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kiss blepharoplasty
A sensible approach to cosmetic eyelid surgery

"Simplicity is the ultimate sophistication."
- Leonardo da Vinci


"Simplicity is . . . not simple."
- Jonathan Ive, Chief Designer, Apple Inc.


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The "KISS" in KISS Blepharoplasty™ has nothing to do with those bite-size pieces of chocolate wrapped in foil, a tender meeting of the lips, or the heavy metal band from the seventies. It's a reference instead to a principle widely revered in science, technology, and business that states that simplicity of design should always be a goal, while nonessential complexity is best avoided.

Or, to say it more directly, "Keep it Simple, Stupid!"

But why? Is there something wrong with complexity?

No, there's nothing inherently wrong with complexity per se, just as long as it's really required.

Think back to Rube Goldberg's cartoons of those wildly complicated "non-KISS" machines, ultimate examples of complexity created just for the heck of it.

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So what does this have to do with blepharoplasty? Just ask any experienced revision expert who provides care to patients unhappy with their results and you'll hear the same answer.

While improper execution of an operation by the first surgeon is typically the primary cause of many mishaps, a common and major contributing factor is often poor judgment in the very selection of the procedures that were undertaken.

Most surgeons like to think of themselves as practicing at the forefront of their specialties by offering only the latest and greatest. Despite increased invasiveness, surgical difficulty, or lack of a long-term track record, some new procedures become quickly touted as superior replacements for more reliable and less destructive techniques.

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A related form of misjudgment is simple overkill -- employing multiple procedures when a single procedure would work as well or even better.

Antoine de Saint Exupéry, author of The Little Prince, noted that "It seems that perfection is reached not when there is nothing left to add, but when there is nothing left to take away."

In many cases, doing less is actually more, while doing more is not only superfluous but an invitation for trouble if not disaster.

Throwing everything but the kitchen sink at a common problem with a straightforward fix can result in delayed healing, an artificial appearance, higher rates of both immediate and late-term complications, not to mention increased costs. In the words of Colin Chapman, the founder of Lotus Software, "Simplify, and add lightness."

Sir Isaac Newton first pointed out in 1687 that "To every action there is always an equal and opposite reaction." While that may seem obvious 350 years later, some surgeons still act in near total disregard of this basic principle of physics.


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Take, for instance, brow elevation, a euphemism for upper face lift and a procedure that is far too commonly recommended to thirty year olds with slightly baggy upper lids and brows that sit exactly where they did the day they turned twenty-one. The forehead may indeed be lifted higher by invasive surgery, but the rest of the face will now be pulling back against it in ways that can degrade the natural harmony of the facial features.

Canthopexy and SOOF lift have, in some practices, become mandatory components of nearly every lower blepharoplasty, even though they increase swelling and bruising, delay recovery, and often leave a noticeable upward tension in their wake. In most such cases of overuse, it's only a matter of time before the now taut tendons and tissues of the cheek will tear themselves loose to reestablish an equilibrium, leaving behind little more than permanent anatomic disruption.

Even when a tissue is too weak to resist a stronger force, that doesn't mean there can't be a negative backlash. Aggressively repositioning fat out of the orbit to partially fill in a modest cheek depression can and often does result in immediate or later eyelid hollowness. Injecting BOTOX to weaken a muscle can and often does cause surrounding healthy muscles to try to compensate, sometimes generating some very odd mannerisms.

Laser skin resurfacing on a young patient with next to no wrinkling can cause prolonged recovery time, pigmentary changes, scarring, and a face that never looks the same.

Even though today's commercial fillers provide a safer remedy for many minor flaws, patients are still undergoing multiple rounds of fat injections, placement of silicone cheek implants, and a variety of midface lifting techniques to hide minor anatomic indentations so subtle that they are nearly imperceptible.

That said, the above does not mean that the non-invasive or minimally-invasive world of injectables and technologically-sophisticated energy sources can yet compare to actual hands-on surgery when addressing issues of real substance. But that is another subject and would involve a discussion more focused around profit/loss than risk/benefit. Sorry if this disappoints, but "non-surgical blepharoplasty" is an oxymoron.

To be clear, the concept of simplicity as used here is by no means synonymous with the least invasive or least challenging methods, which often achieve little. For simpler to succeed, a surgeon must possess a deep understanding of both the problems at hand and all remedial methods and then devote an almost fanatical level of attention to even the smallest details to, in essence, extract more improvement out of each and every step along the way, doing no more or no less than is needed.

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As Albert Einstein once observed, "Everything should be made as simple as possible, but not simpler." In other words, while simplicity for the sake of simplicity alone is not the goal, unnecessarily complex solutions should be shunned.

It may come as a surprise to some to learn that practicing such simplicity demands a very high level of expertise, a good reason for patients to be more selective about choosing a surgeon than most are. After all, it takes a lifetime of dedication and practice for a master Zen calligrapher to learn to create art in just a few strokes.


Richard Williams, the three time Oscar-winning animator behind the Pink Panther and Roger Rabbit, noted that inexperienced animators tend to "overanimate." The same seems to hold true in plastic surgery. Whether established or fresh out of their training, cosmetic surgeons inexperienced with frequent blepharoplasty seem to be the very ones most likely to offer overly complicated solutions.

Of course, some patients do indeed have anatomical conditions that require unusually aggressive or multiple procedures. However, the large majority do not. In the end, the number and complexity of procedures performed correlates poorly with the quality of the result. Proper selection and skilled execution are what matter.

While always hoping for a nice improvement, most realistic patients are not expecting to turn out looking like college sophomores. They want to appear more refreshed while looking natural and still recognizable. Most could care less about a few stray wrinkles or a "touch" of a tear trough (expected features on the face of even the most attractive forty year old). In most instances, the KISS Blepharoplasty will serve them well.

So how exactly is a KISS Blepharoplasty performed? As you may have guessed by now, the specific technique most appropriate for any given patient will vary with the problem while the KISS principles discussed above should not. The end result can be amazing and solve complicated problems without others even suspecting that a flaw once existed.

To learn more about the approaches we favor and why, browse through our site's different sections.

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Frank Meronk, Jr., M.D.