Your Questions
Your Questions
Q: Dr. Eppley, I’m interested in a pinch lower blepharoplasty and am seeing if I am a candidate for the procedure. I took the picture smiling because the wrinkles aren’t as noticeable when I’m not smiling. I have seen a few plastic surgeons about my options. I do have a little fat under my eyes that I’ve been told could be fixed by filler or moving the fat around. That doesn’t bother me as much as the loose skin, and I’m hoping that tightening the skin will help. I will be fifty in November, but I lead a very healthy lifestyle with regular chemical peels. If I did the recommended procedures, what is the recovery time?
A: The difference between someone who needs a pinch lower blepharoplasty technique versus a full lower blepharoplasty is a function of numerous factors. How much loose skin is present, is there an orbicularis muscle roll, presence of any fat herniation and how much loose wrinkled skin do they have. In addition, the age of the patient and how much facial aging they have is also relevant…as pinch blepharoplasties are generally reserved for early signs of periorbital aging. (less than 50 years of age) Your picture is a smiling one so that obscures some of this anatomic information. But clearly you are young and do not have much herniated fat. Thus based on this one picture, I would say that a pinch blepharoplasty combined with a 35% TCA peel for the rest of the lower eyelids and 8 units of Botox for the orbicularis muscle activity per eye would be beneficial. You can’t get rid of all your lower eyelid wrinkles with any procedure, particularly when one smiles, but this would provide a major improvement with limited downtime. Expect one week or less of a ‘cosmetic’ recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had two facial problems my entire life, dark circles and retracted lower eyelids. I have always hated my look when I am not squinting and because of that I think that my ower eyelid muscles have become overdeveloped. I have attached pictures of when I squint and when I don’t. This will give you an idea of my orbital/cheek area.
The area circled in the picture was filled with Juvederm already as suggested by a local plastic surgeon to improve lower eyelid projection but it didn’t help at all. Though I do like my cheeks now and I am also thinking about making this permanent with cheek implants to give even better support to lower eyelid. What do you think about this idea? The local plastic surgeon seemed to think that cheek implants were a bad idea.
What procedures would you recommend? Also would canthopexy/canthoplasty address problem with overdeveloped muscle, or would it need to be trimmed with another procedure ? Could all procedures be done together?
A: Your pictures show a large orbicularis muscle roll of the lower eyelid (when squinting), cheek bone hypoplasia and lower eyelid hollows. (with some slight scleral show) I would recommend medium submalar shell cheek implants, a pinch lower blepharoplasty with excision of redundant muscle and fat injections for undereye hollows, all of which could be done as a single procedure. When done locally this is an outpatient procedure but, if from afar, most patients would return home in 48 hours. It would take about 10 to 14 days to look very acceptable without obvious signs of surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in CO2 laser resurfacing and skin under my eyes and also to remove dark spots on my cheeks. Or maybe I need a pinch blepharoplasty instead. I had a lower blepharoplasty three years ago which left my eyes more wrinkled. I was told this procedure would remove the fat and then cut and tighten underneath. Only the fat was removed. I’ve load an up close picture which also shows the spots and a smiling picture you can see how much extra skin is under my left side, which makes me not want to smile as it shows worse when I do.
A: By your description your original lower blepharoplasty sounds like a transconjunctival one in which no skin was removed but only fat from the inside of the lower eyelid. By deflating lower eyelid ‘bags’ (fat), skin wrinkles are often worsened as the skin retracts. This is why many transconjunctival lower blepharoplasties often include a simultaneous skin resurfacing procedure (laser or chemical peel) to avoid this aesthetic problem with fat ‘deflation’. At this point, you need a pinch lower blepharoplasty, as you have surmised, to get rid of the roll of skin and muscle that is just under your lashline. With smiling not all of the extra skin can be completely removed but a significant improvement can be obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you do the pinch blepharoplasty? I only need skin tightened under my eyes and don’t have bags so I don’t think I would need fat removed. I read about the pinch procedure and it sound like what I would like to do because it seems fairly simple and less invasive.
A:That is a lower eyelid procedure that I do all the time. As long as one does have significant bags, this can be a good lower eyelid tightening procedure that often is combined with either a chemical peel (25% or 35% TCA) or light laser resurfacing to get the best results. You are correct in your assumption that recovery is very quick. This is because the lower eyelid skin is not undermined and a skin-muscle flap is not raised. It can be an ideal procedure for the younger patient who has a small skin excess of the lower lid or an older patient who may have had a prior lower blepharoplasty and just needs a touch-up or some additional skin removal. The pinch lower blepharoplasty is often combined with a transconjunctival approach to fat removal to create a dual effect when one has bags but little skin excess of the lower eyelids.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few wrinkles and extra skin on my lower eyelids that I would like to get rid of. I don’t think I need any blepharoplasty surgery and have read about lasers and chemical peels. Which of these two lasts the longest or do they both last a comparable amount of time? Which is most natural looking result or is there no difference? Which is least likely to excessively tighten skin? I am curious as to why laser resurfacing is so popular over chemical peels. Which has the least downtime?
A: There is no evidence that either method, laser vs TCA chemical peel, is more effective or long-lasting on lower eyelid skin rejuvenation. Laser do have a higher risk of hypopigmentation. Both are commonly used and it is a matter of comfort and experience as to which method plastic surgeons use.
It is likely you may also benefit by a pinch lower blepharoplasty with a TCA peel but I would have to look at your lids to answer that question. This is a favorite method of mine for the lower eyelids because it works very well with a very small amount down time. It is also the most minimalist method to guarantee that lower lid skin would be tightened to some degree.
Lasers are more popular than peels today for a variety of reasons. First they are more ‘high-tech’ and with that comes the assumption that they produce better results. In addition, their high cost and the need for the manufacturers to sell them drives a lot of more visible marketing efforts.
Dr. Barry Eppley
Indianapolis, Indiana