An Aesthetic Vision: Oculoplastic Surgery and Aesthetic Surgery Journal

Welcome to the special Oculoplastic Surgery issue of Aesthetic Surgery Journal (ASJ), in celebration of ASJ's 30th anniversary. This editorial serves not only as a reflection on the 30-year history of ASJ and its role in advancing the field of oculoplastic surgery, but also as an opportunity to look forward and proclaim the bright future ahead. Oculoplastic surgery in one form or another has existed for thousands of years, with the first recorded reference to oculoplastic surgery heralding back to the Code of Hammurabi. However, the commonly accepted genesis of oculoplastic surgery as we consider it today was pioneered by Jaques Daviel in the mid-1700s, followed by von Graefe, who first coined the term “blepharoplasty” in 1818, as well as Fricke, Landolt, Tripier, Dieffenbach, and other surgical visionaries of the time. The next major strides in oculoplastic surgery were made in the wake of World War I and World War II, led by John Martin Wheeler, Wendell L. Hughes, and many more.1,2 In more recent decades, the demand for blepharoplasty has only continued to grow. Modernly, blepharoplasty (also referred to as “eyelid surgery”) has been reported in the top 5 cosmetic surgery procedures performed in the United States for over 2 decades.3-6 Oculoplastic surgery has roots in both ophthalmology and plastic surgery, and plastic surgeons have long worked with ophthalmologists and other specialists in the field of eye surgery to bring surgical advancements to the forefront. This is evidenced by ASJ's decades-long tradition of interspecialty collaboration, both through our editorial board appointments and in the content we publish.7 This interconnection, as well as the shrewd leadership of past Editors-in-Chief Drs Robert Bernard, Stanley Klatsky, and Foad Nahai, led the way for ASJ to launch a devoted section of the journal to oculoplastic surgery in 2009, thus beginning a new age for the advancement and prominence of this surgical specialty. Periorbital surgery has seen great evolution and innovation since the 2009 launch of the Oculoplastic Surgery section of ASJ. We have come a long way in our understanding of periorbital anatomy, surface topography, surgical approaches, and techniques, thanks to the contributions of many pioneers and thoughtful surgeons from all over the world. The manuscript submission rate for the Oculoplastic Surgery section has increased by 100% over the past 10 years, and the section has grown from being overseen by from 1 section editor, Dr Jack A. Friedland, to there now being 3 section co-editors, Dr Mohammed Alghoul (Figures 1-3), Dr Salvatore J. Pacella (Figure 4), and Dr Ted Wojno (Figure 5). Submissions to this section represent all major continents, with a noticeable increase in Asian blepharoplasty papers submitted over the past decade, reflecting the strong international presence of ASJ.8-13 Dr Mohammad Alghoul (left) and Aesthetic Surgery Journal Editor-in-Chief Dr Jeffrey M. Kenkel (right) photographed together at the British Association of Aesthetic Plastic Surgeons in London, United Kingdom, in 2024. Dr Mohammad Alghoul (right) and Aesthetic Surgery Journal Editor Emeritus Dr Foad Nahai (left) photographed together at the Midwestern Association of Plastic Surgeons annual meeting in Chicago, IL in 2016. Phaedra Cress (left), Aesthetic Surgery Journal's senior director of publishing and global partnerships, and Dr Mohammad Alghoul (right) photographed together at the annual IMCAS (International Master Course on Aging Science) meeting in Paris, France in 2022. (A) Dr Salvatore Pacella (far left) speaking at the podium for the “Risk vs Reward in Lower Blepharoplasty” panel, photographed with fellow panelists (seated, left to right) Drs Jason Roostaeian, Mokhtar Asaadi, Gabriele Miotto, Francisco Bravo, and Usha Rajagopal, at The Aesthetic Meeting 2021 in Miami, FL. (B) Dr Pacella speaking at the podium as part of the panel. Dr Foad Nahai and Dr Ted Wojno promoting their book Problems in Periorbital Surgery. The published topics are diverse and comprehensive, including technique-focused papers, articles on periorbital aesthetics and aging, papers focused on clinical and patient-reported outcomes, deeper dives into surgical anatomy, lower eyelid fat grafting and double eyelid surgery, and methods for cosmetic medicine and noninvasive/nonsurgical approaches focused on the periorbital region.14-36 Additionally, many discussions written by thought leaders in the field have provided invaluable insight and critique, enhancing our understanding of the topic in hand.37-41 Although it is difficult to choose among the many great articles published in this section over the years, here we have hand-selected a list of 10 ASJ articles spanning the last 2 decades which have had a strong influence on the literature and clinical practice, 5 of which are the most-cited ASJ Oculoplastic Surgery articles of all time.42-51 We invite you to read these timeless articles, not only for historical purposes but also to emphasize the influence they may have had on our clinical practices. The 2012 “Tear Trough Deformity” paper was written in Atlanta, GA, just as Dr Alghoul was starting his fellowship, by his fellowship predecessor, Dr Ross Stutman, and Dr Alghoul's late mentor Dr Mark Codner.42 To date, it is the most comprehensive review of this topic, and Dr Alghoul will be writing an update on the anatomical insights and treatment options that have taken place since its publication. A highly cited 2013 case review of augmentation blepharoplasty opened our eyes (no pun intended) to the importance of periorbital fat grafting in eye rejuvenation.43 “The Effect of ‘Single’ vs ‘Double’ Eyelids on the Perceived Attractiveness of Chinese Women” published in 2014 helped to establish the concept of “double” eyelids as being the more attractive and desirable feature.44 A systematic review comparing various spacer grafts, of which Dr Alghoul was a coauthor, showed no difference between hard palate mucosa and acellular dermal matrix grafts in the repair of lower lid retraction.45 “New Insights into Physical Findings Associated With Postblepharoplasty Lower Eyelid Retraction” by Griffin et al is a very thoughtful paper that has now become a classic.46 It is no exaggeration to say that many, including the writers of this Editorial, have personally benefited from the insights provided by this article. Another important and impactful publication by Bernardini et al titled “Minimal Incisions Vertical Endoscopic Lifting (MIVEL) for the Management of Lateral Canthal and Lower Eyelid Malposition,” published in 2019, provided new insights into the use of endoscopic techniques to manipulate the lateral canthal system.47 This opened the door for countless surgeons to broaden the applications of endoscopic forehead lifts beyond the brow. “Identifying Aesthetically appealing Upper Eyelid Topographic Proportions” introduced the upper lid arcs concept and detailed the dimensions and proportions of upper lid-brow spaces, establishing a blueprint for creating an attractive upper lid.48 “Management of Postblepharoplasty Chemosis” by McCord et al, is, in the authors’ opinion, the best-written paper on this important topic, expertly detailing the anatomy and postoperative management of chemosis.49 A landmark publication by Dr Foad Nahai, “Transconjunctival Upper Lid Blepharoplasty” is one of our favorite articles. The paper tackles a very specific surgical problem, the residual upper lid nasal fat, and how to approach it elegantly.50 Last but not least, “Concepts in Eyelid Biomechanics with Clinical Implications,” also authored Dr McCord et al, is a must-read paper that challenged the common belief of orbicularis muscle denervation during transcutaneous blepharoplasty.51 Like other fields of aesthetic medicine, oculoplastic surgery continues to improve and gain a better understanding of eye beauty, particularly with regard to gender and ethnic variations. Technical refinements have been introduced over the years, but significant technological advancements in this field are still yet to come. Recently, the reintroduction of endoscopic surgery with its extended applications to the lateral orbital area and face has added another unique dimension to periorbital rejuvenation. Minimally invasive techniques that could improve periorbital morphology and aging with less downtime and anti-aging treatments will be the hot topics of the near future. Mohammed Alghoul, MD, FACS: By the time ASJ turns 40, 10 years from now, I predict we will see more publications on endoscopic techniques to shape the periorbital area, managing and minimizing complications in periorbital surgery, improving eye symmetry, enhancing recovery post blepharoplasty, and introducing new and effective technology to enhance periorbital skin texture and pigment. Also, as the field of regenerative medicine continues to grow, we may also see new, high-powered outcome studies on the use of exosomes and polynucleotides in the periorbital area. I also predict seeing a shift toward publishing outcomes on combination surgeries to create a beautiful eye, instead of focusing on a single surgery, such as upper or lower blepharoplasty. Artificial intelligence (AI) will certainly play a role in nearly every aspect of the medical field. I am sure we will soon have a trustworthy AI-assisted literature navigation system to determine the novelty of any idea or publication. I also predict that we will be able to employ AI very soon as an outcome measure tool by identifying changes in attractiveness score and appreciation of beauty instead of relying on raters. Imagine feeding all your photo files into a proven, data-driven AI program that will precisely crop the eyes, standardize them to the same size, and provide you with all the measurements before and after an intervention—now that is the ultimate outcome measure! Salvatore J. Pacella, MD, MBA, FACS: Oculoplastic surgery will continue to expand with an aging population and rising demand for functional and aesthetic periocular care. AI is expected to play a growing role in preoperative planning, risk stratification, imaging analysis, and outcomes tracking, allowing for more precise and individualized treatment decisions. In parallel, advances in biomaterials—including off-the-shelf adipose-derived products such as cadaveric fat and next-generation fat substitutes—may improve volume restoration and tissue quality while reducing operative time and donor-site morbidity, further shaping the future of periocular reconstruction and rejuvenation. Ted Wojno, MD: The next 10 years will bring many exciting changes and challenges. Firstly, AI will play a larger role in day-to-day practice. The media is full of news on the impact that AI will have on our lives. Indeed, we have barely scratched the surface of what the future holds. In aesthetic surgery, we will see much more accurate programs that will predict and model our surgical outcomes (personal communication, Jhenyang “James” Zhao, MD, Emory University School of Medicine). Such platforms will provide our patients with more realistic expectations of how they will appear after surgery. It will further assist both the surgeon and patient in selecting the best procedure and degree of correction, thus better individualizing how we approach each case. Truly bespoke surgery. Secondly, robotic surgery will also play a larger role. This has been a reality in urology for several years and is also being integrated into general surgery, gynecology, orthopedics, cardiovascular surgery, and most recently, cataract surgery. It is simply a matter of time before this is introduced to aesthetic plastic surgery. This promises to make our procedures more accurate and, hopefully, better controlled. Lastly, aesthetic surgery specific to the Asian population will continue to grow. When I began my practice in Atlanta in 1985, the Asian population here was very small, and no one (including myself) was familiar with “double eyelid” surgery. Patients came to me by default. As immigration patterns have changed, the Asian population in this country has greatly increased, and thus the demand for Asian aesthetic procedures has increased, as evidenced by numerous publications.52-56 By educating myself on the various Asian cultures, philosophies (eg, “face reading” and “Woori”), anatomy, and surgeries, I now have a significant portion of my practice in this area. This growth in Asian eyelid procedures in the United States is also evidenced by the increase of papers on this topic published in ASJ in recent years.8-10,20,57-59 It is necessary for aesthetic surgeons to familiarize themselves with the unique anatomy, needs, and expectations of our Asian patients, which are typically much different from our traditional patient populations. The results for the surgeon and patients will be gratifying. For more perspectives on cultural research relevant to this conversation, interested readers can begin with the writings of Eunkook Suh, PhD, as well as many other articles published in ASJ for more aesthetic surgery-specific information. In the meantime, as the Oculoplastic Surgery section editors and under the intrepid leadership of Editor-in-Chief Dr Jeffrey Kenkel, we will continue to prioritize high-quality clinical papers and well-designed studies with clear methodology and outcome measures. In the next few years, for an oculoplastic paper to be accepted in ASJ, we expect it to present a novel idea or finding with clear clinical impact. Surgical technique has to be demonstrated with high-quality videos or intraoperative pictures, and before and after pictures have to be standardized and representative of the study cohort. Beyond the technical components of the papers published in our section, we look forward to continuing the proud legacy of advancement, innovation, and excellence that has been a tenet of the Oculoplastic Surgery section and ASJ at large. Dr Alghoul is a consultant for Allergan, an Abbvie company (Irvine, CA). Dr Pacella is an advisory board member and consultant for Mentor Worldwide, LLC (Irvine, CA). He is also a principal investigator, consultant, and advisory board member for Keracis, LLC (Arlington, VA) and TelaBio, Inc. (Malvern, PA). Dr Wojno declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.