Facial Plastic and Cosmetic Surgery


What You Should Know About Eyelid Surgery (Blepharoplasty)


YOUR EYES AND THE AGING PROCESS

It is often said that when you look at anyone, we’re really looking into their eyes. It’s one of the most important and most expressive features we have. The eyes, however, are one of the areas of the face that may show the earliest signs of aging, making us look tired, sad and older even though we feel quite energetic. As we age, the eyelid skin stretches, fat bulges and muscles weaken, resulting in puffiness; fat bags or fatty deposits under the eyes; droopiness of the upper eyelids; excessive wrinkling or dark discoloration of the thin eyelid skin. Although these features are more likely to become apparent as one approaches the late thirties to early forties, fatty deposits, which are a hereditary characteristic, may be seen as early as the mid-twenties. Such signs of aging may also be accelerated by other factors, including excessive exposure to the sun, high alcohol intake, smoking, drug abuse, improper diet, poor health, or hormone imbalance. Additional characteristics of upper facial aging such as drooping of the eyebrows, horizontal forehead furrows and frown lines are usually treated by a forehead or brow lift. (See Section on Forehead and Brow Lift)

Fortunately, new techniques and advances in eyelid surgery offer solutions to all of these problems, with a quicker recovery time today than ever before. Aesthetic eyelid surgery, or blepharoplasty, has continued to have a high rate of patient satisfaction among both women and increasing numbers of men, who currently comprise one-fourth of the population seeking this type of surgery. Additional plastic surgical procedures such as forehead lift (brow lift), rhinoplasty, cheek implants, facial sculpturing, chemical peels, or facelifts may be performed simultaneously with blepharoplasty.

The blepharoplasty operation can be performed on both the upper and lower eyelids separately or at the same time. By removing the excess or wrinkled skin or protruding fat, blepharoplasty "opens up" the eyes and give the face a fresher, brighter, more youthful and rested appearance. Blepharoplasty, may also be medically necessary to correct conditions of excess overhanging skin that affect the field of vision. The incisions are made in the natural skin folds of the eyelids, making them virtually unnoticeable after they are healed. Blepharoplasty is usually an outpatient procedure which can be performed under I.V. sedation or under a light general anesthetic depending on the complexity of the procedure.


UPPER EYELID BLEPHAROPLASTY

The upper eyelid procedure removes the excessive skin, muscle folds and fatty bags that are usually found in the inside corner of the eye next to the nose. Incisions in the upper eyelids are made following natural lines and creases. If the upper eyelid skin is excessive it may obstruct vision leading to a peripheral field defect. This becomes more of a medical rather than a cosmetic indication for performing upper eyelid blepharoplasty. In such cases, particularly in men with heavy eyebrows pushing the eyelid skin down, a forehead or brow lift is peformed in conjunction with the upper eyelid procedure. If necessary, the incisions will extend into the fine squint lines, or crow's feet, at the outer edges of the eyes. While crow's feet generally will not be improved by blepharoplasty, the recent use of Botox® has provided a very successful solution to this problem. (See the Botox Section under Procedures.) Careful plastic surgical closure uses extremely fine stitches which are removed within three to four days. Once healed, the hairline scars will fade, leaving a very inconspicuous incision line that becomes virtually unnoticeable after a short time.


LOWER EYELID BLEPHAROPLASTY

Although puffiness of the lower eyelids can be caused by the accumulation of fluid within the skin, it is most often caused by excessive fatty deposits protruding through the lower eyelid. The fatty deposits can be made worse either from allergies or from fluid retention which magnifies the puffiness under the eyelids often appearing worse in the morning. Dark circles under the eyes can not only be caused by dyscrhromias or pigmentations in the skin but also by shadows cast by fatty deposits or the shape of the orbital bone surrounding the eyes.


HOW IS LOWER BLEPHAROPLASTY PERFORMED?

There are different techniques that can be used for the lower eyelid procedure, depending on the pathology and problems.

Transconjunctival Blepharoplasty: Patients who have pockets of fat below the eyes, but do not have excess skin, may have these fatty deposits removed from inside or behind the lower eyelid (transconjunctival blepharoplasty). This procedure avoids an external scar. With this technique, a small incision is made on the inside of the lower eyelid and fatty tissue is eased out or removed. This is an excellent technique, particularly for younger patients with good skin and very little skin wrinkles. Patient’s with the inherited form of eyelid bags may be candidates for removal of the fatty deposits as early as their mid twenties.

Transconjunctival Blepharoplasty and the Pinch Technique: When there are fat bags present and a mild amount of excess skin, a pinch technique can be used to remove the small amount of excess skin. This is a minor procedure that "pinches" the excess skin under the margin of the lower eyelid and the excess is then excised. Because there is no undermining of the skin, the incision usually heals almost invisibly.

Peels and Laser Resurfacing of the lower eyelids: In cases where there is excessive fine wrinkling or pigmentary changes of the lower eyelid skin, usually a 35% TCA chemical peel, or for deeper lines, laser resurfacing can also be performed either in conjunction with or after the eyelid procedure. (See Section on Chemical and Laser Peels)

External Incisions and Canthoplasty: Prior to the transconjunctival approach to blepharoplasty, external incisions under eyelid represented the standard approach to eyelid surgery. However, in time, it was found that the eyelid eventually became weak resulting in a rounding of the eyelid and blunting of the corner (canthus) of the eye. Although a transconjunctival approach is preferred, it will not treat significant excess eyelid skin with severe wrinkling. In these cases, I use an external approach to the eyelid in which an incision is made at the lower eyelid crease just at the base of the eyelashes and if necessary carried out into a crow’s foot crease. This incision line leaves a fine scar that is almost invisible when healed. In conjunction with any lower eyelid procedure, I now use concomitant supporting eyelid procedures with "external incision blepharoplasty". In these cases a supporting Canthoplasty procedure is usually performed to help maintain support for the lower eyelid. The Canthoplasty procedure repositions and reattaches the corner of the eyelid back to the bone of the orbit which strengthens the lower eyelid. Once this is done, any excess skin can then be safely removed and the deep eyelid creases and wrinkles smoothed out. A chemical peel or laser resurfacing procedure can also be performed simultaneously.

Muscle slings and Upper Midface Lifts: "The Tear trough deformity and Festoons": There are other eyelid conditions, because of the severe nature of the problem, require a more reconstructive surgical approach to the eyelid. These problems are conditions involving a drooping of the lower eyelid (called "retraction or ectropion"), or conditions of the eyelid skin and muscle called "festoons". (See photo) The tear trough deformity represents a hollow under the eyelids at the very medial corner of the eyelid at the junction of the thicker cheek skin and thinner eyelid skin. Festoons look like pockets of water which have accumulated around the lower part of the eyelid and cheek area. In these cases, I use a variety of eyelid techniques that also involve improving a part of the upper portion of the midface. The procedures involved include a full Canthoplasty, eyelid muscle suspension procedures and in severe cases grafting techniques. Using the upper midface or cheek lift procedure with muscle suspension will help to improve the tear trough deformity as well as eyelid festoons.

Filling in the Eyelid and Orbital Hollows: Recently, the "hollowed-out" eye deformity has received a lot of attention. Several new procedures have been introduced to treat these conditions in patients who had prior blepharoplasty and had too much fat removed, or in patients who have extremely prominent orbital bone structure causing the "sunken-eyed" look.. They involve Fat Transposition Techniques, Fat Injection and the use of Fillers. In cases predisposed to the hollow eye syndrome, conservative fat removal is performed where necessary and the remaining fat is transposed into the lower corner of the lower eyelid and orbital rim to fill out the depression so that a smooth transition remains between the eyelid and cheek. This is performed during primary blepharoplasty either through a transconjunctival approach or an external approach. For filling in the hollows after eyelid surgery or without surgery, I prefer to use either Restylane® or Juvederm which I have found to work extremely well and requires treatment usually only once per year.


WHAT IS THE RECOVERY TIME FOR EYELID SURGERY?

Recovery after routine upper or lower eyelid surgery is quite rapid. Patients experience surprisingly little discomfort, bruising or swelling, most of which usually subsides within a few days to one week. Most sutures dissolve and the rest are removed 4- 5days after surgery. Make-up can be applied shortly thereafter and in most cases, in about 10 days. If the lower blepharoplasty is performed from behind the eyelid (the transconjunctival approach), the sutures are self-absorbing and do not have to be removed. Infrequently, some patients may experience tearing or dryness that usually resolves within the first few weeks after surgery. Actors, models and others who appear in the public eye can resume camera appearances a few weeks after surgery.

The elimination of the excessive sagging skin and fat around the eyes produces a more rested and youthful appearance. This is why eyelid surgery has continued to have consistently pleasing and satisfying results with a high rate of patient satisfaction.

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