Houston - James R. Patrinely, M.D., believes the so-called perfect eyelid does not exist; that surgeons seeking to satisfy their patients would be well advised to put aside their own perfectionism and salesmanship to focus instead on the goals of their patients and the most appropriate way to attain them.

"The biggest problem I see occurs when surgeons applly a single method to all patients to standardize their results. There are various structural and anatomical ethnic and cultural variations - particularly in the periorbital area - and there is no one-size-fits-all method suitable for everyone," he said.

"Although many patients who have the 'blue plate special' (which typically includes forehead, eyelids, midface suspension) are happy with the results, I see a significant number of unhappy patients who have undergone procedures from very experienced surgeons," added Dr. Patrinely, clinical associate professor of ophthalmology and plastic surgery, Baylor College of Medicine.

"Patients may find they look too different from preoperatively or that their eyes don't function right or close properly. Even when before and after pictures show objective improvement, these patients are not happy."

To avoid unhappy outcomes, Dr. Patrinely focuses on what the patient wants.

"I don't lead them. I let them tell me their concerns - things that may be completely different from what's obvious to me. However, because patients may not always know what is possible, he said, "I might gently point out what seems indicated. But if they're not interested, I back off and focus on their concern."

He said not everyone wants a browlift; and not everyone wants or can afford "all the procedures we surgeons might feel are indicated. We need to listen to what patients want and try to stay within their framework, not ours. Many patients don't want to look a whole lot different - they want subtle changes."

According to Dr. Patrinely, one patient's perfect eyelid may require fat repositioning, while another patient needs fat resection, and a third necessitates a special tightening effect of the lower lid. "You must allow for individuality among patients and not try to make everyone look the same with the same operation," he cautioned.

Dr. Patrinely specifically discussed complications with the commonly over-prescribed midfacelift.

"The operation still isn't 100 percent predictable for everybody. Complications include eyes that don't close normally - either because the skin is pulled too tight or too much is removed. There may be lower eye exposure or nerve-end damage, affecting the patient's blinking or forceful eyelid closure. Raised cheeks may descend over time, dragging everything down."

Dr. Patrinely explained some of this may be technical error - surgeons pull the cheeks up and create a false excess of eyelid skin that they trim off. "When things go south with time and gravity, the excess skin that was taken out becomes necessary, pulling the lids down with the cheeks."

Another problem can occur when the lateral canthus is pulled so tightly at the corner that it straightens out the curvature of the lower eyelid and looks unnatural, said Dr. Patrinely.