An Evidence-Based Approach to Blepharoplasty

Abstract

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references.This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2222 CLINICAL SCENARIOA 56-year-old woman requests improvement in the appearance of her upper and lower eyelids. She had LASIK surgery 3 months earlier. She has ptosis of her left upper eyelid. What is the best evidence to guide you in the management of her condition? There is very little high level evidence in the blepharoplasty literature at this time. The age of evidence is just upon us, and objective measurement in aesthetic surgery is in its infancy. This article is a starting point where most of the evidence is level IV (case series) and level V (case reports or expert opinion). There is almost no level III evidence (retrospective comparative case series) and virtually no level II evidence (prospective comparative studies). It will be very difficult to create level I studies that are prospective randomized blinded controlled studies. Nevertheless, we have to start somewhere. One hundred years from now, there will be serious useful evidence-based studies in cosmetic plastic surgery, like looking from the top of a sky scraper. This is the first step at examining where we are in the basement of evidence based medicine in aesthetic blepharoplasty. METHODS FOR IDENTIFYING EVIDENCEA literature search of PubMed, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library was performed to obtain the best available evidence on blepharoplasty, with emphasis on preoperative assessment, treatment, and outcomes. The following search terms were combined as appropriate, and PubMed MeSH terms were used when available: blepharoplasty, eyelid surgery, diagnosis, preoperative assessment, risk factors, smoking, diabetes mellitus, pulmonary embolism, venous thrombosis, dry eye syndromes, anticoagulants, DVT prophylaxis, antibiotic prophylaxis, anesthetics, premedication, surgical treatment plan, treatment, surgery, outcome, complications, postoperative complications, pain management, and analgesia. The initial search was limited to human studies that were published from 1999 to 2009 and indexed as metaanalyses, randomized controlled trials, clinical trials, or comparative studies. Very fe...

Simplifying Blepharoplasty

“…Previous CME articles on blepharoplasty thoroughly review preoperative workup with regard to history and physical examination findings. 22,23 Patients with lid ptosis should undergo a thorough evaluation as discussed in prior literature. 24,25 Combined ptosis and blepharoplasty surgery should be considered in those patients with concomitant ptosis and dermatochalasia.…”

Evidence-Based Medicine

“…Furthermore, removal of periorbital fat often leaves a hollowed-out appearance of the orbit and a poor cosmetic result. 27 Since that time, six additional publications have presented case series or composite algorithms for lower blepharoplasty; however, no quality randomized controlled trials have been published in the scientific literature. We also try to avoid trauma to the middle lamella and we do not cut through the orbicularis oculi muscle or remove it from the lower lid as described by Jelks and Jelks with the "no-touch" technique.…”

Minimal Pain Local Anesthetic Injection with Blunt Tipped Cannula for Wide Awake Upper Blepharoplasty

“…1 Many surgeons still prefer to use sedation to decrease patient discomfort with the local injection and the procedure. We present our increasing experience 2 using blunt tipped filler cannulas for local anesthesia infiltration to minimize pain and bruising.…”