Combined cosmetic and reconstructive procedures
Often times, during a reconstruction, it makes good sense to perform a cosmetic procedure at the same time. For example, I recently lifted the left upper lid on a forty-ish year old woman who was born with a droop. Since her eyelid did not work at all, reconstruction necessitated a complex procedure involving silicone rod implantation into the eyelid, to better couple the eyelid to the forehead and hence improve the lifting of the lid. (I perform this procedure perhaps twice a month.) However, once the rods are in, cosmetic blepharoplasty is quite complicated, since it would have to be done without disrupting the rods. In this case, I advised the patient that this was a good time to have bilateral upper blepharoplasty, if that was something that she was interested in.
Another example of adjunctive cosmetic surgery is described below.
A young woman of age 53 was diagnosed with a basal cell carcinoma of the right upper lid. She came to me with an ulcerated upper lid and loss of skin over perhaps a third of the lid. It appeared to me that she might need a skin graft to reconstruct the eventual defect.
It turns out that the optimal reconstruction would involve removing more skin. The reason is that a scar running across the middle of the upper eyelid platform would look bad. A general principle of cosmetic and reconstructive surgery involves the treatment of “cosmetic subunits”. In her case, practically speaking, it means that the upper lid would look a lot better if all of the skin in the eyeshadow space was removed and replaced with a skin graft, instead of only replacing a portion of that subunit. And where does that skin come from? I suggested to her that the most sensible thing to do is a cosmetic blepharoplasty on the other side, both for aesthetic reasons and to supply the skin for the reconstruction on the right side.
The photo below shows that patient as she appeared during the initial office visit, prior to resection of the skin cancer of the right upper lid. The skin defect (from ulceration, and from biopsy) is highlighted in blue.
Her surgery was done in a coordinated manner with a Mohs dermatologist. She is depicted below after the skin cancer was removed. The defect is outlined in blue. The proposed reconstruction involved removal of the entire subunit (depicted in red).
Finally, two months after right upper lid reconstruction and left upper lid cosmetic blepharoplasty, she is seen below. The blue arrow demarcates the junction between the skin graft and the untouched eyelid. That line will fade away to invisibility over the next few months.