Eyelid Surgery – Blepharoplasty

Serving New York City, Manhattan

 

It is often the eyes that people focus on when they first encounter another person, and for many patients this is the first thing that they notice has changed as they age. Eyelid surgery is a great “eye-opener” and should not be confused with brow lift rejuvenation, although they are inter-related. The procedures around the eye are categorized under the heading periorbital rejuvenation. The youthful, natural looking eye is essential to provide harmony with the rest of the face, and eyelid surgery can be done in conjunction with other facial rejuvenating procedures. New York Plastic Surgeon Dr. Wallach recreates a natural looking youthful eye by treating the necessary fat and skin from the upper and lower lids. He tries to conserve as much of the soft tissue in and around the eye to prevent the “hollowed-eye” look, which is a sign of aging. If possible, Dr. Wallach will treat the lower eyelids using an incision on the inside of the lid. There are various methods for treating the eyes and they will be described below. The surgical procedure usually takes between one to two hours to perform with a recuperation period of about seven to ten days.

Contents

Techniques:

Periorbital Rejuvenation

Upper Eyelid Rejuvenation

The upper eyelid area focuses on the inter-relationship between the brow and the upper eyelid. If the brow is too low, lateral excess of the upper eyelid region can be mistakenly assumed to be caused by excess upper eyelid skin when, in fact, many times it is caused by descent of the lateral eyebrow. When the brow is positioned in its ideal location, quite often there is little to no upper eyelid skin excess. This relationship is discussed thoroughly during consultation and then a plan is formulated to determine the best surgical approach. Sometimes an upper eyelid procedure is recommended with or without a brow lift. Since the upper eyelid also has two fat pockets, these may need to be addressed as well. The goal is to restore the youthful appearance of the periorbita without hollowing out the eye. A full upper eyelid is often the sign of a youthful appearance.

Skin Excision

For some patients there is only skin excess and a simple crescent shaped excision is all that is necessary.

Skin And Muscle Excision

For patients with a poorly defined eyelid crease, sometimes a skin and muscle excision is performed. If Dr. Wallach needs to remove muscle, it is usually done conservatively. He does not like to remove muscle in most cases, because it may create a hollow eyelid look and cause the patient to appear older.

Skin And Muscle Excision Along With Fat Removal

There are two fat pockets in the upper eyelids: one centrally, and one medially (closer to the nose). If a patient has excess fat, loose upper eyelid skin, and a poorly defined eyelid crease, then some skin and muscle are removed along with the redundant fat. Usually this includes the medial fat only. On occasion, the central fat is removed conservatively. Dr. Wallach does not like to remove central fat in most cases because leaving this fat maintains fullness in the upper eyelid.

Double Eyelid Procedure

Often done for patients of Asian descent, the goal of this procedure is to create an eyelid crease that was not naturally present. There are numerous ways to do this including full incision, and partial incision techniques. Sometimes a medial epicanthoplasty is combined to open up the medial aspect as well.  For more information regarding Double Eyelid Procedure, visit our blog.

Fat Injection, Fillers, And Neuromodulators

Non-invasive procedures using fat injection, absorbable filler products, and neuromodulators can affect the appearance of the eyelid. Fat injection is performed for permanent fill (See Fat Injection Section.) Injectable products like Restylane™, Restylane Lyft, and Juvederm™ (See Filler Section) can be used as well and last six months to a year. They can be used in the upper lid when the eyes appear a bit over-sculpted. They can also be used to raise the eyebrow when facial soft tissue atrophy has caused them to descend. Neuromodulators like Botox™ and Dysport can be used to help improve the position of the lateral brow and thus improve hooding.

Ancillary Procedures Approached Through The Upper Eyelid

Browpexy

A browpexy is a limited incision procedure that suspends the brow to the forehead. This can be performed through an upper eyelid incision. Often the brow is suspended with sutures, but it can also be done with mini-endotines. The endotine is a device that looks similar to a carpet tack and is secured to the outer portion of the skull. The brow is elevated and secured to the endotine to provide the brow elevation.

Corrugator Muscle Resection

The corrugator muscles cause the “11” lines between the eyebrows and can be treated from an upper eyelid incision. The muscles are located medially (centrally) toward the nose and can be removed to soften the “11” lines. Sometimes fillers are injected to soften the skin depressions created by the muscles.

Lacrimal Gland Resuspension

Sometimes a bulge is noted in the upper lateral eyelid. This is often caused by herniation of the lacrimal gland which is a gland that produces tears. Through an upper eyelid incision, the gland can be repositioned with sutures to the underside of the brow.

Procerus Muscle Resection

The procerus muscle is a muscle that contributes to transverse lines at the bridge of the nose, and these too can be treated through the upper eyelid incision. Fillers can be used as well to fill out these lines.


“I believe true confidence comes from a feeling of self-assuredness from one’s inner self. However, I also believe that it is heavily impacted by a lack of confidence with one’s outside appearance as well. Plastic surgery can help improve confidence in this way.”


Lower Eyelid Rejuvenation

The lower eyelid contributes to the overall aesthetic of the periorbital region. Proper evaluation and treatment of the skin, muscle, and fat will improve the appearance of the aging eye. Some of the characteristic changes in the lower lids with age includes: loose skin, herniated orbital fat, accentuation of the lid-cheek junction with accentuation of the tear trough region (by the nose), and weakness of the lower lid leading to lid laxity and scleral show (too much white of the eye is seen). Lower eyelid laxity when not addressed can contribute to scleral show, or worse, ectropion (the turning out of the lower lid) thus showing the conjunctiva. When the lower eyelid is weak a supporting procedure is necessary. This can be done by performing a canthopexy or even a canthoplasty procedure. Proper evaluation and good technique will minimize risks of eyelid surgery and provide for reliable and safe results.

Skin Excision

This can be performed when there is only loose excess skin. An incision can be made just inferior to the eyelid margin and the skin can be elevated off the underlying muscle and then the excess skin can be removed. More commonly a “skin pinch” is performed without elevating a skin flap off of the muscle. With this technique, the skin is literally pinched together and the excess is removed. The theory to do it this way is that there may be less scarring and risk for ectropion or scleral show.

Skin And Muscle Excision

The “classic” incision used for lower lid surgery was performed using a skin-muscle flap that was incised just inferior to the eyelid margin; the skin and muscle are elevated as one unit. This is still performed by some surgeons, and is indicated for some patients. If the lower lid has weak tone then a canthoplasty/canthopexy can be performed.

Skin And Fat Excision

The philosophy regarding how to treat the lower lid has changed over the years. Some surgeons feel that “violating” the muscle layer may lead to a higher incidence of scarring which can lead to scleral show and even ectropion. That is why when some patients have loose lower eyelid skin and herniated orbital fat a different approach is used. A tranconjunctival blepharoplasty (TCB) approach is performed to remove fat from the three lower lid fat compartments. A transconjunctival blepharoplasty uses a hidden incision inside the lower lid. The incision is made in the tissue between the eyeball and the lower lid and through this approach fat is removed. Release of the arcus marginalis to expose the lower lid fat compartments can be performed. Correction of a “double-bubble” like deformity of the lower-lid cheek junction can be performed by releasing the orbito-malar ligament. Fat can be redraped in this region to camouflage the “double-bubble.” If there is loose skin a simple skin excision or skin pinch approach can be performed. This eliminates the more traditional skin muscle flap procedure which has a higher risk of scarring. If patients have weak lower lid tone, canthopexy or canthoplasty can be performed.

Skin, Muscle, And Fat Excision

Sometimes a skin-muscle flap technique is used to treat the herniated fat. Again, if the lower eyelid has poor support, a canthoplasty or canthopexy may be required.

Ancillary Procedure Approaches For/Through the Lower Eyelid

Lower Eyelid Suspension

Canthopexy/Canthoplasty – Lower eyelid laxity is a common phenomenon that develops with age. During the physical examination, the lower eyelid is tested for laxity. A “snap-back” test can be performed to see how well the eyelid will return to its normal position. In addition, if a patient has scleral show or even ectropion, then these are signs of poor lid tone. In addition, patients with a negative vector in which the eyeballs appear to be in front of the cheek prominence have a higher incidence of lower eyelid issues after surgery.

Canthopexy – A canthopexy is a procedure in which the lateral retinacular ligament, a structure next to the lateral canthus (corner of the eye) is supported to the bony orbital rim in a “suspenders” type fashion. This procedure supports the lower lid after eyelid procedures. It may initially create an “almond-shaped” eye but overtime, this usually relaxes.

Canthoplasty – A canthoplasty is a more invasive procedure for severe laxity. The goal is to create a tighter lower lid. It requires cutting the lateral canthus and making it shorter. This may or may not include a canthopexy to raise the corner of the eye.

Fat Injection, Fillers, And Neuromodulators

Non-invasive procedures using fat, filler products, and neuromodulators can affect the appearance of the eyelid. Fat injection is performed for permanent fill. Injectable products like Restylane™, Restylane Lyft, and Juvederm™  can be used as well, and last six months to a year. They can be used to fill the lower-lid cheek junction and the tear trough area. Sometimes herniated fat found in the lower lid can be draped over the lid-cheek junction to soften this “step-off” once the orbito-malar ligament is released. Neuromodulators like Botox™ and Dysport can be used to treat the crow’s feet along the lateral eyelid as well.

Mid-Face Lift

The mid-face lift is a procedure that focuses on the cheek and lower lid junction. The goal is to elevate the cheek fat pad and treat the lower lid region as well. This can be done as an isolated procedure using only a lower lid incision. The soft tissue around the cheek is freed and secured to the temporal fascia of the face. A canthopexy or a support procedure for the lower lid is also performed at the same time. Commonly, mid-face treatment is performed during other face lift procedures such as in a deep plane face lift.

Lower Lid- Cheek Problems

Malar Bags

Malar bags or malar edema are areas of swelling along the lateral lid-cheek junction. They are similar to the condition causing swollen feet. Increased activity and salt intake may make them worse. Sometimes surgery around the eye may make them more noticeable. Commonly, as patients age, they can look worse because the soft tissue in this area descends and the overlying skin thins. There is no definitively one good treatment for this problem and it may not get better. Sometimes face lifting of this area can camouflage it.

Festoons

Festoons are out-pouching of the muscle which cause the muscle and skin in the lid-cheek junction to hang like drapes. A “squinch” test is performed to see if the festoon is mainly muscle or skin. Often the best treatment for this is to elevate a skin flap during blepharoplasty and either imbricate the redundant muscle or take a crescent of muscle out directly over the festoon.

If you would like more information about Blepharopplasty surgeon Dr. Wallach and his success with New York City Eyelid procedures, we hope that you will not hesitate to contact our Manhattan offices at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details.  For answers to general questions, visit our FAQ page.  Also visit the patient gallery for before and after examples.

Blepharoplasty (Eyelid Surgery) Frequently Asked Questions

I have seen some people after they have had their eyes done and have noticed that they have too much of the white part of their eye showing?  How do you avoid this?

This may happen as the result of poor lower eyelid tone.  Preoperatively, patients are examined for this potential deformity.  Sometimes a tightening procedure called a canthopexy or canthoplasty is performed to provide better support to the lower lid.  This is performed by suspending the corner of the eye at the latheral canthus to prevent “the white of the eye” or sclera from showing too much.

Should I have a brow lift instead?

Some patients request eyelid surgery, when in fact they are better off having a brow lift first.  They often complain about hooding of the upper lids.  Commonly, the eyebrows are too low and require elevation.  The elevation of the brow that is performed during a brow lift procedure also can treat the hooding of the upper eyelid and may preclude the need for eyelid surgery completely.

I’ve seen people with very hollow looking eyes after their surgery.  How do you prevent it from happening?

It is very important to perform a conservative upper eyelid procedure.  The goal is to preserve the soft tissue so that the upper eyelid does not appear “hollow” but yet looks rejuvenated.

I have very puffy lower lids, can you treat them without adding scars to my face?

The puffy lower lids are usually due to pockets of fatty tissue. Sometimes the puffiness may be due to edema, or swelling which can occur in the lower legs. If it is due to fat, then I can perform surgery using an incision on the inside of the lower lid.  This eliminates any scar on the outer skin of the lower lid.  Pockets of fat can be removed conservatively or redraped over the orbital rim to improve the contour.

What can I do about the fine wrinkles and loose skin of my lower lid?

Often the lower lid skin can be treated conservatively by direct excision. If there are only fine lines, these can be treated by chemical peeling or by laser treatment.

My upper eyelids have a lot of excess skin. Should I get my upper eyelids done or have a brow lift?

I see many patients that complain of upper eyelid hooding as they age.  They often request an upper lid blepharoplasty to remove what appears to be excess skin. Interestingly, in many patients this is usually due to eyebrow ptosis or sagging. Elevating the brow, especially the lateral brow, often improves this lateral hooding. The eyes can then be re-evaluated when the brow is placed in a normal position, and usually there is less upper eyelid skin to remove. In general, some patients can benefit from the upper lid blepharoplasty alone, a brow lift alone, or a combination of the two.  Even Botox and fillers may play a role in improving the aesthetics of the periocular region.  The exam and the patient’s operative goals assist in determining the appropriate treatment regimen.

What is done in an upper lid blepharoplasty?

Traditionally, an upper lid blepharoplasty entails removing a crescent shaped amount of skin and muscle at the level of the upper eyelid crease at or just above the tarsus.  Fat is removed from both the central and medial compartments. Many times patients become very hollow. My thought process has changed over the years, and I think that the youthful eye is full. So, usually I will only take a small strip of excess skin at the crease level, leave the muscle intact and the underlying central fat.  The medial fat, if it is herniated or protruding, will be removed conservatively.  The incision is then closed and the sutures are removed within the week.  In my opinion, this will often give the most natural results.

How do you perform a lower lid blepharoplasty?

There are several ways to perform a lower lid blepharoplasty, and my choice of procedure depends upon the specific anatomical issues that occur during a physical exam.  Usually a skin muscle flap is elevated just below the eyelash margin.  The fat in the three compartments is conservatively removed and the excess skin and muscle is trimmed and sutured.  Nowadays, I perform a transconjunctival procedure, which is using an incision along the conjunctiva inside the eyelid to expose the fatty compartments.  I either remove fat conservatively or drape the fat along the lower lid-cheek crease. Many times I will free the crease of the lower lid-cheek junction.  If there is excess skin, “pinching” the excess and removing it conservatively at the level just below the lash line is done. If the patient has poor lower lid tone, I will perform a canthopexy (see below).  If lower lid skin is removed, the sutures are removed usually within several days to a week.

What is a canthopexy?

A canthopexy is a procedure to support the lower eyelid in patients with poor lower lid tone.  This is often detected by a lid distraction test or while performing a lid retraction (snap back) test.   Patients at risk for poor lower lid tone and the sequelae of an ectropion or scleral show are those with a poor snap back test, distraction test, and a negative vector or very flat cheeks.  A canthopexy is performed by placing a suture through the lateral canthal ligament and suspending it to the periostium (or connective tissue) along the inner lateral orbital rim.  My analogy is like suspenders on a pair of pants that hold the lower lid in place during the healing process. Early post-op, the patient’s eye may appear slightly almond shaped, but as the area heals the shape usually returns to normal.

What is a canthoplasty?

A canthoplasty is similar to a canthopexy except that it is used to shorten the lower lid because of laxity and stretching of the lateral canthal tendon. The lateral canthal tendon is shortened in a similar fashion to a canthopexy, which is suspended to the inner lateral orbital rim.  This is performed to support the lower lid to minimize the risk of ectropion or scleral show.  One issue with this technique is that it will change the eye shape a bit.

What is scleral show?

Scleral show refers to the appearance of more “white” of the eye, especially lateral to the pupil. This can naturally occur with age or as a result of the progressive weakening of the lower lid. This may also occur as a result of a lower lid blepharoplasty or midface lift when the lower lid is not supported.

What is a pinch blepharoplasty?

A pinch blepharoplasty is performed to remove excess skin in the lower lid.  The surgeon “pinches” the skin along the lower lid margin just below the lash line. The excess skin that is in the “pinch” is then trimmed and the resulting incision is closed.  This is performed without violating the muscle layer.

What is a traditional blepharoplasty?

A traditional blepharoplasty can be performed for both upper and lower eyelids.  A crescent of skin and muscle is removed from the upper eyelid usually six to eight mm’s above the lash line and a variable amount of fat is removed from the central and medial fat pockets. For the lower lid, an incision is made just inferior to the lash line elevating a skin-muscle flap. Variable amounts of fat from the three fat pockets is removed or draped over the orbital rim.  The lower lid skin–muscle flap is trimmed to remove the redundant tissue.  Sutures are usually removed within a few days to a week.  Generally, I try to preserve fullness in the upper eyelid and try to avoid violating the lower lid muscle layer. Often the lower lid is supported by a canthopexy when the lower lid tone is poor.

What is lagophthalmos?

Lagophthalmos refers to the condition in which the eyelid does not close completely.  Sometimes this can occur with swelling after eyelid surgery and when too much skin is removed from the upper eyelid.  Patients with this condition will often complain of dry eye.  When this occurs after surgery, it is often a transient condition that can be treated with eye drops, ointments, and/or taping of the lids at night to keep them shut until the swelling diminishes.

What is a tear trough deformity?

A tear trough deformity occurs in the lower lid-cheek junction. This is usually a depression or hollowing between these two regions often just inferior to the inferior orbital rim. This depression can become more apparent with patient aging and overall facial deflation. Sometimes facial fillers like Restylane, or other similar hyaluronic acid products can be used to camouflage this region.  Fat injections may also show some benefit. There are surgical treatments available as well. This can include releasing the orbito-malar ligament to lift the tissue that is depressed, as well as conservatively removing fat from the lower lid fat pockets or even conservatively draping the fat over the depressed area.

Can a tear trough deformity be treated by a blepharoplasty?

During blepharoplasty, the tear trough region can be treated. I commonly approach this region through a transconjunctival approach and release the orbitomalar ligament along the arcuate line.  Sometimes I will perform conservative fat removal and drape the fat along this region.

Can fat that is bulging in my lower lid be used as a fat graft?

I do not commonly take the fat from the lower eyelid pockets to use as free fat grafts, but will on occasion use it to camouflage the tear trough region by draping the fat over the orbital rim.

What is an ectropion?

An ectropion refers to a lower lid deformity in which the lower lid gets pulled down secondary to scarring and causes the conjunctiva of the inner lid to be visibly pulled outward. Treatment may require release of scar tissue, skin grafting, spacer placement, canthoplasty, and taping to name a few.

Who is at risk for an ectropion or scleral show?

Ectropion is more common in patients with lower lid laxity. Patients who have scleral show (more white of the eye showing) or a negative vector in which the cheek bone is slightly behind the bony orbital rim have a higher risk of ectropion. During a physical exam, if the patient shows poor tone of the lower lid during a distraction test or the lid retraction test (snap back), they are more prone to develop an ectropion.

What is entropion?

Entropion occurs when the lower lid margins actually curls inward and the lashes irritate the eye. Treatment often requires excision of skin and muscle along the lid margin to help evert the lash line.

What is chemosis?

Chemosis is a condition in which the conjunctiva swells. From a surgical standpoint it is usually related to having recent surgery and more commonly with a transconjunctival procedure than a more traditional skin-muscle flap blepharoplasty.  Irritation from sutures, surgical swelling, lagophthalmos, and disruption of tear production are just a few causes of chemosis. It is commonly treated with moisturizing agents, sometimes steroids, and occasionally eye patching.

How is chemosis treated?

Depending upon the cause, there are several different treatments. For typical cases of chemosis, moisturizing agents and potentially steroid eye drops are the first line treatment. This can also include taping the eye shut or patching it.  If there are recalcitrant cases of chemosis, sometimes a snip conjunctivoplasty can help improve the condition.

What is the recovery like from blepharoplasty surgery?

In general, the recovery is fairly easy.  Most patients do not have a lot of discomfort. They will see bruising and swelling, but this will vary from patient to patient.  Sutures usually are removed within several days to a week.

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