Eyelid Surgery

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Upper Eyelid Surgery ( Blepharoplasty )

One of the most frequently performed surgical procedures , upper eyelid blepharoplasty is used to remove the fat deposits , loose. skin and drooping on that may form around the upper eyelids with age.

Heredity and sun damage can accelerate these changes. Younger people also elect to have this procedure done to eliminate puffiness of the eyes from congenital excess fatty tissue. Upper lid blepharoplasty can improve two common problem areas :

1.) excess skin on the upper eyelid itself , often called " hooding of the upper lid , and  2.) puffiness in the inner comer and middle of the upper eyelid caused by herniation ( pushing forward) of fat.

This procedure is frequently done at the same time as other procedures , such as a lower eyelid blepharoplasty , facelift or forehead lift , and can be combined with laser or (chemical resurfacing to smooth skin wrinkles.

When drooping of the upper lids interferes with vision a condition known as ptosis), the procedure may be partially or fully covered M. insurance.

Lower Eyelid Surgery ( Blepharopasty )

Lower eyelid blepharoplasty is used to remove the fat deposits and loose skin that may form on the lower eyelids with age. Many factors , including heredity and sun damage.

This procedure is frequently done at the same time as other procedures , such as upper eyelid blepharoplasty , facelift or forehead lift , and can be combined with laser or chemical resurfacing to smooth skin wrinkles.

When overhanging of the upper lids interferes with peripheral vision , and both upper and lower eyelids are done at the same time , the procedure may be covered by insurance.
If you're considering lower eyelid blepharoplasty , the following information will provide you with a good introduction to the procedure. For more detailed information about how this procedure may help you , we recommend that you consult a plastic surgeon who is board certified or has completed a residency program that includes instruction in this procedure.

Eyelid surgery before                                                                                    Eyelid surgery after 7 month

Eyelid surgery picture-photo after

Eyelid surgery can preserve Asian identify

The key to Asian eyelid surgery is improving patients' lives while preserving their ethnic identity. Even if patients in the United States or elsewhere request a more Western appearance, one must be wary, said Charles S. Lee, M.D., primary plastic surgeon and owner of Enhance Medicine Center, based here.

First, it s not possible to completely erase someone's ethnicity," he explained. "Second, those types of requests tend to be more of a fad, maybe a phase the person's going through. So it's not something that wears well as they mature and grow older."

Patients, usually girls, tend to present as teenagers or in their early 20s. They commonly complain of difficulty applying eyeliner because of puffy upper lids that often lack pretarsal creases. Many also wish to rid themselves of the tired appearance associated with a fatty upper lid. Male patients tend to present in their later 20s to early 30s.

Demand rises in China

In industrialized countries such as Korea and Japan, eyelid surgery blepharoplasty has long been the most popular cosmetic procedure. Doctors in mainland China also have begun to see an upswing in demand for cosmetic procedures including eyelid surgery. In America, demand for the procedure is rising at about 10 percent annually. This increase roughly parallels the growth of the Asian-American population, within which demand for the procedure remains fairly stable on a percentage basis.

When the eyelid surgery procedure was pioneered about 50 years ago, large folds were popular. But as Japan and other Asian countries grew more affluent and self-confident, fold sizes decreased to a level that looks natural on Asians. "For practitioners who only occasionally see Asian patients, I recommend the stitch method of crease creation under light oral anesthesia [Xanax 1 mg]," Dr. Lee stated.

Though this eyelid surgery procedure has a higher failure rate (around 10 percent at one year) than the incision or open method, Dr. Lee added, "an occasional surgeon can obtain an extremely natural-looking fold." This method involves setting a crease 6 mm to 8 mm from the lash line with the skin under slight tension. "Patients with deep-set eyes or brow ptosis Should have the fold set slightly larger, up to 10 mm," he said.

In his practice, Dr. Lee generally prefers the eyelid surgery incision method due to its performance. However, when a suture method is used, he prefers what's known as the semi-open method. "It's the same as the stitch method, except you make a little keyhole and take out some fat," effectively raising the septoaponeurotic sling, he explained. This approach incorporates the natural appearance and low morbidity of the suture method with the permanence of the incision method.

To perform the semi-open method, he offered the following guidelines (available in complete form at http:/lwww.emedicine.com/plastic/topic425.htm):

Depending on the patient, the usual height of the eyelid crease at mid-pupil for young patients with minimal brow ptosis is 7 to 10 mm. Before operating, Dr. Lee recommended marking the patient's eyelid while he or she is on the operating table. To anesthetize patients, he recommended IV or oral sedation, followed by topical 4 percent tetracaine (applied to the conjunctiva) and a lidocaine/epinephrine solution.

Recommended procedure

Dr. Lee generally discourages medial epicanthoplasty out of concern for hypertrophic scarring. But for doctors who choose this, he recommends the following procedure be done this first because it alters medial anatomy:

Total height of a V-W plasty should be about 5mm by 3 mm, with each arm of the V and W measuring approximately 2 mm.

After anesthetic takes effect, cut each arm of the flap with a No. 11 blade and remove the muscle along with the skin before closing the incision. Next, make a 1-cm incision along the lateral aspect of the upper lid marking. Ignoring retroorbicularis fat, remove a sliver of orbicularis, then septum, to enter the prelevator space. Once inside, remove 1 cc to 2 cc of fat.

Then retract the upper lid, flipping it to expose the conjunctiva surface, and take a 5-mm piece of tissue at the mid-pupil along the superior border of the tarsal plate, utilizing double-armed 5-0 nylon. Using the existing needle hole, re-enter the conjunctiva so that a full-thickness buried suture exits on the surface of the upper lid along the lid markings, Secure the knot and let it retract into the orbicularis muscle before placing four sutures equidistant to each other. To verify that the crease extends sufficiently, have the patient open and close his or her eye.

"Patients with thick-skinned or significant preaponeurotic fat get better results using an incision method," Dr. Lee said. To use this method, remove a sliver of orbicularis muscle and attach the skin to the levator aponeurosis or the tarsal plate using buried 6-0 vicryl and 6-0 prolene on the skin.

"For the advanced surgeon," Dr. Lee said, "an excellent result can be obtained by removing pretarsal soft tissue, preserving the muscle and skin, and reattaching the levator aponeurosis to the tarsal plate and skin." Known as Flowers' anchor blepharoplasty, this procedure expands surgeons' artistic possibilities by creating a crisp line and smooth pretarsal skin.
Dr. Lee possesses no financial interests in products mentioned in this article.

Author John Jesitus COPYRIGHT Advanstar Communications, Inc.and Gale Group
 

Assessing entire forehead, eye, eyelid complex key to choosing appropriate treatment

Traditional eyelid surgery blepharoplasty is still the most effective approach to recreating a youthful eye. However, brow lifts can replace upper lid excisions for some patients, and a transconjunctival rather than transcutaneous approach to the lower lid has almost eliminated the potential hazards of lower lid repair.

"Nothing's come up that offers a substitute for eyelid surgery blepharoplasty, although the lower lid is a little more risky" says Edgar Fincher, M.D., Ph.D., clinical instructor, The David Geffen School of Medicine, University of California, Los Angeles. "Thermage[R], C[O.sub.2] lasers, and the new plasma machines tighten upper eyelid skin a little bit, but not to the degree that blepharoplasty can."

Assessing need

Extra folds of loose skin indicate a need for upper eyelid repair. Palpating the skin and pushing upward against the globe can suggest whether skin alone or skin plus underlying muscle or fat should be addressed. When assessing a full lateral upper eyelid, it's important to rule out a ptotic lacrimal gland, which would require suture pexy to be repositioned within the bony orbit, according to Dr. Fincher.

"Many patients come in asking for upper lid eyelid surgery blepharoplasty when what they really need is a brow lift," Dr. Fincher tells Cosmetic Surgery Times. "With age, the brow often drops down from its elevation high above the bony orbit, causing the appearance of redundant skin on the upper lid."

With his fingers, Dr. Fincher repositions the eyebrow to its original position. This pulls the brow and upper lid up, flattening out the excess skin. If excess skin remains on the lid in this position, he performs a combination procedure of lid resection and brow lift.

If the brow hasn't descended, Dr. Fincher resects a minimum of excess skin from the lid, which restores a sharp eyelid crease and smooth upper eyelid contour. Removing too much tissue will leave the patient with a hollow, more aged appearance.

He advises paying attention to the shape and position of the eyelid crease. In a Caucasian woman, the goal is a curved crease that roughly parallels the eyelid margin and ends with a slight upward curvature laterally.

If a ptotic brow is ignored, performing an upper eyelid blepharoplasty will simply draw the eyebrow further into the orbit, reducing the eyelash-to-eyelid width without providing the desired result. Worse, if the need for forehead correction is only recognized after performing blepharoplasty, the subsequent brow lift may result in lagophthalmos.

Traditional meaning

Lower lid eyelid surgery blepharoplasty traditionally meant excision of skin, muscle and orbital fat. When excess skin was removed, the shortened lid often retracted, drooped and became more rounded, altering the eye's natural shape. Excision often overexposed sclera laterally in direct relation to the amount of skin resected and inhibited normal tear flow, leading to dry eye.

Now surgeons recognize that the main indication for the procedure is not loose skin, but fat that protrudes from fat pockets around the eye. Instead of excising outer lid skin transcutaneously, surgeons usually take a transconjunctival approach, placing incisions on the inner surface of the eyelid to access fat pockets and remove fat. No scars or incision lines are visible.

"It's a fairly straightforward procedure that avoids the dangers of contractions and ectropion--the eyelid actually turned out and down. Patients heal quickly and are pleased with the result," he says.

If extra skin remains, laser resurfacing performed simultaneously with transconjunctival blepharoplasty will often tighten the skin adequately, he says. However, elderly patients with loose eyelids may still require some transcutaneous surgery. In such cases, Dr. Fincher advises removing a minimal amount of skin just underneath the eyelid and performing canthopexy, attaching the lateral canthus in an elevated position onto or within the eye's bony orbital rim. This tightens and supports the lower lid without diminishing the length of the aperture and reduces the amount of excision required, he explains.

"Think of the lower eyelid as a sling," Dr. Fincher says. "You tighten up the outer ends to support it, and attach them to something that's very stable."

Patient education

Dr. Fincher advises discussing potential complications with the patient before surgery.

Retroseptal hemorrhage is the most feared complication of blepharoplasty because it can produce blindness, but relatively few cases have been reported in the literature. However, surgeons are acutely aware of the dangers of bleeding during the procedure. They monitor patients closely when injecting anesthetic and during dissection with fine instruments, applying cautery devices throughout to make sure all bleeding has stopped.

Aging causes fat loss around the eye. The cheek fat pad droops, deepening the nasolabial smile line and creating a deep tear trough and dark circle under the eye. Instead of removing fat from the cheek pad, surgeons now preserve and reposition it into the medial depression, filling the space from underneath. This softens the transition between the lower eyelid and cheek in the nasojugal fold. "If you suture fat correctly, it should adhere and last permanently. It's live tissue that you're simply relocating," Dr. Fincher says.
"Attention to the entire forehead, eye and eyelid complex is the key to selecting the appropriate surgery or combination of surgeries," he concludes, adding "Often, encouraging a patient to accept a more conservative correction rather than a drastic change will help achieve the natural, youthful look they want."

Author NINA SHELDON   COPYRIGHT Advanstar Communications, Inc. and Gale Group. For more on anti-aging click here.