The Eyes Have It: The Wide World of Periocular Rejuvenation w/ Dr. Jason Bloom

PA_50 dr bloom The eyes have it.txt
Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Doreen Wu, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is "The Eyes Have It: The Wide World of Periocular Rejuvenation." Joining us for this episode is Dr. Jason Bloom, facial plastic surgeon from Bryn Mawr, Pennsylvania. Dr. Bass, the eyes make up such a small part of the face. Why is it important?

Dr. Lawrence Bass (00:39):
You're right, Doreen, the eye area is small, not much bigger than half of our thumb, but the eyes are where we look about 70% of the time when we're talking to people. It's how we project our personality. It's probably the part of the face we move the most to generate expressions along with our smile.

Doreen Wu (01:03):
Essentially, the eyes are a focal point on our face. So this means that you get your eyes fixed if you're aging, and then you're good, right?

Dr. Lawrence Bass (01:11):
Not so fast. We'd all like life to be simple, but the eyes, as small an area as they are, have big issues. There are a lot of small changes, all of which show as we age and each of which has a different treatment needed to correct it. You can do a single treatment, you can do a bunch of treatments together, pick what bugs you the most. But what's really important is to pick the treatment that addresses the feature you don't like. Picking the wrong treatment will end up not addressing the feature of concern.

Doreen Wu (01:50):
And historically, how was the eyelid surgery performed?

Dr. Lawrence Bass (01:54):
Well, if we go back to the 1980s when there were just a handful of aesthetic procedures as it had been for decades before that, the upper lid surgery was done by taking a crescent of skin out centered over the lid fold and taking out bulging or extra fat in the upper lid. And the lower lid surgery was done by making a small incision under the eyelashes, lifting the skin or the skin and the muscle up and taking out extra fat that, again, was bulging, creating the bags under the eyes. And that was pretty much universally what was done in eyelid surgery, along with an occasional chemical peel on the lower eyelids.

Doreen Wu (02:42):
What's changed? How is it different now?

Dr. Lawrence Bass (02:45):
Well, the upper lid surgery typically has more limited fat removal. We either remove no fat, we add some fat, because if we look at the lids in young people, upper eyelids, in fact, they're rather full. So sometimes we take that fat out in the, in the middle, just by the side of the nose, but we still take that crescent of skin out through the upper lid incision. And so that's very common in the lower eyelid. Probably more often than not, most surgeons are using what's called a transconjunctival approach. So instead of making the incision right under the eyelashes, the incision is made on the inner surface of the eyelid to allow access to the fat that creates the bags under the eyes. And so as a 50,000 foot view, those are probably the biggest changes. But as I said, there's a lot of complexity in this area. So let me turn now to our guest expert my friend and colleague, Dr. Jason Bloom. Dr. Bloom, what do you see as the main features of modern lid surgery compared with the past?

Dr. Jason Bloom (04:02):
Well, first of all, thank you Dr. Bess and Doreen for having me. it's always fun to talk to you guys about these topics and I, I tend to agree with you about what you were saying. I think what we've seen over the past few years and is that hollowed eyelids, whether it's upper uppers or lowers, kind of look aged. So whereas in the upper eyelid we were taking out me, you know, medial fat, and sometimes it can lead to like an A-frame deformity, meaning hollowing of the upper eyelids. And certainly that is done in a very, very, very limited manner now. But upper eyelid surgery, other than the preservation of fat or the or addition of fat to make a more full upper eyelid with still the excision of skin is kind of the one thing that's changed. In lower eyelids, I also tend to agree with Dr. Bass. Really most people are preserving eyelid function, so less going through the muscle and more of a transconjunctival approach. And really what we've seen is that it's more preservation at this point or restoration, so preservation of the eyelid fat, whereas we were in the past taking out the fat of the lower eyelids. Now what we're doing is conservatively taking out lower eyelid fat, but either transposing the fat, meaning sewing it underneath the eyes to preserve some fullness or conservatively removing and fat grafting to that area. So preserving the fat or trans or transposing it or grafting it is going to lead to less periocular hollowing in the future.

Doreen Wu (06:09):
And now that we've discussed some of the main features, what are other features that are also chased?

Dr. Jason Bloom (06:15):
You know what, when we look at the whole eyelid in general or the periocular area, you know, you have to start with the brow position. The eyelid position itself. Is it low on the pupil or the eyeball? What's the status of the skin around the eyes, the crow's feet? Is there crepiness underneath the eyes? Do you have crow's feet around them? Is there periocular or infraorbital hollowing or volume loss? And then finally, is the eye muscle? Is it, is the muscle bulging? Do you have excess you know orbicularis or eye muscle that's causing some thickness in the tissue underneath the eye? So we really look at that whole area.

Dr. Lawrence Bass (07:07):
Yeah, that's really important because each of these details, as I said, typically needs to get chased in a different way. And just using a one size fits all approach of taking down fat is not going to do it. Using an overblown or heavy handed approach is not going to do it. And what Dr. Bloom just said, I agree completely in terms of balancing the amount of fat removal or the positioning of the fat. And it's like Goldilocks and the three bears not too much, not too little, just right, because if you do too much, the lid is hollow. If you do too little, you haven't really corrected it. So you need to get the balance just right. And in a small area like this, that balance point is a very narrow window.

Doreen Wu (08:00):
Like you both said, those are a lot of little fine details in a very small area. Tell me what treatments chase each of these features.

Dr. Jason Bloom (08:08):
So when we talk about the brow, for example, I like to say that helps to frame the periocular area. There are things you can do everything from brow lifting surgery to some neuromodulators, for example, to raise the brows like a Botox or a chemical brow lift. Same thing to treat the the crow's feet. There is everything from neuromodulator or toxin products or topicals, peels to treat crepiness around the eyes. And then the lid position, if someone has ptosis or when the eyelid actually sits lower on the pupil than, for example, on one side or the other or both. There are ptosis surgeries, oculoplastic surgeries that we can do to open up the eye. And now there's even drops, things like UPNEEQ, which is an oxymetazoline drop to open the eye temporarily. And then finally, I would say for kind of the infraorbital periocular, hollowing, everything from filler to fat transfer and those kind of are all very niche things in themselves. So there's, you know, finer details about which fillers we choose and, and how we take care of and process the fat when we're doing these procedures.

Dr. Lawrence Bass (09:42):
Yeah, so you see there's a range of items there. And I agree that considering in process all of those areas and splitting that all out so that you get to the root of what's really going on is critical also in the lower lid lid support as people get older diminishes. And so that's another functional consideration along with the eyelid posis that Dr. Bloom was talking about in the upper eyelid. So all of that needs to be looked at, evaluated and chased. If we want to get the most complete correction in the periocular area.

Doreen Wu (10:25):
Dr. Bloom, what patterns or combinations of treatments are typical? Are these generally true or do we need to break it down by age group?

Dr. Jason Bloom (10:33):
So some of the, the patterns that we usually see kind of progress and get worse with more advanced age. So in younger patients, if we break it up in some of the younger patients, we start to see some of, you know, some lateral hooding of the upper eyelids. We start to see some crow's feet develop as well as some of the elevens or frown lines in between the eyes. And even in our late twenties even, we begin to see some periocular or infraorbital hollowing in some of those patients. Those kind of treatments are usually done non-surgically. We can treat patients with neuromodulators and fillers in those in the early age groups. But as patients get more advanced upper eyelid skin hooding, lower brow position, more hollowing fat bags starting to develop in the eyes. Now with more advanced age, we tend to move into more of a surgical approach with those patients.

Dr. Lawrence Bass (11:44):
And, and I think Dr. Bloom really raised a critical point. The lid area is not an area that shows aging changes late in the game. It's an area that starts to show aging changes, probably the earliest of any place on the face. And, you know, this is our thinnest skin on our entire body, the eyelid skin. So it's not surprising that this is then, and it's out in the sun all the time. So it's not surprising that this is the place that shows early changes, but fortunately, often we can chase those with non-surgical options in the twenties, in the thirties, although some individuals, and you can see a genetic component because their sister and their mother and their aunt will all show a lot of heavy bags in the lower lids or a lot of hooding in the upper lid skin at a very early stage. So there's an occasional person who needs surgery even in the twenties, certainly in the mid thirties and beyond. And very common in conjunction with lid surgery would be peeling of the skin because again, that skin, and when I say peeling, that could be a chemical peel, it could be a fractional laser treatment, an RF microneedling treatment, something to to rejuvenate that skin along with the contouring that's being done with fillers or with surgery to try to bring the lid back into balance.

Doreen Wu (13:28):
Let's talk about provider selection for a moment. With these various combinations, do you need multiple providers or should your plastic surgeon be able to handle it?

Dr. Lawrence Bass (13:38):
So I, you know, I think it's important when you do something not to be a one trick pony. Dr. Bloom has just very clearly described all of the features that we consider in the lid areas, and an experienced surgeon is going to understand and have options for all of these features. They're not going to only address one and not the other. That's really the essence of modern aesthetic surgery is these global corrections considering all the factors involved. So I think anyone who's working in this area on a regular basis and is well trained and experienced can bring what you need to get the best result.

Dr. Jason Bloom (14:25):
Yeah, I tend to agree with that. I mean, I definitely have been trained and performed all the procedures. The one thing is I know my limitations and I work great with my oculoplastics colleagues, and if I feel that something is out of my realm and I don't do a lot of ptosis surgery personally, and that's one of the things that I tend to refer and those patients, I'm happy to send the blepharoplasties to them too, if they're doing it in conjunction with a ptosis procedure. So I know what I'm good at. And I'm happy to refer out if I think that there is a colleague of mine who would perform a procedure better than I would.

Dr. Lawrence Bass (15:23):
Yeah, I think the issue that I'm thinking about when I hear this question is this process that I see frequently in New York City where people have their Botox doctor and their filler doctor and their facial plastic surgeon, and everyone's sticking their finger in the pie. And that's different than taking someone who has a functional consideration in their lids and getting involved with the oculoplastic surgeon who's eminently qualified to chase that particular feature. It also is a product of both the training and the recent experience of the surgeon. I was fortunate enough to be trained by a couple of plastic surgeons who were double boarded in plastic surgery in ophthalmology. So we did a lot of complex lid surgery, including reconstructive things, support things as well as advanced aesthetic procedures. And so that gives me a background in that. But doing that on a regular basis and having just the right balance point, for ptosis surgery or lid support surgery in the lower lid is critical to an excellent result.

Doreen Wu (16:41):
Let's shift gears for a moment and talk about the brow. How is that part of the periocular area? Where do treatments for the brow fall under? Is that more neuromodulator, surgery, muscle stimulation?

Dr. Lawrence Bass (16:54):
So, Dr. Bloom talked about this a little bit earlier, and it is the frame, it's the upper limit of that periocular or around the eye area. The brow position is something that changes as we age and sometimes even in youth is not in an ideal position or can be enhanced. So that's importantly part of what you assess and plan for in performing any rejuvenation around the eye. Now the interesting question is that nowadays mostly Botox and other neuromodulators? Is it surgery like brow lifting? Or more recently, one of the manufacturers has just revisited an old concept, which is muscle stimulation in the face with the thought of rejuvenating the face by training and stimulating muscles to increase muscle tone, which seems paradoxical because it's sort of the opposite of what Botox does, which is to block nerve signals and relax muscles. So Dr. Bloom <laugh>, let me drop this in your lap and let you, you say what you think about it.

Dr. Jason Bloom (18:26):
You know, I'll give my views and also add one other thing, but you know, I've kind of gone back and forth with brow lifting surgery. I've really struggled with something to give me a very long lasting result. I tend to do some endo brows occasionally endoscopic brow lift surgery. But you know, I think that neuromodulators work great. And I've, that is the majority of what I do for brows at this point. We have, I have no experience with the muscle stimulation and I know you have kind of gotten into that. I'd be interested to hear your thoughts. One of the other things that we've been using a little bit more with good results is something called Sofwave, which Sofwave is an ultrasound non-focused ultrasound approach, which basically targets the dermis about 1.5 millimeters under the skin. And by contracting that layer over the brows, they did some clinical trials that actually showed on average a four to five millimeter brow lift, which is quite impressive for a nonsurgical approach. And we've been using it with my practice with some really, really nice results.

Dr. Lawrence Bass (19:51):
Yeah, that's an interesting point because I feel in my hands most of the time I'm trying to encourage patients to work with neuromodulators. I think you have tremendous shape control that is sometimes hard to obtain with surgical approaches. You have more ability probably than surgery to deal with asymmetric brows. Many people have one brow higher than the other, and brow lift surgery is notorious for, not making it worse, but not correcting it as much as one might hope. So that's probably the mainstay. I agree completely. But there is a role in a certain number of patients for brow lift surgery. It's, I think, not in its heyday like it was in the 1990s when we got endo brow lifts or endoscopic brow lifts, and the ability to do a brow lift without a big long incision made it much more appealing to go ahead with.

(20:59):
But I think we've identified a narrower range of patients who really aesthetically have a major brow issue that needs a surgical approach. The muscle stimulation I think was examined in the 1990s and it's more for other parts of the face than the brow. But we'll see as this new product that's just come out develops a little more clinical experience. But the energy lifting approach, every device that's been a non-surgical skin lifter or a tightener has had a brow lift approval that started with Thermage in 2004 and their first FDA approval or clearance, actually, because it's a device, was for brow lift. And then they got a more general facial lifting clearance and then Ultherapy did the same thing. And Sofwave is the newest, most modern iteration with certain advantages in application compared to the older technologies. But brow lift, I agree completely, four millimeters, it may sound small, but that's actually big when it comes to the brow and probably rivals what you can do surgically with a whole lot less in terms of time recovery cost and so forth. So that, that's an interesting development for sure.

Doreen Wu (22:39):
If we turn to the lower lid, what are some of the new approaches in this area?

Dr. Lawrence Bass (22:43):
A lot of the lower lid advancement revolves around chasing the deepening of the tear trough and the lid junction. So you heard Dr. Bloom mention a lot of the options here. One is just fat grafting into the area. Another is using filler nonsurgically to augment the area. And then there are techniques that actually release the ligamentous attachments at the orbital rim, at the bone, at the bottom of the lower lid and take some of that fat that in days past we might have removed and instead it across that, that dividing line, that lid junction in order to have an even curtain of fat. Because as I said, young people typically are not hollow or empty, they're actually full, but their fat is very smooth and even, and that's a typically youthful appearance. So Dr. Bloom, what, what do you think?

Dr. Jason Bloom (23:54):
So I totally agree if we're talking in let's say a younger patient the depth of the, the tear trough for the hollowing around the eye of the infraorbital area really determines a lot if we're treating a patient with with filler and let's say we're not choosing a surgery for that patient, and I'm going to use some like filler names here, but if it's a deeper kind of hollowing in that area, I tend to camouflage the lower eyelid fat or infraorbital area with a product like Restylane. And that has been my go-to for a long time. More recently, and this is in clinical trials so Restylane is not approved for the periocular area. It has undergone clinical trials and most likely would be, will be approved next year for the Infraorbital area. Most recently for a more shallow infraorbital area, infraorbital hollowing, I tend to use a new product called RHA redensity, which I think is really nice for that area also in clinical trials currently for the periocular area.

(25:13):
Now if we're switching gears to a more surgical approach, everything I've done in my practice has kind of been trial and error over the last 13 years. And it's, it's usually because the pendulum in periocular rejuvenation surgically has kind of switched. And what I used to do was excise some of the fat. And what we saw is when you see those patients back five to 10 years later, then they're looking a little bit more hollow. So then I switched to releasing all the ligamentous attachments in the lower lid all through the transconj approach in all these cases and then transposing the fat underneath the periosteum. And I did that for a few years and kind of saw it wasn't as I would say, I was seeing some lumpiness occasionally patients would feel like kind of tethered occasionally. I just didn't love it as as much as I should. And I would say for the past about six or seven years I've been doing some conservative fat removal with fat grafting in that area. And now I've really found that to be the best result in my hand seeing these patients back six or seven years later. So that's kind of been my approach for this entire time.

Dr. Lawrence Bass (26:39):
Yeah, it's, it's interesting because I've gone through a similar kind of evolution in my approach. The, you know, the issues with transposing, the fat, the beauty of that is it sounds very anatomically appealing. You are, you are releasing the tether point, you are taking vascularized fat, fat that has a blood supply that's still attached and draping it across. So you'd expect that to give you a degree of control and predictability. But in fact, releasing the ligamentous attachments means a lot more bruising and swelling in the recovery. And while I was able to get very good correction in the fold up to a point, if it was deeper than a certain amount or that fold extended towards the side too far, that I would be limited in the ability to fully correct those areas. So doing that with some fat removal and some fat grafting is a much simpler approach.

(27:52):
And the other limitation of the release approaches is they didn't help me for older patients because you need good lid support. You either need to have good lid support or you need to build good lid support once you release all of of those bony attachments or you're going to have lid retraction problems. And some of the surgeons who were big proponents of this had rather staggering rates of lid support problems after some of the orbicularis reset surgeries based on their published data. I'm not speaking out of school, it's what they reported themselves in, in their own articles. And that's concerning because we, we want to get people out of trouble, not into trouble when we do these treatments. So you know, I started to mention functional issues even in aesthetic lid surgery. We talked about it earlier in this podcast, but you know, the important thing to understand is that lid support loosens as we age and our eyes reduce tear production and tear quality also diminishes the lubricating aspects of the tears become less good at doing that. And so that's something we have to consider as we look at people from their thirties to their eighties in terms of doing eyelid surgery.

Doreen Wu (29:29):
How would I know if these are a problem? At what point should I start becoming concerned?

Dr. Jason Bloom (29:34):
I, I think one of the, the most important things is, you know, in starting anything when you, it goes back to like very early medicine is, is really getting a good history. I, when I'm when I'm going through and talking to patients about periocular surgery, I'm asking them about have, have they had any history of dry eye? Do they wear contacts? Do they wear glasses? Have they had any orbital or ocular surgery, LASIKS, cataracts, things like that. Do they have any diabetes, thyroid issues, autoimmune issues? So picking some of these things up from the history, right, it's is like, as we learn this in medical school, is getting a good history will give you a lot of information prior to, you know, you, you don't want to like take a patient to surgery and learn they have Sjogren's syndrome after, after the fact, right? And that's dry eye and things like that. So do they see a an ophthalmologist or an optometrist regularly for issues dealing with dry eye and things like that? So picking a lot of these things up from a really good history will save you on the back end in dealing with these problems later.

Dr. Lawrence Bass (30:53):
Absolutely. I mean we want everyone to look beautiful, but it's critically important to remember this is medical care. And medical care needs to follow the correct process of history examination, not just of what your aesthetic concerns are, but of your, your general health and wellbeing, which will alert a knowledgeable surgeon that there's more risk or that something needs to be evaluated in more detail. And we can still almost always perform lid surgery, but we may need to adjust the techniques to compensate for some of the trouble with lid support or with dry eyes. And if we know that ahead of time, it's easy to do and if we don't know about it, then there can be trouble. So some of those support procedures are things like canthopexy and canthoplasty, which are commonly used again as protection or support or even reconstruction at the time of aesthetic lid surgery. So Dr. Bloom, what's the difference between the two and what's your view about when they should be used? Because there are surgeons who feel who will always want to do it or always in certain age groups. so what's your approach to this?

Dr. Jason Bloom (32:21):
So the difference really between a canthopexy is something to support. So the canthus is where the, the eye kind of upper and eyelid come together laterally by the ears or by the nose, so either medial or laterally, and a canthopexy is something that's done to support the underlying campus without truly cutting through that area. And then a canthoplasty would be a reconstruction of that campus where we can actually cut through it, tighten the tendon in the lower eyelid and really give it a lot of extra support. What I can tell you is I tend to avoid doing canthoplasty unless a patient has true, that means cutting the canthus itself unless a patient has true lower eyelid rounding or what we call ectropion, which is pulling down the lid where, where you can see some of the white underneath the eye, underneath the iris of the eye.

(33:43):
So in more of a reconstructive procedure, that's when I would consider a canthoplasty or a lid shortening tightening procedure of the lower eyelid. I tend to do a canthopexy when I'm doing something to support the muscle of the lower eyelid. So for example I am about, I do about 90% transconjunctival lower eyelid surgery, but if a patient has true muscle swag, looseness of the muscle of the eye, I tend to do a transcutaneous, meaning an incision underneath the eyelid, through the muscle. And then I do an orbicularis or a muscle suspension where I'm actually sewing a tag of the muscle up to the orbital tubercle. And what that will do is that will support some of the lower eyelid muscle and help prevent that from pulling down. Additionally, I can sew that muscle and some of the lid, the tendon to that same position to help that pull down. That would be the main reason why I would do a canthoopexy in those cases. but again, it's a rare situation where a patient truly has muscle laxity in the lower eyelid that I need to correct.

Dr. Lawrence Bass (35:22):
Yeah, I, the way I think about it is similar. I think there are people who have an existing support problem and you can usually see that the, just about the instant you walk in the exam room because the lid is not in its proper position. And importantly the idea is that the lid not only has to be up, but it also has to be back against the eyeball. And if it's not up and back, it is not going to be able to do its job properly of spreading the tear film over the eye. so those are the canthoplasty people who need support rebuilt because the support is gone. And then there are people who are loose, they don't have a major problem now, but they're right on the cusp of it. And those are the ones, if they're having extensive lid surgery that I'll think about canthopexy, or a support procedure.

(36:24):
And I don't believe that people who are not symptomatic and have good lid support with modern aesthetic techniques need a canthopexy on a prophylactic basis. And there are surgeons who are doing that, but every intervention has risks and has downsides. And so I've avoided doing that in patients who don't have a clear indication on exam in terms of dryness, in terms of lid snap or lid, some other attribute of of lid support deficit like rounding in the corner or something else as you described. So by being more selective, I feel like I use it when I need it. I could always come if one of the patients who looks like they have good support gets in trouble after a procedure, I always have the option to come back and pex them at that point. I don't want to do an extra procedure and I haven't had to do that in really pretty much the last 20 years, even once. But if I got in trouble, I always have that escape hatch rather than giving everybody the fix that 99% of them don't need. So just as a curiosity I'm interested to hear what you think Dr. Bloom about, we talked about brow elevation using neuromodulators and we talked about brow lifting and energy-based treatments that tighten up the deep layers of the skin, pulling the brow up. what are, what are your thoughts about using fat or fillers as an option for mild lateral brow elevation?

Dr. Jason Bloom (38:22):
You know, I, I think, so my my feeling is I don't use fat or filler to try to elevate the brow, but I think what happens is with age, we lose volume in our brow. And so from both the temple from the muscular standpoint, from some of the subcutaneous fat, and then also we start to lose some of the bony aspects of the skeleton in that super brow area. And it begins to hollow and all happens with age or muscle atrophy in the temple area. And I think I actually enjoy doing fat or filler there to kind of give you back some of that brow height. So I, and not that I'm trying to like crank out up a brow with that, but today actually I use two different fillers to really address, it's mainly the super brow area in that area of the most anterior part of the temple. By injecting in some of those that area either filler or fat, you're beginning to replace some of the really, the skeleton, the brow, the bony brow skeleton that's beginning to atrophy as well as the muscular and soft tissue support in that area, which will kind of bring out that tail of the brow and give you a little bit of support and return of the brow height.

Dr. Lawrence Bass (39:56):
Yeah, I think that's a critical point. You know, we're losing fat in our face from our twenties, but as we get into our fifties and beyond, we're losing muscle volume and bone volume and rejuvenation is, is not just about tightening up skin, it's as much about restoring youthful shape as anything else. And so that's critically important. That being said, I will put filler or fat if I'm working in that area sometimes right along the bony rim in that lateral third just to help with a little bit of arching, projection and elevation of that brow. and I picture that as sort of a subgaleal placement, if you will right at that level along with above the brow in that, in that medial or lower temple area.

Doreen Wu (40:54):
Well, this has certainly been an interesting episode with lots of riveting discussion. Before you wrap up Dr. Bass, can you share some important takeaways for our listeners?

Dr. Lawrence Bass (41:03):
Treating the periocular or around the eye area is a multi-modality approach with specific treatments for specific features. Currently, as we record this at the end of 2022, there's no meaningful substitute for eyelid surgery, blepharoplasty in either the upper or lower lid to do what those procedures do. and this is one of the areas where we see aging changes early on, we didn't talk a lot about the appearance after lid surgery, but the goal is always to create a natural look and it is possible to have eyelid surgery and it should not change the way your lids look again, except for those reconstructive circumstances where, where the lid is not working properly. And as we discussed a capable plastic surgeon is going to be able to bring you the necessary scope of multimodality treatments that are currently state-of-the-art care in this area.

Doreen Wu (42:19):
And Dr. Bloom, would you like to add anything?

Dr. Jason Bloom (42:22):
I will just say in this in this age, we're in where there are, you know, there are so many different practitioners out there doing injectables and lasers and things like that. Dr. Bass and I are lucky to be doing what we do as surgeons because you, you have to, there, there always is, you have to be reasonable when you're talking to patients and explain that sometimes, you know, I like to, you know, keep it simple and do some injectables when it's the right case, but really nothing does take the place for surgery when it's indicated. And, you know I'm sure Dr. Bass feels the same way, but we see patients with all sorts of things injected in and around their eyes and sometimes, you know, it's like all those, those situations when all you have is a hammer, everything looks like a nail. And we see patients that have seen multiple different people and sometimes I just want to say, you know what, your best option here, even if it's a young patient, your best option here is surgery. And so we're lucky to be doing what we do and to, you know, give patients that option if it's indicated in these cases.

Dr. Lawrence Bass (43:46):
You know, the other thing which we didn't mention that's important is the lid surgeries are probably the most durable thing we do in facial rejuvenation. So 10, 20 years or sometimes never for redoing a lid surgery is the norm rather than the exception. And among everything that's available, it is definitively the most durable.

Doreen Wu (44:15):
On that note, thank you Dr. Bloom, Dr. Bass for helping me and our listeners understand this complex area. The eyes may not take up a lot of real estate on our face, but they certainly have a major impact.

Dr. Lawrence Bass (44:27):
And I'd like to thank Dr. Bloom for joining us yet again on the podcast in sharing his extensive experience and his wise perspective.

Dr. Jason Bloom (44:36):
Thank you guys again. It's always a pleasure to be a guest on the podcast.

Doreen Wu (44:41):
Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review, and share the show with your friends. Be sure to join us next time to avoid missing all the great content that's coming your way. If you want to contact us with comments or questions, we'd love to hear from you, send us an email at podcast@drbass.net or dm us on Instagram, @drbassnyc.