Excess and unwanted skin and fat above the upper and lower eyelids is one of the most common concerns of patients desiring cosmetic surgery of the eyelids. The surgical procedure performed to reverse these age-related changes of the eyelids is called blepharoplasty. Our Beverly Hills blepharoplasty surgery helps restore a more energetic and youthful appearance, and is an excellent procedure under local injections of anesthesia with or without sedation, or in some cases general anesthesia can be used.
In upper eyelid blepharoplasty, a fine incision is made in the pre-existing crease above each eye. A crescent of excess skin and muscle is then removed, as well as all fat (puffiness) that is present. The incisions are then closed with fine stitches, which are removed in one week.
In the lower lids, the fatty deposits are typically repositioned (to prevent a hollow look) or removed from the inside of the lid so that no external incision is made. In some instances, when there is excess skin that needs to be removed, a skin pinch is performed with an incision placed under the lashes so as to avoid a conspicuous scar. As with the upper lids, fine stitches are used to close the incision.
The typical post-operative recovery period (the time necessary for bruising and swelling to resolve) after our Los Angeles eyelid surgery is 14 days. It is important to avoid strenuous activity for the first week after surgery, but one can return to work during this time if desired.
Antibiotic eye drops are generally prescribed for several days after surgery, and patients cannot wear contact lenses for approximately two weeks after surgery, as the eyelids may be stiff and sore. Makeup can be worn after 10-14 days, and the resultant fine scars, which follow the natural contour of the eyelid, tend to fade in about two to three months.
Are you a good candidate for our blepharoplasty?
Here is a checklist to see if you are a good candidate for our Beverly Hills eyelid surgery:
- A patient with lot of excess eyelid skin giving the skin around the eyes a baggy appearance. In more severe cases, the excess skin can actually interfere with the patient’s vision
- Dark circles and bags have formed under the lower lids due to excess fat under the eyes.
- Sometimes an endoscopic browlift is done in combination with the blepharoplasty to rejuvenate the eye and brow area.
Procedure
Incisions are made where the natural crease exists in the upper lid and below or behind the eyelash line in the lower lid. Excess fat and/or skin are removed or repositioned and, if needed, the muscles are tightened.
The procedure normally takes only one to two hours for upper and lower eyelids. Frequently it is done in conjunction with the "anti-gravity" mid-facelift or endoscopic browlift.
Recovery
To minimize swelling after your blepharoplasty in Los Angeles, the head needs to be elevated for several days following surgery. Discomfort is minimal and easily controlled by oral medication. Swelling and bruising subside over a few weeks. Sutures are removed in seven days.
Intended Result
A fresher, more rested appearance. Eyelids no longer interfere with vision for better sight.
Fat repositioning
Over the last decade, lower transconjunctival blepharoplasty has become the method of choice by facial plastic surgeons for treatment of lower eyelid herniated fat due to the reduced rate of complications and to the hidden incision. The primary complications of the transcutaneous approach are lower lid retraction with scleral show, lower lid ectropion and rounding of the lateral canthal angle.
Traditionally, lower eyelid herniated fat is removed which may cause a sunken or hollow lid appearance, especially in patients with a tear-trough deformity. A tear-trough deformity or nasojugal fold is usually caused by the inferior descent of the cheek (malar mound) with age or an anatomic bony deficiency of the maxilla, producing a depression at the medial inferior orbital rim.
Additionally, the midface descends creating a double-convexity contour deformity (lower eyelid herniated orbital fat convexity followed by the cheek/malar mound convexity). Fat preservation in the lower eyelid, which was originally described in 1996, may prevent some of these contour irregularities. We define fat repositioning as the subperiosteal repositioning of the medial and central lower lid herniated orbital fat into the nasojugal fold. The lateral orbital fat pad may be repositioned into the lateral inferior orbital region if needed.
Advantages of fat repositioning include the prevention and/or improvement of the tear-trough deformity and treatment of the herniated orbital fat. The disadvantages of fat repositioning are the steep learning curve and potential complications such as diplopia due to injury of the inferior oblique muscle, fat granulomas, prolonged edema and rarely, soft tissue irregularities.
Candidates for fat repositioning include patients with:
- Lower eyelid herniated fat
- Presence of a tear-trough deformity
- Acceptance of the possible risks and complications
- Realistic expectations
Often this technique is used to soften moderate to severe tear-trough deformities in patients with minimal to no herniated fat since fat may be released once the septum is opened. In addition, a lower eyelid skin pinch may be performed in patients with excess skin in the lower lid and adequate lower lid tone. Often, lower eyelid fat repositioning is combined with a subperiosteal midface lift to completely rejuvenate the lower eyelid-cheek region.
Surgical technique
The transconjunctival fat repositioning procedure is performed with the patient under local or general anesthesia. With the patient in the supine position, a surgical marker is used to mark the nasojugal groove. One drop of tetracaine ophthalmic solution is instilled in each eye. One per cent lidocaine (Xylocaine) with 1:100,000 epinephrine is injected into the lower conjuctival surface and subcutaneously and subperiosteally over the inferior orbital rim nasal to the nasojugal fold.
With the use of a Desmarres retractor, the lower conjuctival was exposed. The preseptal approach involves a transconjunctival incision at the inferior edge of the tarsus using a Colorado needle. The incision is carried through the lower eyelid retractors with care not to injure the tarsus. A preseptal dissection is performed bluntly with surgical Q-tips.
A 4-0 black silk traction suture is placed through the posterior conjuctival flap to protect the cornea and to aid with exposure of the fat pads. With slight pressure on the globe, the medial fat is identified. With the Colorado needle, a buttonhole is made in the septum exposing the medial fat pad. The fat is made into a pedicle for repositioning by thinning and elongating the fat with careful dissection of the surrounding fibrous attachments. The base of the pedicle is kept intact to ensure the viability of the fat pad.
While grasping the fat pad with forceps, blunt dissection is performed using Q-tips and/or scissors between the fat pad and the inferior oblique muscle to make sure that the fat pad is not adherent to the inferior oblique muscle. This maneuver prevents tethering of the muscle to the fat pad while repositioning. During the entire dissection, meticulous dissection and hemostasis helps prevent injury to the inferior oblique muscle.
If the central fat pad is to be repositioned, the same procedure described above is performed with one caveat. Fibrous attachments between the medial and central fat pads need to be released with blunt and/or sharp dissection to prevent tethering of the fat pads to the inferior oblique muscle. Following this maneuver, both fat pads are grasped with forceps and a "see-saw" movement is made allowing free movement of the fat pads from the inferior oblique muscle. The lateral fat pad is usually excised or may be used for repositioning if indicated.
For the repositioning portion of the procedure, a Jaeger plate is placed over the fat pads and the inferior oblique muscle. A Senn retractor is used to retract the lower eyelid and the orbicularis oculi exposing the inferior orbital rim and arcus marginalis. Using the Colorado needle, an inferior orbital rim incision is made through the periosteum approximately 2 millimeters inferior to the arcus marginalis.
The medial border of the incision is immediately lateral to the medial puncta. The lateral border of the incision on the inferior orbital rim is approximately above infraorbital nerve but may extend to the lateral rim if repositioning is to be performed with the lateral fat pad. A freer elevator is used to elevate a non-constricted subperiosteal pocket along the inferior orbital rim from the infraorbital nerve to the medial/inferior aspect of the nasojugal fold.
A 4-0 polypropylene suture on a FS-2 needle is passed through the skin medial to the nasojugal groove and retrieved in the subperiosteal pocket. Next, the suture is placed through the medial fat pad pedicle while the pedicle is splayed-out, into the subperiosteal pocket and finally, exiting the skin just inferolateral to the location of the first suture. The suture is used to "pull" the pedicle towards the distal aspect of the medial subperiosteal dissection, in essence, bringing the pedicle "through" the tear-trough deformity while making sure that the fat pedicle is splayed-out and not "bunched".
Once again, care is taken to make sure that the inferior oblique muscle is free from the fat pedicle. The polypropylene suture is gently tied down over a cotton bolster. The central fat pad is repositioned inferolateral to the medial fat pad with the same suture technique. The subperiosteal pocket is irrigated and platelet rich plasma (if used) is sprayed into the pocket. Forced ductions are performed to confirm absence of inferior oblique muscle tethering. There should be no movement on the fat pedicle as the globe is rotated.
This procedure is repeated on the contra-lateral side. If a lower eyelid skin pinch is to be performed, a frost stitch may be used if mild laxity of the lower eyelid is diagnosed preoperatively. If moderate to severe lower eyelid laxity is present, a lower eyelid tightening procedure should be performed. Following the procedure, check both sides for symmetry. An antibiotic-steroid ophthalmic ointment is placed in each eye.
Post-operative care
Prior to their blepharoplasty in Los Angeles, The patient is instructed to apply cold compresses to the eyes for 48 hours. For 1 week, patients are instructed to maintain a semi-upright position when sleeping or resting. An antibiotic-steroid ophthalmic drop is used for 5 days since chemosis in not uncommon. Artificial tears are used frequently throughout the day for 5 days. A steroid dose pack is prescribed as needed.
A cursory eye exam checking for diplopia, gross visual acuity, edema and chemosis is performed on the first post-operative day. On day 5, the polypropylene suture is removed and the repositioned fat is checked for symmetry. The patients may resume full activities after 3 weeks.
Complications
The complications from fat repositioning are generally the same for a transconjunctival blepharoplasty except that the potential risk for diplopia due to injury of the inferior oblique muscle, fat granulomas, prolonged edema and soft tissue irregularities are higher. Diplopia is usually transient due to edema, while persistent diplopia will need evaluation by our ophthalmology colleagues.
Although rare, a fat granuloma may be treated conservatively with intralesional steroids, or if needed, more aggressively with local excision. Prolonged edema (persistent for more than 6 weeks) may be treated with oral steroids and ultrasound.
Results
Since January 2001, we have performed fat repositioning procedures in more than 100 patients with no visible fat reabsorption. This procedure has the advantage of addressing the herniated fat while preventing lower eyelid hollowness and/or improving the tear-trough deformity.
Fat repositioning may be combined with one or more of the following procedures:
- Endoscopic subperiosteal midface lift
- Transcutaneous skin pinch
- Transconjunctival orbicularis oculi excision
As with any new procedure, thorough knowledge of the current literature and anatomy and observation of this procedure by an experienced surgeon should prelude your attempt in lower eyelid transconjunctival fat repositioning.
Blepharoplasty FAQ
Also known as surgery on the eyelid, blepharoplasty is an operative procedure devised to provide a younger look to the eyes. It is achieved by the removal of excess fat, skin and muscle from the upper and lower eyelids. Fat of the lower eyes may be repositioned to prevent a "hollow eye" appearance following lower eyelid fat removal. The procedure may also enhance vision in situations where excess skin of the upper eyelids has sagged to the degree that it hinders with peripheral vision.
The most typically used anesthesia during blepharoplasty is local in conjunction with light intravenous sedation.
Blepharoplasty is considered to be an outpatient procedure and there is not requirement to stay overnight.
It is important to disclose any medications you are taking, including vitamins and supplements, to your facial plastic surgeon. Certain medications and herbal supplements can increase the risk of bleeding, interfere with the healing process, and potentially be dangerous to take if you are having a surgical procedure performed. For example, bleeding may be increased by the intake of vitamin E and non-steroidal anti-inflammatory drugs.
Blepharoplasty does not stop the aging of the eyes, and it is not uncommon for patients to come in for a revision down the road. It really depends on your individual circumstances and the level of change you desire. The sagging could also be due to the brow, which should be looked at as well.
There are scars involved with blepharoplasty just as there is with the majority of other types of surgery. Normally though the scars are hardly seen after a few months and this is because the incisions are put in the normal creases and folds of the upper and lower eyelids. For those patients that only have to have fat removed from their lower eyelids may have incisions made on the inside of their eyelid and therefore having scars going on detectable.
There are procedures developed for elevating a drooping eyebrow or eliminating wrinkles around the eyes and blepharoplasty is not one of them.
Blepharoplasty can slightly help with the dark circles under the eye that are caused by large bags. But the darkness of the lower eyelid skin usually stays even after blepharoplasty. In this case, then chemical peels and laser resurfacing can help.
A facelift can be performed safely in combination with blepharoplasty, and in fact these two procedures are commonly performed together.
You will want to refrain from wearing contact lenses for two weeks following surgery. Eyeglasses are okay after your procedure, provided that they’re cleaned and disinfected prior to use.
Since the fat around the eyes will not regrow after being removed, the results of blepharoplasty are usually long lasting.
Three to five days following blepharoplasty, the stitches will be removed.
The skin of the upper and lower eyelids is changed during blepharoplasty. Generally the shape of the eye changes so that it appears more open and less tired.
I would recommend you speak with your facial plastic surgeon immediately, as he or she knows the extent of your surgery and exactly what was performed. Blurry vision may be the result of the ointment that is used following surgery. It may also be the result of swelling of the whites of the eyes following surgery, and swelling of the conjunctiva of the eye (chemosis). Speaking with your surgeon will help to determine the cause of the issue.
Generally, as individuals age, they may experience a drooping brow along with excess skin over their eyelids. In patients with both issues, having these procedures performed together will enhance the overall result. Addressing only one area may draw more attention to deficiency in the other – meaning, performing only a blepharoplasty on a patient with excess eyelid skin and a drooping brow may accentuate the drooping brow and cause it to look even heavier than before surgery.
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