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    Pivot point: Is it possible for dissatisfied post-bleph patients to do a 180?

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    Dr. Fezza
    "Any person who claims that he's never had an unhappy patient has never done surgery," Dr. Fezza tells Cosmetic Surgery Times . "Even the patients who do turn out perfectly are not always happy."

    Blepharoplasty, in particular, is a procedure ripe for imperfection. A precise surgery, blepharoplasty deals with the intricate and delicate soft tissues around the eyes.

    "We're always cognizant when we are working around the eyes. It's also an area that everybody sees...if something is not correct, it's going to be more obvious because we relate to people by looking at their eyes," Dr. Fezza notes.

    COMMON CONCERNS Unhappy blepharoplasty patients present with functional and cosmetic concerns — often simultaneously, according to William P. Mack, M.D., an oculofacial plastic surgeon in Tampa, Fla., and clinical assistant professor in the Department of Ophthalmology at the University of South Florida College of Medicine.

    "From a functional standpoint, they could have dry eyes, tearing, ocular irritation, lagophthalmos, low eyelid retractions and eyelid malpositions," Dr. Mack says. "Common cosmetic concerns include asymmetry, periorbital hollowing, ptosis, deep superior sulcus, eyelid malpositions and unnatural appearance."

    Adding insult to injury, surgeons themselves sometimes promote unhappiness among blepharoplasty patients by promising too much, according to Dr. Fezza. "We have to set up an expectation that is reality-based — that the patient is going to understand," he says. "With the lower lids, in particular, if we tell people that they are going to have every line and wrinkle removed, they will be unhappy. A lid without wrinkles is not a normal lid; it is a cardboard, plastic lid. Even children have wrinkles when they squeeze their eyes shut."

    HISTORY CRUCIAL Surgeons who focus on patient histories and evaluations could detect potential issues and perhaps avoid unhappy post-bleph patients. Careful note should be taken of prior surgeries and history of trauma, dry eyes or LASIK.

    "Patients with a history of LASIK have an incidence of dry eyes from 15 percent to 25 percent, and dry eye in bleph patients can range from 10 percent to 20 percent. Together with blepharoplasty, either or both of these can lead to severe dry eye," Dr. Mack explains. Therefore, he recommends that surgeons treat patients for dry eye before surgery.

    The patient evaluation offers another opportunity for surgeons to proactively reduce the chance of having unhappy patients. According to Dr. Mack, when assessing patients, surgeons should pay particular attention to the aesthetic relationship among the forehead, eyelids and midface.

    "In our evaluations, we want to assess for brow ptosis and underlying lid ptosis. In the periorbital evaluation, I look closely at whether the patient has a negative vector or prominent eyes," he explains. "We also evaluate for asymmetry in the lid crease or fold, lagophthalmos or deep superior sulcus," he says.

    On the lower lids, surgeons should evaluate for and document lower lid retraction, lid malposition, lateral canthal rounding, scleral show and periorbital hollowing, as well as dry eyes, reports Dr. Mack.

    "These are the things you want to look at whether it's their initial evaluation or [if] patients have had previous surgery because, for example, if someone has laxity to the lower lid and the surgeon does a lower lid blepharoplasty without addressing the laxity, the patient is bound to have cosmetic concerns as well as dry eyes," Dr. Mack says.

    Of equal importance is the intimate relationship between the brows and upper lid. When counseling upper lid blepharoplasty patients, surgeons have to be aware that a brow lift may be necessary to achieve good balance and harmony, says Dr. Fezza. Some of the extra heaviness around the eye might not be loose skin — it might be secondary to a ptotic brow, he says.

    "By not addressing this pre-operatively, it may lead to residual fullness around the eyes that the patient didn't expect," Dr. Fezza says.

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    Lisette Hilton
    Lisette Hilton is a writer in Boca Raton, Fla., who heads up her company, Words Come Alive.

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