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74 MARCH 2016 | Surgical Aesthetics SURGICAL AESTHETICS IN THE EYE OF THE BEHOLDER "I HAVE A VERY HIGH TOLERANCE FOR SUGGESTING A BROW LIFT BECAUSE I REALLY THINK IT CHANGES THE WAY AN INDIVIDUAL LOOKS." Addressing Undereye Bags When a patient wants to minimize the appearance of their undereye bags, Dr. Alessi favors a transconjunctival blepharoplasty. Occasionally a small amount of skin will be removed. For larger festoons, he will revert to a stan- dard skin muscle fl ap. "With either procedure, I usually fi ll in the tear trough with a fat transfer," he says. "With the skin muscle fl ap, I will almost always do a lateral tarsor- rhaphy stitch. A simultaneous TCA peel or laser treat- ment will further help to rejuvenate the lower lid." Dr. Rizk fi nds that while men are far less wrinkle- obsessed than women—they don't mind a few lines and creases—they do tend to zero in on fatty deposits under their eyes that make them look tired and older. "Men prefer minimally invasive remedies with short recovery times and minimal risks, scars or telltale signs of major cosmetic procedures," he says. "My main goal for male patients is to provide a natural and long-lasting result with a rapid recovery that gets them back to work fast, so no one knows they have had work done." To this end, he also addresses fatty bulges through a scarless transconjunctival procedure that involves plac- ing an incision only inside the lower lid to remove small pockets of excess fat and smooth out the contour of the undereye area. "Undereye bags respond well to mini- mal and conservative fat bag removal, when needed," says Dr. Rizk. "For advanced laxity, skin removal is also required. Lastly, if there is scleral show, we may need to do some muscle tightening, but for men, the recovery is often hard to accept." Dr. Rizk rarely recommends resurfacing lasers for male patients due to the downtime, but for women who have concerns about fine lines, wrinkles or pigmentation, he uses Ellman's Cortex Laser, which combines CO 2 and Er:YAG wavelengths to even skin tone and tighten skin. Periorbital Cautions In order to provide the most natural-looking results, physi- cians must know their facial anatomy. "Eyelid skin is very unforgiving, so be cautious about doing too much too soon—before the patient really needs surgical interven- tion," says Dr. Rizk. Whether you are working with a male or female patient, he recommends taking your time during consultations to present all of the options available to the patient. This will help you avoid disappointment and miscommunication regarding expected outcomes. "If a woman presents with a heavy upper lid and excess fat, ask to see photos of her at age 30 or 35," he says. "These formations are usually genetic, and if you give her a deep-set upper lid and remove too much skin and fat, it will change her look dramatically, which may not be what she wants or expects. She may not recognize herself after surgery, and this is basically irreversible." Dr. Rizk notes that eyelid scars will be more visible on men because they do not wear makeup. "Avoid extending the incisions laterally, which are telltale signs of surgery," he says. Dr. Stevens finds that it is important to be judicious in selecting brow lift patients. "There are differences in men and women; especially with men, less is more—particu- larly when you are dealing with the upper lid," he says. "If you lift a man's brows, it really changes his appearance. I would certainly recommend doing less." On the lower lid, Dr. Stevens tries to preserve the fat as much as possible. "Once that fat is gone there's no turning back, and that's what is going to make somebody look older," he says. "It's going to hollow out their eyes. So preserve the fat—use what's there to rejuvenate the orbit as opposed to removing soft tissue, including fat, muscle and skin." "A surgeon should have several tools in their tool bag and choose the appropriate tool for each situation," says Dr. Alessi. "Also, don't overdo. The enemy of good is perfection. Minor revisions are always better than major reconstructions." Daniel Casciato is a Pittsburgh-based freelance writer.