Revitalizing upper blepharoplasty: Preserving volume.

TO THE EDITOR
Blepharoplasty is among the most frequently performed cosmetic surgeries today[1]. It is indicated for enhancing the cosmetic appearance of the eyelids and addressing age-related changes in these structures[2]. The results of this surgery are both aesthetic and functional, as they can impact the cornea, intraocular pressure, dry eye syndrome, and overall visual quality[3]. The conventional method of subtraction blepharoplasty, which sought to eliminate fat and excess skin, is now considered old[4-6]. The growing demand for a "full" look achieved through augmentation blepharoplasty highlights its importance as a key area of research and clinical attention[1].
The strengths of Gorgy et al’s editorial commentary lie in its thorough focus on the impactful findings of Miotti et al's systematic review[1,7]. It revealed that most studies supported a conservative approach, prioritizing anatomical preservation over tissue reduction, aligning with the views of Tonnard et al[5]. It also highlighted that fat pad management varies among patients, as demonstrated by Massry's controlled trials[6]. It underscored the need for surgeons to exercise discretion in customizing techniques for different demographics, including the distinct anatomical features of the Asian upper eyelid[7]. It pinpointed a gap in the systematic review, specifically the absence of long-term comparative studies. Except for a related study by Alghoul et al[8], which investigated the long-term outcomes of conservative vs traditional blepharoplasty techniques, more research is needed to confirm the efficacy and safety of these conservative approaches.
Despite the promising results, the editorial has some limitations. It did not discuss how the small sample size and single-center design might affect the generalizability of the findings, particularly in terms of patient diversity and external validity. Regional or institutional variations might influence the outcomes observed in our study. Future research should address these issues by involving larger, multi-center groups and extending the follow-up period to assess better the durability of the benefits observed and improve the generalizability and robustness of the results. Additionally, evaluating the cost-effectiveness of these interventions will be crucial for their broader adoption in clinical practice due to the difference in the long-term outcomes, complication rate, and efficiency of using healthcare resources. The editorial also did not emphasize the strengths of the study design systematic review) that followed PRISMA guidelines, which enhanced the validity of the findings, although data pooling was not possible due to the heterogeneity of the included studies. This suggests potential directions for future research, including the need for more homogeneous study designs, including retrospective cohorts or preferably randomized clinical trials, to allow data pooling via meta-analysis.
Gorgy et al’s editorial commentary effectively points out that a conservative approach is favored for upper eyelid blepharoplasty because it maintains the patient’s natural anatomy by enhancing rather than altering it, providing a more complete perspective on facial aesthetics[7]. It also highlights the necessity for long-term, prospective studies to assess the aesthetics, durability, and alignment with patient expectations. Larger, multi-center studies with extended follow-up periods are needed to validate the findings and refine intervention strategies. Exploring the cost-effectiveness of these interventions will also be critical for their broader integration into clinical practice. The commentary might have benefitted from emphasizing the strength of the study design in following PRISMA guidelines. Additionally, data pooling was not possible due to the heterogeneity of the included studies. Overall, the conservative approach to upper blepharoplasty can potentially improve patient outcomes on a global scale.

ACKNOWLEDGEMENTS
The authors wish to extend their heartfelt thanks to the continued support of the team at the Plastic and Reconstructive Surgery Department, Hamad Medical Corporation, in advancing our research by the expertise provided by them.