us that
they experienced a corneal abrasion or other corneal injury
postoperatively.
9
Face suspension (64) Skin resurfacing (91)
Facelifts, 41 CO2 Laser, 53
Mid-facelift, 16 RF Treatment, 19
TCA peel, 19
Discussion
The presented peri-orbital aesthetic rejuvenation protocol
implements the accepted teachings of learned plastic sur-
geons, facial plastic surgeons, oculoplastic surgeons, and
cosmetic surgeons.
A comprehensive armamentarium of treatment options is
the hallmark of a successful aesthetic algorithm. The limita-
tion with this approach is that it requires a sole practitioner to
possess specialized training and skill in numerous cosmetic
invasive and minimally invasive procedures. Alternatively,
several colleagues may work in concert to achieve the com-
prehensive aesthetic outcome.
To achieve optimal peri-orbital rejuvenation, patients
should add to their blepharoplasty surgery one of the follow-
ing groupings of aesthetic treatments: browlifting, facelifts,
facial volume replacement, and skin resurfacing.
Although some patients do not need a procedure from
each of these headings to optimize their aesthetic outcome,
most in this patient population should consider volume
replacement and skin resurfacing. Women were more likely
to choose an adjuvant treatment for peri-orbital rejuvenation
and perform a larger number of procedures than their male
counterparts. So performing a comprehensive aesthetic
examination prior to blepharoplasty surgery will identify the
facial anatomical cosmetic concerns that should be addressed
to heighten patient satisfaction.
The surgical goal is to minimize complications and risks,
while optimizing cosmetic outcomes. The postoperative
assessment entails cosmetic issues, functional issues, or a
combination of the above. The functional risk with the high-
est incidence after upper eyelid cosmetic surgery is dry eyes.
Comparing the incidence of dry eyes in this patient data base
is less than 1%, which is comparable to that of Mendelson
and Luo15 of less than 2%. However, the results were signifi-
cantly less than those of others, including the highest inci-
dence of dry eye syndrome of 26.5%.12-14 The key to lowering
the risk of dry eye formation is compulsive measurement of
the amount of skin excision. The other complication of thick-
ened scar or eyelid ptosis is related to understanding the eye-
lid anatomy and good surgical technique.
The main concern with the lower eyelid surgery is to
avoid corneal injury and scleral show. Avoidance of the sub-
ciliary approach is the best method to avoiding scleral show
or ectropion formation. When performing both the upper and
10
lower blepharoplasty procedures together, there is a higher
risk of complications, so a more conservative approach
should be entertained. Choosing a transconjunctival lower
eyelid approach combined with a skin pinch and lateral can-
thopexy will lower the incidence of lower eyelid retraction.
To avoid lower blepharoplasty complications, effort must
be to ensure adequate lower eyelid strength. The eyelid
strength is achieved by limited skin excision, a lateral can-
thopexy or lid shortening procedure, mid-facelift suspension,
or dermal filler placement to the tear trough area. These pro-
cedures were found to not only minimize complications, but
to optimize the cosmetic appearance as well.
Good surgical technique minimizes the risk of corneal
injury. To lower the risk of corneal injury, one can do the fol-
lowing: (1) using a lacrilube-coated corneal shield or Yaeger
eye shield during the transconjunctival incision, (2) suturing
the lower eyelid mucosa over the corneal during the surgical
procedure for a second line of corneal protection, (3) adding
an oral steroid to reduce swelling, (4) educating patients not
to rub their eyes and to keep eyelids closed when placing
cold compresses postoperatively, and (5) avoiding excess
lower eyelid skin excision and using a canthopexy or mid-
facelift as necessary to prevent scleral show formation.
This surgical preoperative and intraoperative protocol
along with the step-by-step surgical techniques noted
achieves the aesthetic surgical goals and minimizes the inci-
dence of complications.12-15
Additional study observations were patients treated with a
methylprednisolone dose pack or prednisone taper were
noted to have much less eyelid swelling and chemosis. This
steroid treatment is safe with no side effects, and it speeds up
recovery and limits ocular complications.14
The fat transposition procedure, although improving the
aesthetic outcome, still required an additional filler to com-
pletely treat the tear trough volume deficiency in most
patients (60%). In the surgeons opinion, this procedure
should only be elected in patients who have a limited amount
of tear trough volume deficiency that is estimated pre-treat-
ment to be completely or near-completely resolved with fat
transposition alone. Performing lower eyelid fat pad excision
followed by tear trough volume deficiency correction with
dermal fillers yields superior results with less bruising and
swelling than the fat transposition procedure.
Patients undergoing upper blepharoplasty surgery who
years ago had a previous blepharoplasty procedure (n = 18)
required slightly less amount of skin excision than a primary
upper blepharoplasty patient. The method to determine the
amount of skin excision was the same as the primary blepha-
roplasty, although an estimate of 1 to 2 mm more postopera-
tive skin retraction was used in the measurement process.
As noted by Perkins and Prischmann, blepharoplasty out-
comes have less to do with the amount of skin excision or
herniated fat removal and more with identifying and treating
the peri-orbital changes associated with aging. Developing a
comprehensive yet individualized aesthetic treatment plan,
The American Journal of Cosmetic Surgery
as presented here, optimizes the cosmetic result, while antic-
ipates postoperative outcomes and identifies predisposing
factors to complications.
Conclusions
The peri-orbital rejuvenation surgical protocol, surgical
blepharoplasty techniques, and adjuvant procedure tech-
niques performed revealed a high benefit to risk profile, high
patient satisfaction rate, and high treatment success rate.
Authors Note
The data from this manuscript were acquired by surgical logs of the
primary surgeon, direct patient questioning, and from medical
records of patients.
Acknowledgments
I would like to acknowledge my office staff at Beauty by Design in
Las Vegas, Nevada, Rose Flores and Monserrat Robles for both
their surgical expertise and their assistance in the manuscript photo-
graphic compilation and patient data acquisition. I would like to
acknowledge my office staff at Estrella Aesthetics & Surgical Arts
in Corona, California, specifically, Susan Velasquez, for her surgi-
cal assistance expertise. In addition, I would like to thank the rec-
ommendation of the reviewers of this journal and the editor in chief
for improving the quality of this manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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Author Biography
Robert J. Troell, MD, FACS, is currently in private practice in Las
Vegas, Nevada and Orange County, California. He is a Stanford
University Medical Centertrained surgeon and diplomate of the
following organizations: American Board of Otolaryngology-Head
& Neck Surgery, American Board of Facial Plastic & Reconstructive
Surgery, American Board of Sleep Medicine, American Board of
Facial Cosmetic Surgery, American Board of Cosmetic Surgery,
and the American Board of Stem Cell & Fat Transfer Physicians.