When patients come for a blepharoplasty consultation in my office in Denver we always discuss the individual patient’s eyelids, how the procedure works, the recovery, risks, healing period and other questions that patients may have. Patients often ask "what determines the outcome of an eyelid surgery?. Why is it one patient may have a great blepharoplasty whereas another ones is just “ok”?". There are three potential outcomes of any blepharoplasty surgery: fair, good and great. The big secret is that not every patient has the potential of a “great” outcome. Some may only be able to have a “good” or “fair” outcome. How is that possible? There are two main factors that go into whether someone has a fair, good or great outcome.

The first factor is the patient’s anatomy. This is the actual structure of their eyelid, anatomy of their eye socket bones behind the eyelid, position of their brows, wrinkles around their eye, how well developed their cheek bones which support their lower eyelids are, how young and elastic their skin is, if they have other medical issues with their eyelids. Though beyond the scope of this article, the patient’s individual anatomy will determine a large part of what their final outcome will be. What do I mean exactly? Let me give you an example.

A patient who is has poor skin quality will have less elastic skin. This may due to aging, genetics, smoking, sun exposure, or previous trauma. This patient will not be able to have a lot of skin excised during their blepharoplasty in their upper or lower eyelids. A patient with good skin quality may be able to have a lot of skin removed in the upper eyelids resulting in a “great” outcome. That same patient who has a lot of skin damage resulting in less elastic skin may only be able to have a “fair” outcome. In Denver, where these is a high UV index this is of particular importance. Patients who have a lot of skin damage who undergo a blepharoplasty may be limited to the maximal amount of skin that can be removed without a problem of eyelid closure occurring. As a result, they may have a little more skin than they or I would like but this limits their risk of eyelid retraction or eyelid closure problems. The tricky thing is that the surgeon may be able to determine anatomical limitations before surgery but often it is during the surgery many unique things about the patients individual anatomy are noted.

The second factor is surgical skill. Surgical skill is simply based on the experience and training of the surgeon. Training is just another version of experience. Like anything in life, the more you do of something, the better you tend to get. The psychologist, Ericksson in 1993 largely disproved the theory that talent and innate skill play a role in mastery development. He found that it is primarily from practice and more so “focused practice” that one becomes an expert or masters something. People are not born good surgeons. Based on the individual experience of the surgeon in blepharoplasty, this can determine their ability to maximize an individual patient’s result. A well experienced specialized surgeon may give an individual patient a “great” result, whereas an inexperienced surgeon will give the same patient a “fair” result. Patients often perceive that cosmetic surgery such as blepharoplasty is performed step-wise and has similar steps among all patients. Therefore, all patients will end up with a "great" result if the steps are performed properly. Anything else means that "surgery was botched". That is true on a very superficial level. To a novice surgeon or layperson, a blepharoplasty involves steps in a certain order which all give the same outcome, but to an experienced oculoplastic surgeon a blepharoplasty is a complex procedure that involves intraoperative decision making based on the patient’s individual anatomy and tissue. This intraoperative decision making will largely determine the success or how well the eyelids come out after surgery for each individual. The difference between a “practitioner” and “expert” when it comes to eyelid surgery is simple. A “practitioner” performs the same surgery in steps in all patients. Some patients have better outcomes than other but the same steps in the same way are done in everyone. An “expert” eyelid surgeon is one who has a basic framework of steps for blepharoplasty but as soon as he or she recognizes something is different about the anatomy or tissue, changes their steps or plan of attack to give the patient the best outcome possible and reduce the rate of complications. Generally, you want an expert.

This factor of “surgical skill” is something different than knowing if you have a “qualified eyelid surgeon”. “Qualified eyelid surgeon” in the United States basically means any self proclaimed “eyelid surgeon”. There is nothing limiting a surgeon who has never done the procedure before from claiming to be an “expert in eyelids” and performing blepharoplasty. Any doctor who is a surgeon and has operating room privileges can post on their website or office “I am an expert or qualified eyelid surgeon”.

Oculoplastic surgeons who are members of American Society of Ophthalmic Plastic Surgeons have a regimented training structure, perform a large number of eyelid surgeries in training and focus on not only maximizing outcomes but treating complications from cosmetic eyelid surgery. They take a written and oral exam and have to submit a surgical log of cases done to show basic competence in eyelid work before becoming a member of the society. In practice the eyelid is the main area of their surgical work. In short, an oculoplastic surgeon is who you want cutting you if you want to reduce your complication risk from blepharoplasty. Their familiarity with the eyelid anatomy, structure, function and eye function below makes them uniquely trained to identify on the operating room table when an individual patient’s anatomy is different in some regard and to pull back from preventing a complication. Other surgeons may perform a blepharoplasty well but as a group oculoplastic surgeons are known as the masters of the eyelid.

In the surgical world, we all want to believe that we are masters of every procedure that we perform. Yes, I believe that surgeons can perform a lot of different procedures “competently”. That being said, I believe if you focus on one procedure or one area and do it well, you can achieve mastery. Mastery of eyelid surgery is a lifelong journey as new techniques emerge, understanding of anatomy changes, and the surgeon develops knew insights into the surgical technique themselves. I believe the claim that one has “mastered” many different procedures basically means as a surgeon you have set a very low bar for what your definition of "mastery" is. Michael Jordan, who one would argue mastered the art of basketball attempted a professional baseball career and gave it up after struggling in the minor leagues. It is very hard to achieve mastery at any one thing without focusing your life on it and doing it all the time.

These two components discussed: patient’s anatomy and surgeon skill are largely the two determining factors of what the outcome after blepharoplasty will be. In my office in Denver during my consultations I try to educate patients as to all if any limitations based on their anatomy that they may have. Sometimes it is not revealed to me until the patient is on the table but knowing ahead of time as much as possible benefits the patients. I have dedicated my entire career towards mastery of the eyelid surgery and feel I offer a unique set of skills very few surgeons who perform blepharoplasty in Denver give to their patients. When it comes to self proclaimed "mastery", I think most masters are hesitant to say that they have mastered the eyelids completely and have no need to develop and expand my skills. I think once you do that it is the same as saying there is no further room to grow, expand, learn, get better and develop. If you have that attitude, you probably wouldn’t of become a master in the first place. I think an open, growing approach gives me the opportunity to present the best surgical skills to my patients every year. Blepharoplasty is not a “simple” procedure or “one size fits all” surgery. The best surgeons for the eyelid know that and are constantly searching for better techniques and approaches. These are the people who can give you your best personal outcome from the surgery.