Q: Dr. Eppley, I had upper and lower blepharoplasty surgery about two years ago. My upper eyelids have scars, the left eye is worse than the right. Another surgeon said the right eye just has some extra fat that needed removed. I have very high cheekbones and when I smile or laugh I still have extra skin below my lower eyelids that bunches up and makes me look a lot older than I really am. I didn’t know if that could be fixed by doing a little tuck. The only problem is I do have dry eyes. I also had a neck lift which I was very pleased with but my double chin seems to be coming back. The other surgeon I spoke with said he would do a chin tuck up. I would go ahead and book with you because I have read all the great reviews about you and I’m not really satisfied with my current plastic surgeon.
A: Thank you for sending your pictures. What I see are upper blepharopasty scars that are not in the eyelid crease line and are above it. The actual appearance of the blepharoplasty scars are not atypical but because they are high they are ore noticeable than they otherwise would be. Unless there is more skin to remove (and there is in the right eye) the scars ca not be lowered or made less noticeable. While a pinch lower blepharoplasty can be done, whether there would be any worsening of your dry eyes is unknown. It often is not a good idea to do an operation based on excess skin that appears in facial animation. While that may be effective during smiling, the critical question is what impact that may have in eyelid position when you are not.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in blepharoplasty surgery. My upper eyelids are very heavy and my lower eyelids have large bags under them. They make me look very tired and old. Attached are some eye pictures for your review and recommendations.
A: Thank you sending your pictures. Both your upper and lower eyelids show considerable tissue redundancies. The upper eyelids have a lot of extra skin and hooding (skin pushing down on the lashes) and the lower eyelids show tremendous herniation of the orbital fat pads. They are so pronounced that you can actually see all three fat pads under eye distinctly. (medial, central and lateral fat pads) You would benefit tremendously by both upper and lower blepharoplasties. What is unique about your lower eyelids is that your infraorbital bones are deficient so when the fat is taken away the bags will be gone but the eyes will look very shallow. For this reason that fat that would be removed actually needs to be repositioned so it is draped over the infraorbital bones to correct the tear troughs and infraorbital rim deficiency. So your lower eyelids fat pockets don’t need to be removed per se but they needs to be repositioned to get rid of the prominence and simultaneously correct the bone deficiencies.
Dr. Barry Eppley
Q: Dr. Eppley, I am having quite a bit of dental surgery in my mouth, two 2 dental implants were put in this past April.. Hopefully, I will be having the customized permanent titanium abutments put in next month. After that I will be having permanent crowns put on these abutments. When these crowns are finished, I will then be having another crown put on another tooth unrelated to my dental implants. I am concerned about having any eyelid lift surgery so soon after my dental work. Should I be worried? Should I space several months in between the time I have my last dental work and my cosmetic surgery? Should I be taking an antibiotic before each the above dental procedures? How can I prevent any chance of infection from occurring in my eyes? I would so appreciate your input regarding this matter.
A: There is no solid scientific or medical evidence that would link the bacteremia that may emanate from skin surgery to causing infection around osseo-integrated dental implants, particularly when the placement of the implants were put into the bones months before. Or in reverse. I think it is unnecessary to take antibiotics before your dental procedures but that is a decision between you and your dentist. I see no connection between any of this or your family history to any risk of infectivity from having eyelid or blepharoplasty surgery, particularly since antibiotics are given during this surgery anyway.
Dr. Barry Eppley
Q: Dr. Eppley, I am 37 yrs old and I have some wrinkles under and around my eyes I would like to get rid of and not sure if I should just do Botox or try and have surgery to remove them. I have attached some pictures for your review.
A: There are basically three treatments for aging eye issues, Botox, blepharoplasty surgery and skin resurfacing. (chemical peels vs. lasers) Botox is the only treatment for wrinkles that occur OUTSIDE of the eyelid area. (e.g. crow’s feet area) Blepharoplasty (eyelid) surgery is the only treatment that can remove excess skin and fat of or ON the eyelids. Skin resurfacing using either chemical peels or fractional laser resurfacing can be used for fine wrinkles ON and OUTSIDE of the eyelids. Given the nature of aging around the eyes, many people need a combination of these approaches to get the best result…not to mention the need for maintenance therapies such as Botox injections, topical skin creams and the avoidance of smoking and extreme sun exposure.
What I see in your pictures is hooding of upper eyelid skin and a roll of skin underneath the lashline of the lower eyelid. These are definitely surgical (blepharoplasty) issues. I suspect there is wrinkling beyond these areas but the quality of the pictures does not permit that assessment. These pictures are also only smiling which creates animated rolls of skin on the lower eyelid which may or may not be present when not smiling.
The short story is that you are likely in need of surgery for major improvement but I would not use the term ‘remove’ when it comes to eyelid aging changes as that is not realistic. You need to think improvement of them that is not going to be a permanent cure to them.
Dr. Barry Eppley
Q: Dr. Eppley, I have had nasal congestion bilaterally for years since I was young. So I think it make my flabby upper eyelids and lower eyelid bags is related to that nasal congestion. If I remove the the lower eye bags without treating the nasal congestion, can the eye bag regrow again after surgery?
A: It is a common misconception that puffiness of the lower eyelid is related or caused by nasal and sinus congestion. Actually, there is no correlation between nasal congestion and excess tissue on the upper eyelid or bags in the lower eyelid. They may be close in anatomic proximity but one’s genetics, aging and environmental factors is what makes for such changes in the upper and lower eyelids Thus the results of eyelid surgery, like a lower blepharoplasty with bag (fat) removal will not be affected by persistent nasal congestion after surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I just turned 60. I had breast implants in 1985, thinking I need to have them removed and put in new ones. How much would that be? Also,wanting to find out about around my eyes, had botox but my skin is thin and I look tired all the time. Is there fillers? Had filler around laugh lines and below my eyes but didn’t work or last. I need help.
A: Thank you for your inquiry. I will assume that since your original breast implants were placed in 1985 that they were silicone and probably were placed above the muscle. The pertinent questions about them now 25 + years later is do they need a total capsulectomy (removal of all surrounding scar tissue), are the existing implants ruptured, and what type of implants (saline vs silicone) do you want to replace them. All of these factors control what needs to be done and the cost to do them. So any information that you can provide me in that regard would be helpful in deriving the cost of surgery.
When it comes to your face, you have already learned that injectable fillers are not going to provide any solution for tired looking eyes at your age. Most likely this is a surgical issue of removing excess skin and fat (blepharoplasty surgery) to really get a substantative change in your eye appearance. I can answer this question more definitively if you can send me some pictures of your eyes.
Dr. Barry Eppley
Q: Dr. Eppley, Not sure what I really need. My forehead has deep wrinkles, I have sagging eyelids, bags under my eyes and jaw line and under chin drooping. Is this a full facelift or what?
A: What you are describing are numerous facial aging changes that are located around the two main areas that bother people the most, the eye area and the jawline/neck region. Unless there is some significant eyebrow sagging, the forehead wrinkles are treated with Botox injections and not surgery. Changing these two aging facial areas require a combination of blepharoplasties (eyelid lifts/tucks) and a neck-jowl lift. This is often interpreted as a ‘full’ facelift but this is not really an accurate description. A facelift is the purest sense of the word really just addresses the neck and jowl area and nothing above the lower 1/3 of the face. You may have interpreted eyelift surgery as part of a ‘facelift’ but they really are a separated procedure that is often done simultaneously for a more complete facial rejuvenation effect.
Please send me some pictures of your face for my assessment and a more individualized answer for your needs.
Dr. Barry Eppley
Q: Dr. Eppley, I am sending you photos of my eye. I will let you know that about 13 years ago I went to a surgeon and he said it was the eye lid that was at fault and ‘drooping’, I did not agree, but I was 22 and I went with it in a desperate state to ‘fix’ it. He said he ‘crimped’ a muscle of my right eye lid and it did lift it but it looked even more obvious as it was not the fault of the eye lid. I can tell you this, and it sounds strange, but I know it to be true. When I was very young, I remember sleeping on my right side and the pillow was pushing against my eye ball and I remember thinking that I should not sleep like this, yet I did, and I didn’t move the entire night. In the morning my parents were very concerned and everyone at school noticed it and that is how it stayed. Years later I got eye lid surgery to ‘lift’ the eyelid. But i am VERY sure that the fault lays within the eye ball position and not the eye lid. I have looked, measured and worked out many things with my eye and I am beyond sure that it is the eye ball position in relation to the socket and the other eye that is off. You can clearly see that my left eye is flush against the ‘wall’ of the exterior [filling the entire area of lids upper and lower] and the right is somewhat ‘away’ from the outer corner, leaving a mm or 2 of ‘gap’. I want this fixed like no tomorrow. Now over to you and your expertise. Is this ‘fixable’?
A: Thank you for sending your pictures. In answer your question, I am first going to ignore what is a far more obvious deformity which is the difference in the horizontal position of the upper eyelids on the eyeball. You clearly had a right upper eyelid ptosis repair which has now left you with residual ptosis of the left upper eyelid which sits too low relative to the iris of the eye and asymmetric to the right upper eyelid. But since that is not your focus, let me address to what you are referring to.
Based on what I am seeing, the gap to which you refer at the corner of the right eye may or may not be due to the position of the eyeball. But the reality is that one can not move the eyeball from side to side so that is not a corrective option. To close that gap it would be far simpler to tighten or close down where the upper and lower eyelids meet by corner of lid tightening. That will bring the lid tissues in better approximation to the globe, thus eliminating the gap to which you refer.
Dr. Barry Eppley
Q: Dr. Eppley, I am an active lady just turned 80 and I have a small amount of normal puffiness under my eyes. My concern is that I have puffiness in the corner of my eyes between my eyelid and nose bridge. It looks like a lump or a swollen gland and is puffy. Is there anything I could apply that would reduce that puffiness cosmetically or is this a surgical issue? Would cold or hot compresses reduce the size of this area of the eye? Could the fat behind the eyeball be causing this area to swell? What works best? Thanks for any suggestions you might have for this problem.
A: Undoubtably the puffiness that you see between your nose and your eye is not swelling. That is actual tissue, a combination of skin and fat, that is causing the bulge. Your assumption is correct that it is bulging eye fat. It will not be remedied by any type of external compression. Rather it is going to require surgical excision to remove the now protruding and excessive upper eyelid tissue. This can be done through an upper eyelid incision. (blepharoplasty)
Dr. Barry Eppley
Q: Dr. Eppley, Can you tell looking at a person if the fat is herniated prior to surgery and is the entire fat pads removed in bilateral upper lid surgery? Also, you mention a strip of muscle excised…is it removed from inner to outer corner of the eyes or is this just done for blepharospasm?
A: Photos are generally very helpful to determine if one has herniated eyelid fat. Most herniated fat generally occurs in the lower eyelids and less so in the upper eyelids. The lower eyelids have three distinct fat pockets that often herniate and are removed. The upper eyelid, however, has only two fat pockets that may be treated as the lateral compartment of the upper eyelid contains the lacrimal gland which should not be removed. It may be tucked back up with sutures if needed. The concept of removing the entire fad pads is not done either in the upper or lower eyelids as creating a ‘skeletonized’ and more aged looking eye area is possible with too much fat removal.
A strip of orbicularis muscle is often removed in upper and lower blepharoplasty surgery. It is done in the upper eyelid to help create more of an upper eyelid fold and is done on the lower eyelids to get rid of fullness below the lashline, often called an orbicularis roll. The condition of blepharoplasm is treated with Botox injections, not muscle removal.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 46 year-old female. I would like to get an upper and lower blepharoplasty. However, I have problems with my nose due to a sinusitis and a collapsed septum. I got an x ray last week and the doctor said I have a deviated septum as well as thickening of turbines. I have been on antibiotics for five days. This problem wears me out a lot. I am often tired with headaches and my face always looks puffy due to continous allergy symptoms. My question Dr Eppley is what do you suggest for me to have first or not to have- a Rhinoplasty/Septoplasty to correct the nose issue and then a blepharoplasty? Please doctor I would appreciate your advise. I found your website very helpful, thank you again.
A: There is no question that septorhinoplasty and blepharoplasty can be performed together. This is not a technical nor a safety issue. It is an issue exclusively of how much recovery do you want and how long can you tolerate (socially and workwise) the way you will look during this recovery. When combining rhinoplasty and blepharoplasty the swelling and bruising around the lower eyes can be quite severe, particularly when nasal osteotomies are performed. Otherwise, there is no reason why the two facial procedures can not be performed together. There may also be other advantages beyond one single recovery period for combining them, such as cost.
Dr. Barry Eppley
Have you ever looked in the mirror and seen that tired look and wondered why? If you are over forty, this might be a near daily occurrence. Fullness or extra skin of the upper eyelid is one of the most common causes of tired looking eyes. You may be wondering what’s the best way for me to remove this fullness and restore the youthful, attractive look to my eyes. Is it an eyelid lift (blepharoplasty), a browlift or some combination that is right for me?
Fullness and heaviness of the upper eyelids occurs for two reasons. The most common reason is too much skin and fat. Due to the constant stretching of opening and closing your eyes (the upper eyelid accounts for most of eyelid closing) extra skin is created over time. Eventually this can become so significant that it hangs down onto your eyelashes, known as hooding. The other contributing reason can be the position of the eyebrows. If the eyebrows have dropped down and are too low (gravity does usually win) this can also add fullness to the upper eyelids as it pushes the eyelid skin down.
To really know whether it is the eyelid skin, the eyebrows or a combination of both that is causing those full and tired looking upper eyelids, you must do an eyebrow placement test. By putting your eyebrows in the proper aesthetic position (by pulling up on the forehead skin until you have the desired eyebrow position) and then opening and closing your eyes, one can see the true amount of upper eyelid fullness remaining. By so doing, there are three possibilities for correction which will be revealed.
When the eyebrows are lifted to a better position, all the upper eyelid fullness is gone. This means the fullness is due to low eyebrows and the solution is some form of a Brow Lift. In this situation if only an eyelid lift was done, it would actually cause your eyebrows to become lower.
When the eyebrows are lifted, some but not all of the upper eyelid fullness gone. This means a combined browlift and eyelid lifts are ideally needed. It would also be perfectly appropriate to just do an eyelid lift and accept the lower eyebrow position. For men this is usually more common than in women as most men have naturally lower eyebrows.
If the eyebrow is already in a good position on the lower end of the forehead and all of the eyelid fullness remains, than only eyelid lifts are needed. This is , by far, the most common tired eye scenario particularly if one is under the age of 55 or so.
Plastic surgery correction of aging of the upper eyelids must consider its upstairs eyebrow neighbor to determine the best solution to a less tired and rejuvenated look.
Dr. Barry Eppley
Q: Dr. Eppley, I am 54 years old and am interested in getting a facelift, rhinoplasty, and blepharoplasty surgery. I’m trying to achieve a more youthful look, less sagging, and not so tired looking appearance. I have attached some pictures of me so you can show me by imaging what the results may be like.
A: Thank you for sending your pictures. Here is some imaging for the following procedures; a facelift (neck-jowl lift) and a rhinoplasty.You could get a really significant improvement in your neck wattle as it is a large amount of loose hanging skin. That would dramatically change your neck-jawline profile. It is interesting as to why you have such a large amount of hanging neck skin even though it appears you are relatively thin. Perhaps you have lost a lot of weight ?? Regardless a full facelift will remove inches of skin from the neck and tighten up the entire jawline.
From a nose standpoint, you tip is wide and thick and turns down slightly. There is also a small bump higher up on the nose. A full rhinoplasty would take down the bump, shorten and narrow the tip with some lifting and narrow the size of the nostrils. This type of nose change at your age changes the structure of the nose and makes it look smoother and more refined, a look that has a more youthful quality.
The combination of these two procedures, as the imaging illiustrates, would make significant rejuvenative changes to your overall facial appearance
As an addendum, I did not do nor is it possible to do realistic blepharoplasty computer changes. It is clear from the pictures that you have some extra eyelid skin that can be removed as well as some herniated fat from the lower eyelid. Your lower eyelid shows no significant skin excess, however, other than a few millimeters. Together, this type of upper and lower blepahroplasties will make you look less tired.
Dr. Barry Eppley
Q: Dr. Eppley, Thank you so very much for the information you have provided on blepharoplasty. I found you through a Google search hoping to find some information on whether insurance will cover surgery in severe cases. My hooding is genetic; insurance paid for my grandmothers surgery by the age of 50. Now at almost 50, I look 20 years older all because of my hooding. My huband doesn’t understand my desire to have surgery because he sees me as beautiful the way I am. After reading your information and seeing the images, I can see that perhaps someday there is hope for me as well. Thank your for your encouragement.
A: Hooding or extra skin that hangs on the upper eyelids is easily and often dramatically improved by the blepharoplasty procedure. Of all the anti-aging surgeries of the face, an upper blepharoplasty is one of the ‘simplest’ in terms of the results, short recovery and very low risk of any significant complications.
When it comes to medical coverage, things have changed dramatically since your grandmother’s time. Insurance rarely covers an upper blepharoplasty anymore and, even when they say they will, they often reverse their position when the procedure is done and the physician submits their charges. For this reason, many plastic surgeons no longer process a cosmetic or even a functional blepharoplasty as a medical procedure to an insurance company. It is done on a cosmetic fee basis only.
Dr. Barry Eppley
Q: I am developing deep folds on the sides of my mouth and my eyelids have extra skin that make me look tired. I have attached a picture so you can see my concerns. What type of plastic surgery will get rid of these problems?
A: Thank you for your inquiry and picture. There are two comments that I can make based on your pictures. First, you have a thin and lean type of fat. As a Caucasian, this makes your skin thin and extremely prone to wrinkles particularly around the mouth area. Such wrinkles around the mouth, known as smile lines outside the corners of the mouth, are virtually resistant to any treatment other than temporary injectable fillers. There is no surgery that can provide a cure or any long-lasting treatment for that resistant wrinkle problem. It is resistant because the one thing that would help in not making them continue to develop is to stop smiling or moving your mouth…not only an impossible but not a good social habit to develop.
From an eyelid standpoint, you have deep set eyes (again due loss of fat around the eyeball area or, in your case, you may have never had it to start with) with some moderate skin redundancy of both upper and lower eyelid skin. The real issue is whether the skin on your upper eyelids needs to be removed (eyelid tuck or blepharoplasty) or whether lifting of the eyebrows is better. You can determine that by doing a simple lift test on your eyebrows and see what it does to the skin on your upper eyelids and the new brow position.
For all of these reasons, I don’t think computer imaging is helpful in making these facial aging treatment decisions. It would be better to come in and sit down and go over the options that are available…and see what they can and cannot do.
Dr. Barry Eppley
Q: Hello! Do you perform the laser eyelid rejuvenation procedure? I am 48 and have eye hooding and really don’t want to have the surgery at this time. I have read that there is laser treatment that is quite successful. Thank you for your help!
A: I am not aware of any laser eyelid procedure that does not involve making incisions to do a blepharoplasty or eyelid tuck. The term ‘laser eyelid rejuvenation’ may suggest that there is some type of a laser which magically tightens eyelid skin without surgery, but that is not the case. When eyelid hooding exists, the only known effective treatment is actual skin removal. When upper blepharoplasties are done alone, they can be performed under local anesthesia and, in some cases, may even be done in an office setting. Mini-blepharoplasties exist using a pinch technique which is also an office procedure done under local anesthesia. Given the effectiveness of even these more limited skin removal procedures, any non-surgical approaches have never yet been developed that remotely compares.
Dr. Barry Eppley
Q: I would like to get my eyelids done as they are very heavy looking and make me look bad. People tell me all the time that I look tired even though I am not. I am sick of hearing that! My only real concern about the surgery is recovery. How long is the recovery and what will I look like?
A: Thank your for your inquiry. Recovery after blepharoplasty surgery is largely social…meaning how do I look? (how much bruising and swelling will you get) That would depend on whether one is doing only upper eyelids, only lower eyelids, or all four eyelids.. When all four eyelids are done, most people will have noticeable bruising and swelling for up to 10 to 14 days after surgery. If only one set of eyelids is done, it will be less than that. Lower eyelids develop more welling and bruising than the upper eyelids after surgery. There are also different types of blepharoplasties done in which the overall swelling and bruising may well be less, what we call limited blepharoplasties which are either of the pinch type or lower eyelid which use only a transconjunctival (inside the eyelid incision) approach.
There are numerous strategies for keeping the amount of swelling and bruising as limited as possible. This includes pre-and postoperative oral Arnica, keeping one’s head elevated above one’s heart for the first few days and a good icing of the eyes the night after surgery. I also use gentle surgical technique with delicate amounts of cautery to keep down the amount of bruising that can develop.
Dr. Barry Eppley
Q: Dr. Eppley, My droopy eyelids are driving me crazy. While I have always had very fleshy and heavy eyelids, they have gotten worse as I age. After my 40s (I am 55 now), they began to sag badly. Putting on makeup has become very difficult. What’s even worse is that it is making my forehead wrinkle. My eyelids are heavy and they seem to be in the way of me seeing. Without realizing it, I tense my forehead muscles to lift my brows up. This lifts up some of the eyelid skin and makes me see better. All of this forehead muscle tensing has given me permanent creases in my forehead. Should I just have my eyelids done or both my eyelids and my forehead?
A: Droopy and heavy eyelids, besides interfering with you seeing, can make you look sad and tired. Blepharoplasty (eyelid lift or tuck) can open them up dramatically and give you a fresher and more alert appearance. (some call it a youthful change) That is certainly what you would benefit from as you have realized.
A browlift is a good complementary procedure to blepharoplasties if your brows have dropped with age. Lifting one’s brows up can signify that it is either a reaction to drooping eyelid skin or that the brows are too low as well. That is an important distinction to make. I suspect that it is more of a reaction to your eyelid skin issue. Therefore a browlift is not what you really need. More likely you would benefit from Botox injections to ‘detrain’ your forehead muscles from the muscular responses they have now learned to do.
Dr. Barry Eppley
Has anyone ever said to you that you look tired…have puffy eyes…or commented on the bags under your eyes or your dark circles? If you are over 35 or 40 years of age, you have undoubtably been told that at least once. Many have been told that more than just a few times. While I could espouse on the merits of pointing out the good in people rather than the bad, that would be a pertinent subject for a different column that has little to do with plastic surgery.
Without being told, most people that develop tired-looking eyes know it from looking in their own mirror. Women are particularly sensitive to how their eyes look as they engage in the daily ritual of make-up application. The vast majority of men, however, are unaware until their tired eye problem almost interferes with their vision. While there are some useful simple home ‘remedies’ that can help, such as astringents and endless numbers of creams, they do not remotely produce an improvement that is comparable to what blepharoplasty surgery can do.
Blepharoplasty, or ‘cosmetic eyelid’ surgery, is one of the most successful of all facial plastic surgery procedures. By removing loose and extra skin and fat from the eyelids, one can look refreshed again helping restore an eye appearance that one used to have. But many people are unduly hesitant about undergoing it because of misconceptions about recovery and pain after the surgery.
The thinness of the eyelid tissues and their superb blood supply make swelling and bruising an inevitable, but temporary, sequelae of the surgery. Despite how it looks, it is not painful and most patients only comment that their eyelids initially feel a little tight. There may be some slight stinging discomfort around the eyes the first night after surgery, but that passes quickly by the next day. Bruising and swelling are what persists and that will take up to two weeks after surgery until one is fully in the ‘benefits’ period. For some, this is a time for social reclusion. For others, they embrace it and do not let it be a hindrance for returning to work or getting out and about.
One of the great things about blepharoplasty surgery is that it is not a ‘one size fits all‘ procedure. There are different types of eyelid tucks based on how slight or severe the tired eye problem appears. If one has a lot of droopy or hanging skin then the traditional blepharoplasty would apply. But for those that have just a little extra skin or lower eyelid wrinkling, then the new ‘pinch and peel’ blepharoplasty can be done where just a pinch of skin is removed and the wrinkles reduced by a chemical or laser peel at the same time. If one is just bothered by their undereye bags, that protruding fact can be removed from inside the eyelid, having no external incision at all.
While the eyes may be the window to the soul, the eyelids are the window shades. They create, fairly or unfairly, an impression of our alertness and liveliness. A crisper and refreshed eye appearance is readily possible through blepharoplasty surgery and is easier to go through than most people think. Whether one’s tired eyes are just beginning or are quite advanced, blepharoplasty surgery can be customized to just the right amount needed to put that twinkle back and still fit into one’s lifestyle.
Dr. Barry Eppley
Although eyelid surgery (blepharoplasty) treats only a small area of the face, it has a dramatic impact on facial appearance. Dollar for dollar, blepharoplasty surgery has the best value of any plastic surgery procedure of the face because it is seen by all in everyday conversations. The eyes show age more than any other body part due to smiling, squinting, frowning, sun damage , and heredity. A lot of what you perceive in other people has to do with how their eyes appear. Most of us know this because when we go into work, more often than not, what does someone seem to frequently say…you look tired!
Upper eyelid surgery gets rids of hooding and excess skin that may be hanging down on your eyelashes. Upper blepharoplasty helps restore a natural, youthful appearance by removing skin through an incision in the eyelid crease. In some cases, fat may also be removed or redistributed. Since the incision is carefully placed, it is undetectable once healed. The only way that fine little scar can be seen in the upper eyelid is if they look while you are sleeping!
The lower eyelids are one of the first areas of the face to show age-related changes. Most of us know this because the appearance of bags and wrinkled skin. Loose skin and muscle create a droopy appearance and a protrusion of fat, which normally is under the eyeball, creates that classic but dreaded appearance of lower eye bags. These bags are really prone to absorbing fluids which is why they are more swollen in the morning or if you have eaten really salty foods the day before. The lower eyelids can be improved by an incision which is hidden either inside the eyelid (if fat only needs to be removed) or just below the lashline. (when all tissues need to be treated) The muscle, support tendon, and skin are reshaped and tightened back up against the eye. That protrusion of fat is either removed, tucked back in, or repositioned over the edge of the eye socket bone, dependent upon what will look best. In some patients, chemical peels or laser resurfacing can be done at the same time (only when the incision is on the inside of the eyelid) to improve wrinkles and loose skin on the lower eyelid and crow’s feet area.
One of the most interesting things about these procedures is that most patients say… the most surprising thing about eyelid surgery is the lack of pain during recovery. While eyelid surgery may look bad, it actually produces very little pain. Your recovery is largely social and about how you look.
The other comment that patients often say is…why did I wait so long? I spent a lot of money on creams and other potions and none of them worked…and they promised they would! (hope still remain the #1 selling point) Eye creams are beneficial but they are largely about prevention and not about reversing the age changes that are already there. They simply can not tighten or lift skin to any visible degree.
Dr. Barry Eppley
Q: I’m interested in learing more about dermabrasion or micropeeling. Can this be done on the eyelids? (above and below) Will this help reduce the beginnings of a fold in the top eye crease? I live two hours away. If you can answer these two questions about this procedure would help me determine if I should come in for a consultation.
A: By the way your question is phrased, it appears that you seek a non-surgical solution to the appearance of wrinkles on the eyelids. There are a variety of skin resurfacing methods that are commonly used on all other areas of the face so it is reasonable to ask about their use on the eyelids.
The eyelids represent skin that is very unique from that of the rest of the face. It is different primarily because it is so thin. Being thin makes it very sensitive with higher risks of scarring if the skin resurfacing method is not carefully selected and performed.
Microdermabrasion (superficial) and dermabrasion (deep) are not effective (microdermabrasion) or safe (dermabrasion) skin resiurfacing methods for use on the eyelids. Traditional laser resurfacing is not either for the same reason that dermabrasion should not be used, it penetrates too deep.
The use of laser micropeeling and chemical peels, however, are both effective and safe methods for the eyelids. Laser micropeeling at the depth of 20 microns or less, TCA (trichloroacetic acid) chemical peels of 15%, 25% and 35% as well as the newer Vi chemical peel are all potential choices. Which one of these is best for your eyelids will require an actual consultation to determine.
Another very effective option is the combination of ‘mini-blepharoplasties’ with chemical peeling. The actual removal of a small amount of excess skin and then tightening the rest can be a very effective eyelid wrinkle-reducer.
Dr. Barry Eppley
Q: I am in the very early stages of looking into treatment for the area under my eyes. I believe the problem could be easily fixed by the right Dr. and this is my first attempt to find out what is involved and how much it would cost. The skin directly under each eye is all wrinkled and takes completely away from my appearance and has caused me to be completely self conscious for many years now and if I can do something about it, I would like to.
A: Aging around the eyes is often one of the first signs that many people notice as they get older. Changes in the lower eyelid are usually more obvious than that of the upper eyelids since they are not hidden or distracted by the eyebrow and are larger by surface area. Since so much of human conversation involves direct eye contact, how our eyes look is seen by all. It is no wonder then that many people seek plastic surgery for an improved and more youthful eye appearance.
While there are many topical creams out there, and they do have some anti-aging merits, they are no replacement for more invasive eyelid skin treatment methods. Depending upon the amount of loose skin that exists on the lower eyelid, some version of a lower blepharoplasty or eyelid tuck can be very helpful. Through a fine line incision along the lower eyelash line which extends slightly out from the corner of the eye, loose skin is removed and the lower eyelid is tightened.
Lower blepharoplasty will definitely help remove some but not all of the eyelid wrinkles. You never want to risk removing too much skin from the lower eyelid in an effort to work out every sinle wrinkle and then end up with a pulling down of the eyelid after. (ectropion) Lower blepharoplasty is an excellent wrinkle reducer but should not be thought of as a complete wrinkle remover.
Dr. Barry Eppley
Q : I am writing because I am bothered by bags under my eyes. Since I was a teenager these bags have been there but are now much more prominent as I have gotten older. I don’t expect my eyes to be perfect but I shouldn’t look this way at only 38. I have tried every cream out there and nothing seems to make them better. Is there a plastic surgery for this problem?
A: Lower eye bags are the result of herniated eye fat. Most of the time they appear as a result of aging. But some people have it appear much sooner in life, even during their teenage years. One occurs as a result of weakening of a lower eyelid membrane with age, teenage eyebags are the result of a congenital weakness in the same membrane.
To understand lower eye bags, one must know that our eyeball sits in a bed of surrounding fat for padding and protection. The lower eyelid is like a gate in which fat underneath the eye is held back by a membrane between the lower eyelid margin down to the lower edge of the eye socket bone. When this membrane is weak, eye fat can protrude through like a hernia through an abdominal wall defect. This is easy to demonstrate by closing your eye and pressing on the eyeball. You will see that the tissues underneath the eye bulge out as you press in. This is eye fat being pushing out.
Lower eyebags can only be removed by lower blepharoplasty surgery. No topical treatments or other external treatments will cause the fat to go away. If there is no significant extra skin which is common in younger patients, the fat can be removed through an incision from inside the lower eyelid. (trasnconjunctival blepharoplasty). If there is extra skin from aging, the fat and skin are removed through an incision right underneath the lashline. (external lower blepharoplasty)
Dr. Barry Eppley
The eyes may be the window to the soul, but they also create a strong impression of how we look. So many people comment to and about others based on how their eyes look. We all have had the experience of someone asking us if we are tired or have been up late. You can be certain their question is not probably based on how we were dressed or what we were eating.
But it is not the eyes per se that give these impressions, it is what is around them. The drapes of the eyes, the lids or window shades, are largely responsible for their appearance. Too much skin, deepening wrinkles, and bulging fat creates a tired and aging appearance. When combined with falling eyebrows, the amount of eye we see gets smaller and one really does look older. All this excess lid tissue is also prone to collect and retain fluid, hence those swollen eyes in the morning.
Because of the impact of how our eye area looks, eyelid surgery (blepharoplasty) is the best value in all of facial rejuvenation surgery. This is certainly true based on the size of the treated surface area. But more importantly, changing the look of the eyes does exactly what one is after…to look more refreshed. Few want to look different, but all want to look like themselves, only better.
While there are some non-surgical treatments that can make some areas around the eyes look better, none of them can improve the way the eyelids look. Botox can decrease wrinkling between the eyebrows and around the sides of the eyes, and that can be a great benefit for sure, but that affects expression only. If you look in the mirror without your face smiling or moving and your eyes still look tired, eyelid surgery is the only option.
By the way, forget about some magical cream making your eyelids look better. Amongst the many hundreds that exist, a few can make some minor reduction in fine wrinkles and puffiness. But really visible differences require removal of what makes them look that way, too much skin and fat.
While blepharoplasty surgery works on the lid skin, there are differences between what is done on the upper versus the lowers. The upper eyelids are largely about skin removal and re-creating an upper eyelid crease. Having a well defined eyelid crease is more important than trying to remove all excess skin. In the lower eyelid, more focus is on fat removal and skin tightening and making it as smooth as possible. There is no lower eyelid crease that needs to be made.
Many potential patients fear that blepharoplasty surgery will make them look unnatural. While this is possible if too much skin is removed from the eyelids, most overdone results come from browlifting not blepharoplasty. While browlifting can be a valuable addition to eyelid tucks, it is a procedure that is easily overdone. High eyebrows can easily change the appearance of the eye area and not favorably. Consider browlifting very carefully. It is not a cavalier addition to eyelid surgery.
If you are tired of looking tired, blepharoplasty may be a good choice to get a more youthful look back.
Dr. Barry Eppley
One of the first signs of aging is what happens around one’s eyes. We are so expressive with our eyes and forehead that they bear the brunt of much of the early and visible signs of the aging process. How many times has someone said to you…are you tired?…have you been working late?…when in fact you just had eight hours of sleep. The development of extra eyelid skin, lower eye bags, and wrinkles around the eyes can be telling.
This makes the blepharoplasty (eyelid tucks) a vital plastic surgery procedure in making one look more refreshed. Many patients fear, however, that such an eyelid procedure will change their appearance rather than just making it more youthful or rejuvenated. This fear is promoted by just looking at today’s over-operated celebrities who have had too much surgery, or overly aggressive surgery, and look very unnatural. Such changes do make one look different, but not better.
Modern blepharoplasty surgery avoid these problems using a more conservative approach based on a better understanding of how the eyelid and face changes with age. Greater emphasis is placed on not disturbing the eyelid’s complex system of support and removing just the right amount of extra skin. This leads to a more natural looking result that does not alter one’s appearance.Baggy upper and puffy lower lids can now be treated with less tissue disruption and scarring for a safer and more natural long-term result. The goal is to look like yourself…just better!
When considering an upper eyelid procedure, the position of the eyebrow must be considered. A low hanging eyebrow can make it look like there is more skin in the upper eyelid than really exists. A browlift procedure is occasionally done with a blepharoplasty when it is determined that a higher brow is aesthetically beneficial. How do you know if your eyebrow is too low? That would depend on where one’s brow was when they were young. I would submit that most people do not remember where it was in their younger days. You simply have to play with it in the mirror to decide if higher is better.
Browlifts are primarily a procedure for women, they are rarely done in men. When browlifts are done, emphasis should be on more lateral brow elevation and less inner brow elevation. A woman’s eyebrow usually has an upward and outward sweep to it towards one’s temple area. Bringing up the inner part of the eye brow is what creates an unnatural overelevated look.
Today’s in-office ‘needle’ treatments can also provide some around the eye area improvement. Botox (and Dysport), not injectable fillers, is what is used. It is a great treatment for reducing the frowning look between the eyebrows, horizontal forehead lines, and crow’s feet wrinkles at the side of the eyes which can be particularly evident when one smiles. As an early treatment before significant eye aging changes occur or as a complement after blepharoplasty surgery, Botox is a simple and cost-effective non-surgical treatment.
One no longer has to be told that they look tired or are seeing their eyeball slowly disappear in a sea of loose and hanging eyelid skin. Between the three Bs (blepharoplasty, browlift and Botox), a more rested and refreshed you awaits!
Dr. Barry Eppley