Reply

Abstract

Sir:FigureWe sincerely appreciate Dr. Gradinger's comments and astute observations regarding our study, “The Five Step Lower Blepharoplasty: Blending the Eyelid-Cheek Junction.”1 Dr. Gradinger has raised some interesting points that further underscore the need for enhancing our ability to truly grade our results objectively using evidence-based medicine, and the challenges plastic surgeons face in effective and predictable lower eyelid rejuvenation. Directly correlating quantitative outcomes with clinical improvements in aesthetic surgery continues to be a daunting task. The crux of Dr. Gradinger's comments centers around our computer-generated outcomes. It is important not to distract our readers from the key points of our study with computer-generated data, which only served to confirm the safety of our study. Dr. Gradinger's queries are valid and require clarification. Overall, we saw a cumulative improvement in the aesthetic outcomes and had no complications that required reoperation. This is quite rare in performing lower eyelid rejuvenation surgery. The goal of our study was to delineate a safe and effective method of blending the eyelid-cheek junction without disrupting the orbicularis oculi muscle or performing operative techniques that have excessively high morbidity. The high complication and reoperation rates seen in lower eyelid surgery served as the impetus for the five-step combination and research design. Although our maneuvers may not have had 100 percent desired change in each of the individual data points measured, overall aesthetics were improved. Does a slight increase in pupil-to–eyelid margin distance in 36 of 100 eyelids mean that the technique is ineffective? Is it possible that in many of the same patients who demonstrated an increase in pupil-to–eyelid margin distance there was also a decrease in tear trough width and pupil-to–tear trough distance? If so, then the sum of effects was effective and safe, because the overall improvements did not require further surgical correction. It is the sum of the five steps and the overall combined effect of these individual techniques and their direct morphologic changes that lead to improved eyelid-cheek junction blending. Just as the individual steps should not be isolated, so should the results not be judged on each isolated data point. Rather, these data points were measured to evaluate the spectrum of changes that can be observed, whether it decreased in some respects and increased in others. The orbicularis retaining ligament is a key structure in bringing together the cumulative changes. With that said, we will address all the points raised by Dr. Gradinger. Selective release of the orbicularis retaining ligament is as effective as arcus release because the major significance assigned to the arcus is its translated effects by means of the orbicularis retaining ligament to the overlying skin and soft tissue. Full release is not always necessary. Lateral retinacular support served as prophylaxis against lid malposition during the healing/edema phase and is not meant to be permanent. All eyelids undergo slight to minimal lower lid fat removal, sometimes purely for contour and “smoothing,” not just for debulking purposes. We have not witnessed any posterior and/or middle lamellae contracture with the five-step method. All patients in our study required at least slight skin pinch excision, and no patients demonstrated exophthalmos, which is a contraindication to this technique. The conservative degree of skin removal and avoidance of injury to the septum/orbicularis muscle anteriorly all help to eliminate tension and resultant anterior lamella shortening. Concern regarding exacerbation of tear trough as a result of adjacent augmentation of the deep malar fat pad is valid and is a common source of trepidation. Selective orbicularis retaining ligament release allows migration of native lower lid fat to coalesce with the superficial and deep malar fat compartments. Molding is performed intraoperatively to further blend this region. Reducing skin laxity with pinch removal also helps reduce tear trough appearance. Deep malar fat augmentation also acts to elevate the superficial fat compartments cephalically to meet the now released lower lid fat. We thank Dr. Gradinger for his clear and directed comments on the numerous challenges inherent in lower eyelid rejuvenation. We hope that our five-step technique helps to shed more light on the key principles and techniques in safe and effective lower eyelid-cheek rejuvenation.2–5 Ashkan Ghavami, M.D. Department of Surgery, Division of Plastic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, Calif. Rod J. Rohrich, M.D. Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas