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 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, 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: 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
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 had my lower eyelids tucked (blepharoplasty) over 6 months ago. While my lower lids look much better, I have had a problem with dry eyes and tearing since the surgery. It was really bad right after and has gotten somewhat better. It is almost painful to be out in direct sunlight and my eyes really tear if there is any wind. My lower eyelid also doesn’t look right. I think I show more whites of the eye than before and it looks pulled down. My doctor keeps saying to give it more time and it will get better. But it has been some time now since surgery and I just don’t see it happening. What do you suggest? By the way I am a women who is 58 and I still have to work!
A: One of the potential, although fortunately uncommon, risks of lower blepharoplasty surgery is ectropion. This sounds like exactly what you have.
The lower eyelid, unlike the upper, is like a clothesline strung out between the inner and outer eye socket bones. The eyelid is attached to the bone by tendons called the canthal tendons. This clothesline effect keeps the lower eyelid snugged up against the eyeball just at the lower edge of the iris. By being tight up against the eyeball, it is protected from drying out and being irritated. Any slight change, even one millimeter, between the eyelid and the eyeball (out or down) will cause eye symptoms of dryness, irritation, and tearing. Manipulation of the lower eyelid through surgery can disrupt this relationship if the eyelid and the lateral canthal tendon are snugged back up properly as part of the operation.
While small amounts of ectropion may correct itself with the passage of time and upward massage, six months with this degree of symptoms indicates another approach is necessary. Performing a canthopexy or canthoplasty (tendon tightening and eyelid re-suspension) and retightening of the outside eye corner can provide an immediate solution to this very irritating problem. Once the lower eyelid is back tight against the eyeball, it will not only look better and more natural but the eye is protected once again.
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