The upper eyelids and brow communicate emotion to those around us. The lower eyelids communicate vigor and youthfulness. With age, as the brow descends onto the upper eyelid and the upper eyelid develops excess skin, an expression of anger or sadness can be perceived. Lower eyelid skin, muscle and fat changes often lead to a tired appearance. One of the most powerful surgical procedures to rejuvenate a face is to address the eyelids and brow.
A blepharoplasty is a surgery that tightens the eyelid skin, smoothes the transition between the cheek and lid, and opens and reframes the eyes to create an overall rejuvenated appearance.
A brow lift is a procedure that repositions the eyebrow to a natural position that frames the eyes to accentuate their beauty.
TYPES OF BLEPHAROPLASTY
An upper blepharoplasty utilizes an incision in the upper eyelid crease to remove excess skin, and at times fat, to refresh the appearance of the eyelids. It is often referred to as a skin pinch blepharoplasty.
Asian blepharoplasty is a procedure used to create an upper eyelid crease in individuals born without one. This results from an anatomical difference in the way an upper eyelid muscle inserts on the edges of the upper eyelid. It is a cosmetic preference and creates a more ‘Caucasian’ appearing eyelid. It is done through the same upper eyelid incision as a skin pinch blepharoplasty.
Lower eyelid blepharoplasty is technically one of the most demanding facial cosmetic procedures. It is a finesse surgery on a delicate facial structure. The surgery can be done through an incision below the lower lid eyelashes (transcutaneous) or with an invisible incision inside the eyelid (transconjunctival). Often fat is removed or relocated to fill hollows. Skin may or may not be removed.
There are many variations of lower eyelid surgery, including combined techniques utilizing laser or chemical peel resurfacing and fat grafting. No two lower eyelids are the same and a consultation is required to sort out the safest and most effective approach for each person, as some techniques can worsen the appearance of the eyes in some people, but enhance the appearance in others.
WHO IS A CANDIDATE FOR EYELID SURGERY?
Men and women with excess upper eyelid skin, puffiness or drooping brows are candidates for upper eyelid blepharoplasty with or without a brow lift. Individuals seeking double eyelid surgery are also candidates.
Those with hollowing, dark circles, puffiness or folds of excess skin on the lower eyelids are lower eyelid surgery candidates. Eyelid muscle tone, eye position, and integrity of the eyelid tendons determine candidacy for lower eyelid surgery. Some lower eyelids are best served with volume replacement with fat grafting and non-surgical skin tightening to avoid eyelid deformities and chronic dry eye complications.
EYELID SURGERY BY DR. BRACE
Dr. Brace is a skilled eyelid cosmetic surgeon and reconstruction expert. He routinely corrects eyelid malposition and reconstructs eyelids after cancer surgery. He is involved in treating patients with facial paralysis and inability to close their eyelids and routinely sees and treats patients with cosmetic eyelid concerns on a weekly basis. He takes a delicate and conservative approach to eyelid surgery and will often stage lower eyelid procedures.
Dr. Brace is a double board certified facial plastic surgeon. During his time at the Ohio State University’s Wexner Medical Centre he worked in partnership with the oculoplastic surgery team to correct difficult trauma and cancer related eyelid deformities. He has taught courses on eyelid reconstruction and cosmetic eyelid surgery and is highly regarded by colleagues for his mastery of eyelid surgery.
Blepharoplasty is one of the most common surgeries performed by Dr. Brace. During the consultation Dr. Brace will assess the health of the eyelids and the layers involved. Photographs are taken to document your eyelids and discuss the anatomical limitations, if any exist, to achieving the desired aesthetic result. He will recommend the surgical procedure required to achieve the best blepharoplasty result. In many cases, a brow lift is required to fully frame the eyes and lift the upper eyelid. Dr. Brace will discuss how a brow lift may optimize your surgical result.
Upper Eyelids Surgery
Upper skin pinch blepharoplasty can be accomplished with local anesthetic as a day procedure. Tiny sutures are used to close the skin incisions. The procedure takes approximately 1 hour. There are some sensations of discomfort during the procedure from injection of the local anesthetic. In addition, discomfort similar to an ‘ice cream headache’ may be experienced if the upper eyelid fat pockets are being addressed. It is a well-tolerated procedure overall. Dr. Brace will remove sutures at the 1-week mark. This procedure is often coupled with other procedures such as a facelift, and in those cases is done while you are under general anesthetic. Double eyelid surgery follows the same course as upper skin pinch blepharoplasty.
Recovery from upper eyelid surgery
Day 0-6– ice eyes to minimize bruises and clean scabs off incisions.
Day 6/7– sutures removed. Incision kept clean. Bruises nearly resolved
1 month- scar check
3 months– photos and scar check. Milia sometimes form along incision line and Dr. Brace removes these
6 months– scar check and photographs
Lower Eyelid Surgery
Lower eyelid blepharoplasty can be done under local anesthetic if it is a simple skin pinch excision or minimal transconjuctival fat removal. It is often done in the OR with IV sedation if done alone, or general anesthetic if done in combination with other procedures.
Skin pinch procedures involve a similar recovery as upper skin pinch blepharoplasty with suture removal at 1 week. Bruising is usually minimal and resolved in 7-10 days.
Transcutaneous lower eyelid surgery is used to address excess skin, muscle and fat and is effective at reshaping the lower eyelid and eliminating the separation between the eyelid and cheek, creating a smooth contour and transition between the lid and cheek. It is also associated with the most bruising and swelling and recovery. Injections into the lid with anti-inflammatory medications are performed. The usual time for this procedure is 1-2 hours. Antibiotics, steroids for swelling and pain medication is provided.
Transconjunctival lower eyelid surgery is used to address the fat of the lower eyelid sometimes called the ‘eye bags’. From this approach the fat can be repositioned into the hollows below the eye or removed if excessive. This approach does not address the skin. This procedure takes 1-2 hours. Medicated eye drops, antibiotics and pain medication are provided. Often a laser resurfacing, chemical peel or skin pinch will be used secondarily to tighten the skin of the lower lid.
Fat grafting is reserved for those cases where there is not enough fat in the lower eyelid to fill the hollows below the eye. The fat is harvested from the abdomen or thigh in most cases through a single tiny 2-3mm incision. The fat is then injected in tiny aliquots under the eyelid into the hollows. This is done in the OR under IV sedation or general anesthetic. This process takes 30-60 minutes. This is rarely done in isolation and requires 6-12 weeks to see the final result as the facial swelling decreases after fat injections. Rarely does all of the transplanted fat survive and sometimes a second grafting procedure is required to gain more volume enhancement.
Recovery from lower eyelid surgery
Day 0-6– ice eyes as bruises form. If an incision is used, clean with Q-tips according to instructions
Day 6/7– sutures removed/incision inspected. Eyelid assessed. Gentle upward massage initiated. Injection of anti-inflammatory medication if required. Pulse dye laser treatment to bruises.
1 month– scar check and eyelid tone assessment. Injection of anti-inflammatory medication if needed. More aggressive massage if needed. Assessment of fat graft early take.
3 months– scar and eyelid tone assessment. Eyelid should be back to normal position. Possible injection. Photographs taken to document result to date. Fat graft result assessed. Discussion of adjuvant procedures to enhance result
6 months– full healing should be complete. Final result assessed with photographs. Discussion of adjuvant procedures to enhance result if required.
Cosmetic brow lifts are done in the OR under general anesthetic or IV sedation. They are usually combined with upper blepharoplasty surgery. A variety of techniques can be used, but most commonly Dr. Brace will use two 2-3cm incisions in the hair bearing scalp where they can be camouflaged.
The eyebrow is released from its attachments with specialized instruments and is elevated into a new position using strong absorbable sutures to anchor the brow to the deep fascia in the scalp. The procedure takes 30-45 minutes. The incisions are closed with absorbable sutures. Antibiotics and pain medication are provided.
Recovery from brow lift surgery
Day 0– bruising forms around the upper eyelids. Ice is applied to the forehead and eyes during first 72 hours.
Day1-6– bruising continues to gather around the eyes. Arnica can be taken to minimize.
Day 6/7– incisions and brow lift assessed. Pulse dye laser is performed for bruising
1 month– sutures are dissolved. Bruises are resolved. Some swelling in upper eyelid may persist. Massage of incisions may be initiated.
3 months– swelling is resolved. Photographs taken. Scars assessed.
6 months– Photographs taken and final result assessed.
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