Universal Steps in Blepharoplasty

Whether performing upper or lower eyelid surgery, surgeons are generally addressing 3 problems: too much fat, too little fat, or loose/wrinkled skin. For a blepharoplasty to be successful, the cosmetic eyelid surgeon must first and foremost closely analyze the eyelids and decide whether to remove fat, from where, and how much. Similar decisions must be made about the replacement of fat into eyelid hollows. Finally, excess skin must be trimmed, repositioned, or “shrink wrapped” to achieve the best results.

Upper Blepharoplasty

Upper blepharoplasty is a fairly straightforward operation, and is one of the easiest cosmetic facial surgical procedures to recover from. The surgeon measures the precise amount of upper eyelid skin that may be safely removed to maximize results – too little risks a poor result, too much jeopardizes eyelid closure and risks dry eye syndrome. Once this critical decision has been made, the appropriate amount of eyelid skin is removed. In cases with bulging fat in the upper eyelids, especially in the inner corner (“medial canthus”) of the eyelid, the excess fat is trimmed. Sagging tear glands, seen as a bulge in the outer corner (“lateral canthus”) of the upper eyelid, may be resecured. Finally, the incision line, which is now mostly hidden in the upper eyelid crease, is closed with dissolvable sutures, or with sutures that are removed after 3-6 days. In some cases, if there is hollowing in the upper eyelid area, fat may be transferred to the area at the end of the procedure, once the incision is closed.

Upper blepharoplasty recovery is essentially painless, and bruising is generally mild and subsides in several days to a week.

Skin Flap Lower Blepharoplasty

Skin Flap Lower Blepharoplasty is the oldest form of cosmetic lower eyelid surgery. It is the easiest form of lower blepharoplasty to understand and the easiest to learn, however, it has the highest rate of complications (hyperlink), such as lower eyelid retraction, of any form of lower blepharoplasty. In skin flap lower eyelid surgery, an incision is made underneath the lower eyelash line and the skin is lifted away from the underlying lower eyelid muscle. The bulging lower eyelid fat pads are accessed by poking “buttonholes” through the muscular and fibrous layers of the lower eyelids and trimmed. Finally, the lower lid skin flap is redraped, the excess is trimmed, and the incision line is closed. This procedure alone can address bulging lower eyelid fat, but does not fill the tear trough nor does is do the best job in removing lower eyelid wrinkles. For these reasons, and its relatively high complication rate, it has largely fallen out of favor.

Skin Muscle Flap Lower Blepharoplasty

Skin Muscle Flap Lower Blepharoplasty is also one of the oldest forms of lower eyelid surgeries, but is still performed with some frequency today. It, too, is conceptually straightforward. An incision is made underneath the lower eyelash line and the skin together with the underlying muscle layer are lifted away from the underlying fibrous layer (orbital septum). The bulging lower eyelid fat pads are accessed by poking “buttonholes” through the septum of the lower eyelids and trimmed. Finally, the lower lid skin muscle flap is redraped, the excess is trimmed, and the incision line is closed. This procedure alone can address bulging lower eyelid fat, but does not fill the tear trough nor does is do the best job in removing lower eyelid wrinkles. Although complications (hyperlink) are less frequent with skin muscle flaps than with skin flaps, they are still more common than with transconjunctival blepharoplasty.

Suspension Lower Blepharoplasty

Suspension Blepharoplasty is a modification of the Skin Muscle Flap Blepharoplasty which strives to avoid its single most common complication: lower eyelid retraction (also known as “lateral scleral show”, “lateral rounding”, or “hound dog eyes”). Suspension blepharoplasty is performed in the same manner as skin muscle flap lower eyelid surgery, but a strong permanent or long-lasting dissolvable suture is used to anchor the muscle layer up to the bony rim of the eye socket, at a structure inside the orbital rim called “Whitnall’s tubercle”. Suspension sutures of this type have been generally successful at lowering the rate of lower eyelid retraction after skin muscle flap technique.

Transconjunctival Lower Blepharoplasty

Transconjuctival Lower Blepharoplasty is probably the safest method of improving lower eyelid fat “bags,” but requires a more complete understanding of eyelid anatomy, and is more technically and conceptually challenging than Skin Flap or Skin Muscle Flap Lower Blepharoplasty. In the transconjuntival approach, the bulging lower eyelid fat is removed through a hidden incision on the inside (back) of the eyelid, through the pink “conjunctival” layer. By avoiding incisions through the front side of the eyelid, the lower eyelid orbicularis oculi muscle is not damaged, and healing problems such as lower eyelid retraction are exceedingly rare. The transconunctival blepharoplasty approach alone, however, cannot treat crepey or wrinled lower eyelid skin, nor can it fill the tear trough depression. For this reason, it is often combined with a Skin Pinch, Chemical Peel, or Laser Peel of the eyelids to tighten excess skin, and with Fat Repositioning or Fat Transfer to fill the tear trough depression.

Skin Pinch Blepharoplasty

Skin Pinch Blepharoplasty is a technique that is sometimes used together with a Transconjuctival Lower Blepharoplasty. Once the fat has been removed from behind the eyelid, the excess skin at the lash line is “pinched” into a ridge and trimmed away. The benefit of this technique is that the orbicularis oculi muscle layer remains undisturbed, so complications are rare, but excess skin and fat may both still be excised. This technique does, however, create the possibility for a visible incision line under the lower eyelid eyelashes.

Canthopexy

Canthopexy is a technique that uses a permanent internal suture to secure tendons of the outside corner of the , or “lateral canthus”, to the bony rim of the eye socket at their existing level. Like the suspension of the muscle layer done in Suspension Lower Blepharoplasty, canthopexy is primarily a preventative step to prevent sagging of this area with the healing process.

Canthoplasty

Canthoplasty, unlike canthopexy, seeks to free up and reposition a lateral canthus area that is already too low. The tendons of the outside corner of the eye are separated from their attachements to the outside rim of the eye socket, and resecured in a higher position. A subtle canthoplasty can restore a youthful look in carefully selected patients, while an overdone canthoplasty can create a cat-like eye shape.

Ptosis Repair

Ptosis repair, unlike cosmetic eyelid surgery, is a functional (not cosmetic) procedure. Ptosis is a condition where the eyelid does not open fully, not a problem of excess skin or fat. In ptosis repair surgery, the muscle that opens the eyelid is shortened or reattached inside the eyelid, allowing the eye to open fully and vision to be restored. In patients with excess skin or fat in the upper eyelids, cosmetic blepharoplasty may be considered at the same time.

Browlifting

When sagging brows are contributing to a tired or sad appearance, upper eyelid surgery alone can actually make the problem worse, not better. In these cases, a browlift, with or without upper eyelid surgery, is the appropriate choice.

Direct Browlift

In a Direct Browlift, a crescent of skin is removed just above each eyebrow. In appropriately-selected individuals, the incision can heal into a fine, barely-visible scar. Direct browlifts are rarely used, but are sometimes the best approach in very asymmetric brows, or in balding men with thick eyebrow hair.

Midforehead Browlift

Midforehead Browlifts remove skin at the center of the forehead to lift the brows. While rarely performed, this kind of browlift may be a good choice for a balding man with deep forehead lines in which to hide the incision.

Internal Browpexy

Internal Browpexy is a technique that can be performed through the upper eyelid skin incision when an upper blepharoplasty is performed. It attempts to “pexy”, or stabilize, the eyebrow to prevent additional drooping, while avoiding the creation of additional incision lines. Little to no enduring lifting effect is achieved with this technique.

Hairline/Trichophytic/High Forehead Browlift

Together with Coronal Browlifts, the Hairline/Trichophytic/High Forehead/Hairline Lowering Browlift is one of the most effective and longlasting types of browlift. It utilizes one continuous incision, from the top of one ear, across the hairline, to the top of the other ear, to perform the lift. Since all of the excess skin that is removed is in front of the hairline, this type of browlift is best for people who would benefit esthetically from a shorter forehead. Additional maneuvers may be performed to lower the hairbearing scalp even further in special cases. Since this procedure may possible leave a visible incision line at the hairline, it is best for women who are open to wearing bangs, and a poor choice for men who may lose their hair in years to come.

Coronal Browlift

A Coronal Browlift is similar to the Hairline/Trichophytic Browlift, except the entire ear-to-ear incision is behind the hairline. It, too, is one of the most effective and longlasting types of browlift. It tends to be a good choice for women with visually short foreheads, who would benefit from a higher hairline. It is a poorer choice for women with thin hair, or balding men, as the incision line may be visible.

Endoscopic Browlift, Minimal Incision Nonendoscopic Browlift

The Endoscopic Browlift relies on 3 to 5 short incisions hidden in the hairline to free the forehead and brow area and reposition it into a higher, more youthful and pleasing position. Once the tissues are repositioned, they are held there using a variety of techniques. A surgical telescope, or “endoscope”, is often used to aid the surgeon’s identification of important structures such as muscles and nerves through the small incisions. Some surgeons perform a variation of this lift without the endoscope, and this is often referred to as a “Minimal Incision Nonendoscopic Browlift”. In that procedure, the surgeon relies on proper adherence to tissue planes and a throrough understanding of forehead anatomy to safely perform the procedure without an endoscope. In either procedure, no scalp is removed, and incisions are short, so visible incision lines are rare. This type of browlift is generally possible even in balding, men, as long as a fringe of hair remains in the temple.

Laser Blepharoplasty

Laser Blepharoplasty refers to using a laser to make the incisions for upper or lower cosmetic lower eyelid surgery, and also to do any necessary fat trimming. There is generally less bleeding with laser blepharoplasty, but healing times are not significantly different than when incisions are made with a blade, and the final healed incision is no better or worse. Risks of laser burns and fires, however, are introduced, and therefore comparatively few surgeons choose to use the laser to perform blepharoplasty incisions.

Chemical Peels/Laser Resurfacing

When wrinkled or crepey skin exists in the eyelid area, surgical skin removal is not enough to make an enduring improvement. Because the skin is wrinkled due to sun damage and aging of the skin itself, the skin itself must be renewed. Various types of lasers, such as the CO2 laser and Erbium:YAG laser can produce this effect, as can various types of chemical peels, such as trichloroacetic acid (TCA) or phenol/croton oil peels. Because wrinkled skin is often a component of lower eyelid surgery, the addition of a peel to a lower eyelid cosmetic blepharoplasty is often an appropriate “finishing touch”.

Fat Transfer (Lipostructure)

Fat transfer is a technique in which the surgeon removes fat from an area of relative abundance – usually the hips, belly, or thighs – and transfers it as a living filler to areas of relative hollowness in the face. The fat is removed by gentle “liposuction” through tiny cannula about as thick as a piece of spaghetti, then purified to obtain only quality, living fat cells. Once purified, the fat is reinjected, usually into the tear trough, infraorbital rim, dark circles, upper lid, eyebrow, cheek, lip, or jawline area. Since fat transferred this way is from your own body, there is no chance of rejection. However, since fat is a living tissue, there is some degree of unpredictability, and not all of the fat may survive. Although it may require 1-6 sessions to achieve desired results, must patients are satisfied after only one or two.

Thermage®

Thermage® is a trade-name for a type of skin tightening which uses a electrical energy. The device applies radiofrequency waves to the skin’s deeper layers. This causes the collagen in the skin to contract, thereby causing the skin to tighten. Changes from Thermage and skin tightening lasers tend to be unpredictable – not every patient sees improvement – and modest when compared to surgery. Patients looking for greater improvement in eyelid may not achieve desired results from this procedure.

If you would like to learn more about blepharoplasty procedures please contact our office.