As the inherent shortcomings associated with aggressive tissue removal and tucking have become gradually understood, efforts to devise more restorative approaches to eyelid rejuvenation have yielded a number of alternatives that seek safer short and long-term results.Traditional blepharoplasty is, basically, a subtractive technique in which varying amounts of skin, muscle, and/or orbital fat are removed with the goal of debulking the upper and lower eyelids.
However, once fat has been excised or repositioned out of the orbit, normal volume relationships are altered. Once muscle has been cut or removed, its closing power is forever weakened.
Over the last decade, a number of conceptual and procedural innovations directed at conserving these vital tissues have appeared. Some such advances have garnered enough attention to become influential, while others have remained obscure and are thus seldom discussed, studied, or incorporated into current surgical technique.
The most common functional problem resulting from excessive tissue removal is a weakening of the eyelids' support and closure mechanisms, while the most frequent aesthetic problem is eyelid hollowing. Aggressive canthal tightening and muscle lifting procedures around the lower lids can produce an upswept appearance not unlike the Nike "swoosh" logo.
In their milder manifestations after traditional blepharoplasty, such outcomes have generally been viewed as unavoidable limitations rather than as complications, especially when compared to eyelid retraction or severe scarring. They are, however, still undesirable and do nothing to help the eyes appear more alert, expressive, attractive, or youthful.
"Tissue-sparing" should not be misunderstood to simply indicate performance of the traditional operation in a more conservative manner. While in some instances this may be the case, in most it more accurately denotes "selective tissue sparing" in terms of both removal and tissue injury. Some patients may most benefit from leaving certain tissues entirely alone while carefully excising others. Other patients may be candidates for newer and very different approaches that subtract little or nothing.
We have employed such alternatives for a number of years. Upper eyelid tissue-sparing blepharoplasty is a well-developed operation that is safe and effective. Lower eyelid tissue-sparing is still developmental and not in wide use.
