What You Should Know About Combined Periorbital Surgeries
3 December 2019 onur
In periorbital (around the eye) cosmetic surgeries, we often combine various surgical procedures.
If you have read my previous articles,
you must have learned how the forehead and the upper eyelid are an anatomical whole and should be handled together, and – similarly – how the lower eyelid and the inner cheeks are a whole and should be handled together. Our face basically ages as a whole. Therefore, it is best to consider a holistic treatment. That is why we frequently combine various procedures in periorbital cosmetic surgeries.
There are 6 basic groups, each of which includes many different surgical approaches and techniques.
I’m not going to list or delve into the different techniques within each group. I’ll simply describe what the groups are. What you need to know at this stage, for instance, is that there are dozens of different techniques in the first group: Forehead/Eyebrow procedures. In this group, the technique is chosen specifically for each patient.
Here are the groups:
- Forehead/Eyebrow procedures
- Upper eyelid procedures
- Lower eyelid procedures
- Midface procedures
- Volume Enhancement
- Surface Treatments
Our patients can choose to age naturally without taking anything from these groups, or they are free to take as much as they want according to their own order of priority.
However, if a patient wishes to achieve the most ideal result possible, things are different.
In order to have the most ideal result in the advanced stages of aging, it will be necessary to support the combination (periorbital rejuvenation project) with a procedure from all these groups. All of these can be done in a single session or can be planned for several sessions to facilitate patient comfort and healing process.
In the early stages of aging, patients can start by choosing the procedure that meets the most obvious complaint. The key point here is that patients know all groups will probably need to be completed one day (perhaps in 10 or 20 years) to achieve the ideal aesthetic result.
The issue with combined periorbital surgery is that the area around the eyes is the most sensitive area in facial aesthetics. As you combine the procedures, the effect increases, but the time it takes after surgery for swelling and bruising to heal and for resuming work and social life is extended. In this group, the patient-doctor relationship is difficult. Even those patients who usually say “I trust you very much. I am fully confident to walk into surgery when you are at the helm,” just wait for 3 days or a week, and then they lose their nerve and start asking their appearance will remain that way. If it were me, I’d ask, too. Particularly when the healing process deviates from what is normal and a complication develops, things get much more difficult for both patients and physicians.
Periorbital surgery has managed to alienate many plastic surgeons from the procedure when they have not performed even 10 or 20 operations yet. I have many colleagues who say, “I don’t do eyelid surgery, I don’t do forehead lift, I don’t do midface”. All of them have their own justifications and professional traumas.
After this introduction, I will share some brief notes on some key combinations as well as their pros and cons.
Combination of Upper and Lower Eyelid Surgeries:
The upper eyelid fold and the lower eyelid fold surround a beautiful eye like a frame. The upper and lower folds present an elliptical integrity. In the aging process, both folds become indistinct. When the two eyelids are operated together, a more holistic result is obtained and the eye is beautifully highlighted. Another important advantage is that it is easier to perform operations such as muscle suspension / canthopexy / canthoplasty, which we use while supporting the lower eyelid, from the outer half of the incision on the upper eyelid.
However, when the two treatments are combined, the recovery time is almost tripled. While upper blepharoplasty alone and lower blepharoplasty alone are fast healing procedures, the combination of the two will require an early recovery period of at least 3 weeks and a medium term of 3 months. The swelling will last longer as the lymph flow in both valves is affected. The swelling of the upper eyelid will travel down to the lower eyelid, and the dark circle under the eyes will persist for a little longer. When the two eyelids are joined, edema and aneurysm of the conjunctival surface called “chemosis” are more common. The pros and cons should be determined according to the specific needs of each patient.
Combination of Lower Eyelid Surgery and Midface Surgery:
This can be dubbed the gold standard surgery for the area under the eye. It lifts the cheek mass in a way to cover the bone under the eye, shortens the elongated appearance of the lower eyelid and effectively reduces bags. The results are permanent and highly long-lasting.
However, the healing process is challenging. Typically, the eye will be slanted and the face will be swollen. Both patients and their relatives give this appearance some unpleasant nicknames. Unfortunately, you have to live with this for about 3 months, with the impacts being evident during the first 3 weeks. It is not psychologically easy to get involved in social life and return to work.
Combination of Forehead Lift and Upper Eyelid Surgery:
This can be dubbed the gold standard surgery for the area above the eye. From a biomechanical point of view, both processes complement and support each other in the long run. Since I have a separate blog post written on this matter, I will not repeat the same things here. Every milliliter of blood and tissue fluid likely to accumulate in the forehead lift area will gravitate downwards. Even if these patients do not get a lower eyelid surgery, they will have bruises under their eyes as if they had one. The bruises may even extend to the cheek/neck.
Combination of Eyelid Surgery and Volume Enhancement Procedures:
We mostly transfer fat tissue as well as using periocular prostheses for volume enhancement. While prostheses are basically used to solve congenital/structural problems in the bone skeleton, adipose tissue transfer is mostly used to replace the soft tissue volume that we lose as we age. As you can guess from the previous posts, both options significantly prolong the healing process. For instance, multilayer fat injection may cause an additional 2-3 weeks of edema and bruising. Prostheses, on the other hand, have their own process of adapting to tissues. Although the first reaction we get here is something like, “Oh, I don’t want it then”, you should know that a healthy soft tissue architecture cannot be built on a structurally deficient skeleton. Again, the loss of fat tissue volume around the eye is an element that skeletonizes the eye. Eyelid surgeries ignoring adipose tissue transfer provide a nice early result but may lead to a depressed, skeletal appearance later. In patients who need to heal quickly, we can sometimes avoid performing the fat tissue transfer during surgery. However, patients in this group need to know that the treatment scheme has not changed but has only been postponed. In the long run, when the lack of volume becomes prominent, a second session may be required to complete the fat tissue transfer.
Eyelid Surgeries and Surface Treatments:
Among all surface treatments around the eyes, my favorite is chemical peeling. We use TCA or Phenol/croton oil as peeling agents. In the peeling process, we do a controlled surface abrasion with a strong acid. During the healing process, the upper skin is peeled off and replaced by a healthier skin.
Performing the peeling process together with open eyelid surgery is risky due to the possibility of shortening / pulling of the eyelid skin. A rest period of at least 3 months is needed between the two procedures.
The exception to this is the patient group in which we perform closed lower eyelid surgery (transconjunctival lower blepharoplasty). In this group, chemical peeling can be applied simultaneously to complement the surgery smoothly. We can also perform chemical peeling around the eyes in combination with procedures such as isolated forehead lift/isolated midface lift, where the eyelids are not operated but we start the procedure around them.
There are many combinations other than those listed here. Each option has its own pros and cons and present different risk/benefit profiles. Therefore, aesthetic surgery around the eyes cannot be simply reduced to an answer to this question: “Doc, do you give almond-shaped eyes to your patients?”
If a scientific, individual and holistic approach to the aging process around the eyes makes sense for you, feel free to contact us for detailed information.
I will be happy to help you.
Take good care… of yourself and your beauty.