Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members

Abstract

Background

Patients presenting for upper blepharoplasty can exhibit different aging patterns and we have anecdotally observed wide variability in upper blepharoplasty approaches among surgeons. However, upper blepharoplasty practice patterns have not been systematically analyzed among members of The Aesthetic Society.

Objectives

The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the incidence and management of ptosis as reported by members of The Aesthetic Society.

Methods

A 29-item electronic questionnaire was distributed to 1729 Aesthetic Society members with available email addresses.

Results

In total, 214 Aesthetic Society members submitted the questionnaire, for a response rate of 12.4%. There was a significantly increased rate of volume preservation among surgeons with greater experience (≥10 years in practice) and a high-volume (≥100 cases in past 12 months) of upper blepharoplasty cases. Furthermore, high-volume upper blepharoplasty surgeons were significantly more likely to perform concomitant upper lid fat grafting (P = 0.03), browlift (P = 0.02), and ptosis repair (P = 0.01). Ninety-five percent of respondents reported a mild/moderate ptosis (MRD1 2 to <4mm) incidence of <25%. Among surgeons who perform ptosis repair, 97.4% utilize levator advancement or plication as their most commonly used technique.

Conclusions

High-volume upper blepharoplasty surgeons are more likely to preserve upper lid volume and perform concomitant browlift and ptosis repair. Our data suggest that different upper eyelid aging patterns and mild/moderate ptosis are underrecognized.

“The eyes are the window to your soul … and age.”

Anonymous (modified)

Periorbital aging changes profoundly affect the perception of an individual’s age.^1,2 According to The Aesthetic Society 2019 statistics, blepharoplasty is the fifth most commonly performed surgical aesthetic procedure and the most common aesthetic surgical intervention among patients age 65 years and older.³ Upper lid aging is characterized by dermatochalasis, volumetric changes, upper lid arc aberrations, and bony orbit resorption.^1,2,4-7 Additionally, the size of the palpebral aperture diminishes with time, which can be compounded by varying degrees of upper lid ptosis.^6-9 Historically, upper blepharoplasty has been an excisional procedure addressing excess skin, fat, and redundant muscle.¹⁰ Several publications, however, introduced novel approaches to conceptually redirect the procedure towards volume preservation.^4,11-16

In an attempt to improve our understanding of the procedure’s objectives, our team previously identified aesthetically appealing upper eyelid topographic proportions in females.¹ Our findings not only emphasized the unique ratios of the upper lid fold to pretarsal space, but also revealed the important relation between the 3 upper lid arcs in attractive eyes—the lid margin, upper lid crease, and brow. Achieving excellent and consistent aesthetic outcomes in upper blepharoplasty is challenging. Several maneuvers may be necessary, all of which are reliant on correctly diagnosing the underlying aging pathology—only then can the individually tailored preoperative plan be made and artistically executed. Aesthetic optimization requires a harmonious relation between the upper lid arcs.¹ Controlling upper lid fold skin tension across the upper lid and addressing the temporal brow (if necessary) is required for a smooth upper lid crease and to reveal the desired amount of pretarsal show. However, if ptosis is present and not corrected, achieving proper skin tension at the upper lid fold may occur at the expense of excessive pretarsal show and an iatrogenically high lid crease. Additionally, adding and subtracting volume to sculpt the surface of the brow and upper lid fold are essential to artistically create an attractive contour, therefore making modern upper lid surgery more complex than conventional reductive upper blepharoplasty.

We have recently applied our ideal proportions findings to critically analyze a cohort of 316 upper blepharoplasty patients performed in our institution.¹⁷ Three presenting features were identified related to the pretarsal space: no show (ie, pretarsal space not visible on frontal view; Figure 1), partial show (ie, pretarsal space partially visible), and complete show (ie, pretarsal space completely visible; Figure 2), suggesting different aging patterns. To our surprise, 59% of patients preoperatively presented with complete pretarsal show—these patients had a significantly increased incidence of no improvement or worse aesthetic outcomes after conventional upper blepharoplasty. Furthermore, it became apparent that mild/moderate ptosis (MRD1 2 to <4 mm) could be, in part, responsible for complete pretarsal show. Mild/moderate ptosis, however, can be subtle and easily missed during consultation. The key is to maintain a high level of suspicion, particularly in patients with complete pretarsal show; in these patients, phenylephrine testing and close inspection of standardized preoperative photographs is critical. Furthermore, patients with complete pretarsal show potentially benefit the most from volume conservation and enhancement with fat grafting. Our findings emphasized the need to better understand the different aging patterns of the upper lid to improve surgical planning.

There are several described approaches and maneuvers for upper lid rejuvenation,^{4,8,11-16,18-22} which is reflected by our observation of significant variability in surgical approaches among surgeons. However, variability in upper eyelid rejuvenation interventions among plastic surgeons have not been systematically analyzed. The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the reported incidence and management of ptosis among members of The Aesthetic Society.

MATERIALS AND METHODS

A 29-item anonymous questionnaire was reviewed and electronically distributed by The Aesthetic Society to its 1729 members with available email addresses (Appendix). The survey remained available from November 13, 2019 to January 3, 2020. Results were tabulated in Microsoft Excel (Microsoft Corporation, Redmond, WA). Respondents were permitted to skip questions and select more than 1 answer choice for several questions. Skipped questions were excluded from total answer counts for each individual question. Percentages were calculated by taking the total number of respondents of each question as the denominator. Statistical analysis was performed with SPSS (IBM Corporation, Armonk, NY). Two-tailed Fisher’s exact test was used to evaluate the correlation between answer choices to different questions. A P value <0.05 was considered statistically significant. Margin of error calculation was performed with α = 0.05 (ie, 95% confidence interval [CI]) to assess if survey participants’ responses reflected that of the population.²³ This study was did not require institutional review board approval because it was a survey.

RESULTS

A total of 214 Aesthetic Society members submitted the questionnaire, a response rate of 12.4%. Respondent characteristics are shown in Table 1. Ninety-one percent of respondents had been in practice for ≥10 years. Eighty-six percent of respondents practiced in the United States or Canada and 62% of respondents reported to have performed between 11 and 50 upper blepharoplasty procedures in the past 12 months. The overall margin of error for the survey responses accurately representing the 1729 Aesthetic Society members upper blepharoplasty practice patterns was ±3.1%, at a 95% CI.

Skin Management and Incision Planning

Eighty-one percent of respondents report utilizing a skin pinch technique to determine how much skin to remove (Table 2). Regarding the lateral most extent of the upper blepharoplasty incision, 35.9% routinely extend the incision past the lateral orbital rim, whereas 20.6% and 43.5% routinely limit the lateral extent of the incision to the medial or lateral edge of the lateral orbital rim, respectively. Compared with less-experienced surgeons, those in practice >20 years were significantly less likely to measure how much skin remains between the brow and upper incision line (58% vs 77%, respectively; P = 0.02). After dichotomizing surgeons into those who routinely extend the upper blepharoplasty incision past the lateral orbital rim and those who do not, there was no difference in the reported concomitant browlift practices between groups (P = 1.0)

Orbital Fat and Orbicularis Oculi Muscle Management

Ten percent of respondents stated their most common upper blepharoplasty technique consisted of skin excision only (with preservation of the orbicularis muscle and orbital fat), 14.1% muscle excision without orbital fat manipulation, 12.7% muscle excision with orbital fat manipulation, and 18.4% muscle preservation with orbital fat manipulation (Table 3). Most commonly, however, 44.8% of respondents reported performing a combination of skin, muscle, and orbital fat manipulation depending on the patient’s presenting features.

Browlift

Nearly 20 percent of respondents do not concomitantly perform brow lifting with upper blepharoplasty (Table 4). Sixty-eight percent of respondents perform concomitant brow lift in 1% to 25% of upper blepharoplasty patients, whereas 3.3% perform browlift in >50% of patients. The most common reported brow lift techniques include endoscopic full brow lift (27.7%) and subcutaneous temporal brow lift (25.3%). Interestingly, surgeons who had performed >100 upper blepharoplasties in the prior 12 months were significantly more likely to perform concomitant browlift (P = 0.02).

Ptosis

Surgeons reported variations in the preoperative prevalence of mild/moderate (MRD1 2 to <4 mm) and severe ptosis (MRD1 <2 mm) (Table 5). Only 6.1% of surgeons reported use of preoperative phenylephrine testing. Fifty-seven percent of respondents perform blepharoptosis repair, with LA overwhelmingly the most common reported technique (97.4%). Interestingly, surgeons who perform phenylephrine testing were significantly more likely to use a posterior approach for ptosis repair (P = 0.02); however, only 3 respondents used a posterior approach as their most common technique, increasing the possibility of type 1 error. All surgeons who do not perform ptosis repair stated they referred patients with blepharoptosis to an ophthalmologist. For patients with preoperatively diagnosed mild to moderate ptosis, however, 40.9% of surgeons reported performing ptosis repair at the time of upper blepharoplasty and 6.3% reported performing ptosis repair in this group only when patients complained of ptosis. Almost 53% either did not address ptosis at the time of upper blepharoplasty or referred the patient to an oculoplastic surgeon. Surgeons who reported a preoperative mild/moderate ptosis incidence >10% were significantly more likely to perform ptosis repair (71.3% vs 44%, P = 0.001).

Fat Grafting

Forty-eight percent of respondents do not perform fat grafting to the brow or upper eyelid (Table 6). Thirty-four percent of respondents perform fat grafting in 1% to 10% of patients and 10.3% perform fat grafting in 11% to 25% of patients. Of surgeons who fat graft the upper periorbital area, 43.4% fat graft only the brow (retroorbicularis oculi fat compartment; ROOF), 39.3% fat graft only the upper lid fold/sulcus, and 16.8% fat graft both these areas. In surgeons who perform fat grafting to the upper lid and/or brow, 35% perform fat grafting before and 43% perform fat grafting after skin closure. Eighteen percent perform fat grafting after upper blepharoplasty as a separate staged procedure. Surgeons who had performed >50 and >100 upper blepharoplasty cases in the past 12 months were significantly more likely to perform fat grafting (P = 0.002 and 0.001, respectively)

Preoperative Complete Pretarsal Show: Incidence and Management

Sixty-three percent of respondents reported that complete pretarsal show (Figure 1) was present in ≤10% of their patients (Table 7). Regarding technique modifications in this patient population, 57.3% decrease the amount of skin resection, 40.0% remove less or no orbital fat, 23.4% perform more fat graft the upper eyelid fold, 19% place the incision caudal to the native eyelid crease (ie, lower the eyelid crease), and 20.7% are more likely to perform concomitant ptosis repair. Sixteen percent of respondents do not change their technique in this patient population. Five respondents (2.4%) “free-text” answered that, in this patient population, they would not operate (2 respondents) or would reconstruct the upper lid crease (3 respondents). Surgeons who reported performing >100 upper blepharoplasties in the past 12 months were significantly more likely to fat graft the upper lid fold (P = 0.03), preserve more orbital fat (P = 0.04), preserve orbicularis muscle (P = 0.04), and perform concomitant ptosis repair (P = 0.01).

Preoperative Absence of Pretarsal Show (ie, Pseudoptosis): Reported Incidence and Management

Preoperative obliteration of the pretarsal space was commonly reported (Figure 2, Table 8), with 48.1% of respondents reporting its presence in >50% of their upper blepharoplasty patient population. Regarding technique modifications, 56.5% remove more skin and 21.5% remove more orbicularis muscle compared with their technique in patients without pseudoptosis. Twenty-four percent remove more fat whereas 10.6% remove less fat. Seven respondents (3.3%) “free-text” responded that, in this patient population, they modify their approach by concomitantly performing browlift or brow-pexy.

Skin Resurfacing

Forty percent of respondents do not perform upper eyelid skin resurfacing (Table 9). Among practitioners who do skin resurfacing, fractionated laser was most common (52.3%), followed by unfractionated laser (24.4%) and chemical peel (23.3%). Regarding the timing of skin resurfacing, 50.6% perform resurfacing as a staged procedure after blepharoplasty whereas 41.1% perform skin resurfacing concomitantly. Surgeons who had performed >100 upper blepharoplasty cases in the past 12 months and surgeons from the United States and Canada were significantly more likely to perform eyelid skin resurfacing (P = 0.001 and 0.008, respectively). Interestingly, surgeons from Latin America and the Caribbean were significantly more likely to use chemical peeling as their resurfacing modality of choice (P = 0.018)

Practice Pattern Modifications Among Surgeons in Practice ≥10 Years

Survey responses among surgeons in practice ≥10 years reflects the trend towards volumetric preservation seen in more recent upper blepharoplasty publications (Table 10).^4,11-16 Among the respondents, 73%, 40.4%, and 16.1% reported preserving more orbital fat, orbicularis muscle, or upper lid skin, respectively (Table 2). Furthermore, surgeons in practice >20 years, compared with surgeons in practice ≥10 but ≤20 years, were significantly more more likely to preserve more orbital fat (73% vs 50%, respectively; P = 0.002) and perform more eyelid skin resurfacing (25% vs 12%, respectively; P = 0.04).

Twenty-two percent of respondents report performing more upper eyelid and brow fat grafting compared with their earlier technique. Interestingly, a nearly equal number of respondents reported performing concomitant brow lifting more (19.2%) and less (20.2%) commonly. Twenty-one percent of respondents perform more ptosis repair compared with earlier in their career vs 1.6% who report performing less ptosis repair.

DISCUSSION

To our knowledge, this is the first study assessing upper blepharoplasty practice patterns among plastic surgeons. We demonstrate a tendency towards tissue preservation, as only 27% of The Aesthetic Society members routinely excise muscle and 31% routinely manipulate orbital fat. More importantly, nearly 45% performed a combination of procedures depending on the patient’s presenting features (Table 3). This flexibility in applying various techniques to address specific anatomic features may reflect a better understanding of periorbital aesthetics. Another indicator that plastic surgeons are recognizing the importance of volume is the high number of surgeons who report use of fat grafting, albeit in a small percentage of patients. However, there seems to be an underrecognition of the different upper lid aging patterns and the significance of pretarsal show. The majority of respondents reported that <10% of upper blepharoplasty patients present with complete pretarsal show (Figure 1, Table 7), which according to our data,¹⁷ is the most common presenting aging pattern. Underrecognition of the different upper lid aging patterns could potentially have adverse cosmetic outcomes, as was reported in our series.¹⁷

The reported incidence of ptosis among respondents likely underestimates the actual ptosis incidence: The Aesthetic Society survey respondents who reported a higher preoperative incidence of mild/moderate ptosis were also more likely to perform ptosis repair (P = 0.001). Furthermore, on preoperative photographic analysis of 316 patients (mean age, 55 years) who presented for primary upper blepharoplasty at Northwestern Memorial Hospital,¹⁷ 69% had a MRD1 <4 mm, 31% <3 mm, and 5.7% <2 mm. In a longitudinal periorbital aging study of 21 patients by Guyuron et al,⁹ 90.5% (19/21) of patients exhibited mild/moderate ptosis at follow-up (mean age, 57 years)—notably, all patients who developed ptosis were observed to have concomitantly developed relative enophthalmos, indicating that mild/moderate ptosis is very common and suggesting that mild/moderate ptosis may be, at least in part, a consequence of loss of tension on the upper lid structures due to aging-related volumetric orbital changes.^2,5-7 In contrast, among survey respondents in this present study, only 8.1% reported a mild/moderate preoperative ptosis incidence of >25% (Table 5), strongly supporting our aforementioned suspicion about the discordance between the actual vs reported ptosis incidence. Interestingly, for patients preoperatively diagnosed with mild/moderate ptosis, 17.8% of respondents stated they often perform upper blepharoplasty without ptosis repair, further indicating that ptosis is commonly not treated even when preoperatively diagnosed. However, it is possible that those who do not perform ptosis repair with upper blepharoplasty are referring the patient to an ophthalmologist for ptosis repair afterwards.

Only studies in the ophthalmology literature have previously investigated upper blepharoplasty and ptosis practice patterns. In a 2016 survey of the British Oculoplastic Surgery Society²⁴ on ptosis management, 76% of surgeons most commonly use levator advancement (LA) for ptosis repair and 40% routinely use preoperative phenylephrine testing. In contrast, among The Aesthetic Society members who perform ptosis repair, 97.4% use LA as their most common technique and only 10.9% (13/119) of these surgeons report some form of preoperative phenylephrine testing. Differences in practice patterns among plastic surgeons and oculoplastic surgeons are likely secondary to differences in training. Unfortunately, we did not ask which The Aesthetic Society members completed separate oculoplastic fellowship training.

Putterman and Guyuron have published extensively on the value of preoperative phenylephrine testing to detect subtle ptosis and simulate the effect of conjunctivomüllerectomy.^25-29 Furthermore, they have advocated for expanded indications of conjunctivomüllerectomy due to improved and more predictable aesthetics.^8,25-31 Interestingly, in our study, surgeons who perform phenylephrine testing were more likely to perform müllerectomy-based ptosis repair—we suspect this is a consequence of training and familiarity. Although LA can be highly effective in certain hands, ptosis repair via LA is known to have surgical revision rates as high as 35%.³² In a retrospective study comparing LA and conjunctivomüllerectomy,³³ the reported incidence of lid contour abnormalities (20% vs 0%, respectively; P = 0.01) and overcorrection (13% vs 0%, respectively; P = 0.04) significantly favored conjunctivomüllerectomy. Furthermore, a prospective randomized trial comparing LA and Müllerectomy demonstrated improved cosmetic outcomes and a lower reoperation rates with Müllerectomy. It is our observation that true levator dehiscence is less common. The senior author (M.S.A) primarily uses conjunctivomüllerectomy for ptosis repair as he finds the results predictable and producing a more harmonious lid crease, reserving LA only for true tarsolevator dehiscence with minimal response to phenylephrine stimulation.

In our experience, the management of patients with complete pretarsal show (Figure 1) is particularly challenging. This was our initial impetus for conducting this present study. Interestingly, 2 survey participants “free-text” responded that they would not perform upper blepharoplasty in this patient population. We have found mild to moderate ptosis to be exceedingly common in these patients and ptosis diagnosis often missed during initial consultation—making phenylephrine testing^26,27 and close inspection of preoperative photographs even more critical for operative planning. In addition to mild/moderate ptosis, we have noticed that these patients often present with subtle compensatory frontalis strain, hollowing of the upper lid sulcus, and a deflated appearance of the lateral upper lid fold (Figure 1). In patients with complete pretarsal show, traditional blepharoplasty without ptosis repair risks a paradoxically aged and gaunt appearance by further accentuating excess pretarsal show and upper lid fold hollowing by elevating the upper lid crease location and failing to counteract compensatory frontalis strain. The apparent skin excess is mostly relative (to volume loss and ptosis) and tends to be minimal.^34,35 We believe this is due to a combination of aging-related volumetric deflation, which when combined with mild/moderate ptosis and frontalis strain, results in a loss of upper lid fold convexity and youthful aesthetic “window-shading” of the upper lid fold over the superior border of the tarsus.^1,8 This is not to be confused with “lateral hooding” (ie, excess “window-shading”), which is a different upper lid aging pattern and is associated with brow ptosis and obliteration of the pretarsal space (Figure 2)—traditional excisional blepharoplasty techniques do play a role in the management of this aging pattern and can be combined with browlifting and lateral suspension of the orbicularis to the arcus marginalis,^21,22 as indicated, per the patient’s preoperative evaluation.

In patients with complete pretarsal show, youthful restoration of the upper lid fold convexity, apparent lid crease curvature, and aesthetic (⁠$upperlidfoldpretarsal$⁠) show ratios¹ requires a thoughtful approach because traditional blepharoplasty techniques, although well intended, risk a poor aesthetic outcome. In the authors’ experience, these patients are best aesthetically managed by a posterior approach ptosis correction, minimal skin excision, and volumetric addition, if indicated. Conjunctivomüllerectomy cephalically restores the tarsal plate to a more youthful position and reliably recreates an aesthetic smooth upper eyelid crease curvature.^1,33,36 Tailored volumetric preservation and volume addition via preseptal upper lid fold and ROOF fat grafting, if indicated, helps achieve further upper lid fold contour restoration. These maneuvers restore convexity of the upper lid fold and the apparent lid crease location, resulting in less pretarsal show which is aesthetically advantageous.¹

Many approaches for upper lid rejuvenation have been described,^{4,11-16,18-22} with several publications advocating various forms of volume preservation and augmentation.^4,11-16,35 In this present study, survey respondents with ≥10 years in practice reported modifications in their upper blepharoplasty approach including more orbital fat (73.1%), orbicularis muscle (40.4%), and skin (16.6%) preservation compared with earlier in their practice (Table 10). Furthermore, surgeons with even greater numbers of years in practice (>20 years) reported an even higher likelihood of upper lid volume preservation. In a 2018 survey of American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) members,³⁷ 33% of surgeons perform adjunctive fat grafting, with 81% of these doing so in 1% to 20% of cases. In comparison, 51.6% of Aesthetic Society members in our study report performing adjunctive fat grafting, with 84% of these doing so in 1% to 25% of cases, showing a slightly higher prevalence of fat grafting among Aesthetic Society members compared with ASOPRS members. Further improvements in aesthetic outcomes have resulted from fat grafting and correction of upper lid and brow ptosis in the appropriately selected patient.^20,38-41 Interestingly, however, among survey respondents with ≥10 years’ experience, a nearly equal proportion of Aesthetic Society members report performing more and less concomitant brow lifting procedures (19.2% vs 20.2%, respectively). However, more years in practice is not necessarily synonymous with a high volume of upper blepharoplasty cases. High volume upper blepharoplasty surgeons (>100 cases, prior 12 months) further modified their approach and were significantly more likely to perform concomitant browlift (P = 0.02), preserve upper lid volume (P = 0.04), perform fat grafting (P = 0.001), and perform ptosis repair (P = 0.01). However, it is possible that this observed difference is due to type 1 error as only 10 of 214 survey respondents reported performing >100 cases in the last 12 months. We hypothesize, however, that high volume upper blepharoplasty surgeons may be more attuned to subtle nuances of periorbital aesthetics, resulting in technique modifications to achieve better aesthetic results. Although not specifically included in our survey, we anticipate that revision rates are likely lower among more experienced surgeons. The senior author (M.S.A.) improved his preoperative analysis and resulting operative planning, particularly with a higher index of suspicion for mild to moderate ptosis and diagnosing excess pretarsal show, which has led him to modify his operative approach, improve aesthetic outcomes, and decrease his revision rate.

This study is not without its limitations. Our collected data may not accurately represent the practice patterns of the 1729 available Aesthetic Society members; however, margin of error calculation was ±3.1% at a 95% CI, strongly suggesting that our sample population of 214 respondents accurately represents the overall population. Type 1 error is also possible because there were a low number of respondents for certain answer choices. We acknowledge the possibility of response bias—where survey participants’ answer choices may be influenced by question wording and restricted answer choices—unfortunately, this is a limitation of all surveys. For example, for technique modifications in patients with pseudoptosis (Table 8), 3 participants “free-text” responded that they perform browlift more commonly in these patients because we did not include browlift as an answer choice for that question. Furthermore, it is possible that survey participants answer choices that do not accurately reflect the individual surgeon’s practice patterns due to recall and response bias.

CONCLUSIONS

We present upper blepharoplasty practice patterns among members of The Aesthetic Society. It is likely that preoperative complete pretarsal show and mild/moderate ptosis is underrecognized and possibly mismanaged. There is a significant positive association with higher upper blepharoplasty case volume and an increased incidence of volume preservation, volume addition, browlift, and ptosis repair. There are variations in surgeon-reported approaches to patients with different upper eyelid aging patterns. Among surgeons who perform ptosis repair, LA is overwhelmingly the most commonly used technique.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES