In general, incisions are made following the natural lines of the eyelids – in the creases of the upper eyelids, and just below the lashes in the lower lids. Your cosmetic surgeon then separates skin from fatty tissue and muscle. Excess fat is removed. When necessary, skin and muscle are contoured. Your plastic surgeon will close the incisions with very fine sutures.
A key to the success of this surgery is choosing a cosmetic surgeon who is highly talented and experienced in performing it. It requires great precision and skill – very small differences in the removal of fat and skin lead to noticeable differences in the outcome.
Upper Eyelid Surgery- Upper Blepharoplasty
To correct the droopy appearance of your upper eyelid, your cosmetic plastic surgeon will first mark the excess amount of skin to be removed, while you are sitting up. The incision lines are usually drawn in the normal eyelid crease (about 7-10mm above the lashes). The upper border of the skin removal flap is drawn approximately 10-18 mm below the level of the brows, allowing enough skin to remain for adequate eye closure. At the time of surgery, after you are sedated and eyelids are anesthetized, a fine incision is made along the previously marked lines in the natural eyelid fold. This incision can be made with a scalpel or laser. Having performed many Blepharoplasties with either laser, radio frequency (RF), or scalpel, I can assure you that there is no difference in the final outcome.
Next, the excessively hanging skin and the underlying redundant eyelid muscle (Orbicularis Occuli Muscle) are precisely trimmed. The Orbital Septum which is a thin sheet that holds in the orbital fat is incised and protruding fat is removed, or remodeled in order to shape the eye. This is performed very carefully to avoid making the eyes look too hollow.
In some cases, the Lacrimal tear gland has fallen out of the orbit and into the eyelids which make the eyelids appear puffy and fat. Ptotic Lacrimal gland is repositioned if indicated.
There are also people who have excess heavy fat of the skin adjacent to their eyebrows (SOOF- Supra-Orbital Ocular Fat) that slides down onto the upper eyelid. There are times when the droopiness or Ptosis of the eyelids is also corrected by addressing the Levator Muscles which are responsible for pulling up the eyelids.
Other facial aesthetic units such as the brows or the frown muscles can also be addressed while the eyelids are open. For example, a Trans-palpebral corrugator muscle excision can permanently soften the frowns and the forehead; and a Trans-Palpebral Brow-lift or Browpexy can reposition sagging brows to their original natural position.
At the end, the upper eyelid incision is precisely closed with hair-like fine sutures.
Lower Eyelid Surgery - Lower Blepharoplasty
There are two types of lower Eyelid Surgery or Blepharoplasty depending on the incision made, either under your lash lines (Transcutaneous incision), or on the inside surface of the eyelid (Trasnconjunctival Incision).
In the Transconjunctival approach an incision is made on the inside surface of the eyelid which only enables the removal or repositioning of the excessively herniated fat. This might be a good option for younger people who, while having puffy lower eyelids, don't have any laxity, redundancy, or wrinkles of the lower eyelid skin.
One the other hand, those who also need to have loose wrinkled lower eyelid skin removed would be better served by a Transcutaneous/ Sub-Ciliary Incision below the lash lines. Through this approach the lower eyelid skin can be re-draped and tightened. This approach also offers access to the cheeks and the middle face for the performance of Mid-Face Lift, Mid-Face Suspension, or "SOOF Lift" (Sub-Orbicularis Occuli Fat). These adjunctive procedures are detailed in the later sections.
Transconjunctival Blepharoplasty vs. Transcutaneous Blepharoplasty
In a minority of patients whose lower eyelid bags consist of only excess fat and have a very firm and tight lower eyelid skin a Transconjunctival Blepharoplasty might be preferable to that of a standard Transcutaneous Blepharoplasty. This group of patients are usually very young and don't have any lower eyelid wrinkles or excess skin. Their lower eyelid bags are a result of genetic herniation of fat from the orbit (eye socket). In these people, instead of making an incision at the eyeliner (Cilliary margin), the fat can be reached through an incision from insides of the eyelid fold through the conjunctiva.
More specifically, during a transconjunctival blepharoplasty the lower eyelid is moved away from the eyeball, which is then protected with a plastic plate. Through electrocautery, the cosmetic surgeon sweeps across the back layer and most of the length of the eyelid. The fat in three pockets is "teased out" of their capsules, clamped, excised and cauterized from each pocket. Sometimes, the surgeon closes the wound with dissolving sutures, although possibly no sutures will be required. The cosmetic surgeon will remove only fat and not any skin.
Advantages of Transconjunctival Blepharoplasty over traditional lower eyelid surgery include that it leaves no external scar, is less invasive, results in less bruising and swelling and has a more rapid recovery. But don't forget that if you have loose hanging lower eyelid skin, you would not be a candidate for Transconjunctival Blepharoplasty.
Repair of Eyelid Ptosis or Droopy Upper Eyelids
The Levator Occuli Muscle is the upper eyelid muscle responsible for raising the upper eyelid while we gaze upward. The mechanism of eyelid elevation can be defective either at birth or at an older age by damage sustained by traumatic lacerations, or even cataract surgery. There are also rare muscle diseases such as Myasthenia Gravis which can cause the Levator muscle paralysis.
Repair of eyelid ptosis varies depending on the origin and cause of the ptosis. In general the Levator Muscle's tendon is repaired or shortened in order to restore the normal eyelid excursion. In extreme cases, a variety of slings are used to "prop-up" the eyelids.
Repair of Lower Eyelid Laxity or Drooping - Canthopexy?
Extreme Blepharoptosis or the sagging of the lower eyelids is termed Ectropion. More specifically, Ectropion refers to abnormal laxity of the lower eyelids to a point that too much of the white of the eyes show. The loss of lower eyelid integrity can damper the normal flow of tears causing them to spill over onto the cheeks and resulting in the dryness and irritation of the eyes.
Canthopexy refers to a variety of procedures designed to re-establish the support mechanism of the lower eyelid skin so it no longer sags. Depending on the degree and cause of the Ectropion, the type of Canthopexy surgery varies. In those with minimal laxity, or a pre-disposition to developing Ectropion after lower Blepharoplasty, the outer edge of the lower eyelid is tightened against the rim of the eye socket or orbit. This procedure is called Lateral Canthopexy. In cases when Ectropion is caused by extreme horizontal redundancy of the lower eyelid skin, a wedge section of the lower eyelid is excised, thus shortening the horizontal length of the lower eyelid. This procedure is called a Lateral Tarsal Strip Re-suspension. In some cases, Ectropion results from a deficiency of lower eyelid skin, caused by scarring or previous eyelid surgery. In this circumstance, the deficiency of the lower eyelid skin is addressed via skin graft, flaps, or superior cheek advancements.
Your plastic surgeon must be alert of the risks of developing Ectropion, and should have the knowledge and skills to be able to surgically address it at the time of Blepharoplasty.
How Long Does Eyelid Surgery Take?
Depending upon how much you choose to have done, your cosmetic surgeon will take between less than an hours to two hours to complete Eyelid Surgery. As a rule, performing upper or lower eyelid surgery alone takes a bit less than an hour, while both performed together take between one to two hours.
What Kinds of Instruments Will the Surgeon Use?
Some cosmetic surgeons employ carbon dioxide lasers or Radio frequency (RF) for Eyelid Surgery as suppose to stainless steel scalpel. Personally, I have performed many eyelid procedures with all of these instruments and I have not noted any difference in the final outcome. In my opinion, in eyelid surgery, it is the surgeon's skills that are of most importance rather that the tools that he/she might use.
Your cosmetic surgeon will perform the surgery under local anesthesia with sedation, or under general anesthesia. The sedation can be through the administration of oral drugs, including tranquilizers and narcotics, or through an intravenous sedative, such as Propofol. This intravenous sedation allows for a more pleasant patient experience, and rapid awakening following the procedure. Once the patient is relaxed and monitored by the anesthesiologist, the cosmetic surgeon will inject the eyelids with a local anesthetic, such as Lidocaine. The cosmetic surgeon will probably administer the Lidocaine periodically, as he or she gauges how much is needed to keep the patient's discomfort to a minimal level. This may cause the patient to feel a mild burning sensation, but an experienced and skilled surgeon will know how to administer the injection to cause a minimum of discomfort.
You will never have an injection into the eyeballs themselves. Rather, they will be numbed by eye drops. You will be in a "slumber." However, the sensation will be similar to that you feel when having a dental cavity filled, or a tooth pulled.
Many cosmetic surgeons feel that there are a number of advantages to using local anesthesia with sedation. This is because of the delicacy of Blepharoplasty, and the extreme precision with which it must be performed. A local anesthetic allows the surgeon to get desired feedback from the patient by rousing him or her from slumber to induce movement in the eyes. This allows the cosmetic surgeon to monitor results without guesswork that may be necessary when a general anesthetic is administered.
However, this is a choice that should be discussed thoroughly with your cosmetic surgeon. Some patients have a much higher degree of anxiety than do others about the prospect of eye surgery, and may have a better outcome under a general anesthetic.
Patients having Eyelid Surgery along with re other complex or lengthy procedures would be better served with general anesthesia.
Dr. Younai is a Board Certified Plastic Surgeon with formal training in Plastic & Reconstructive Surgery, as well as General Surgery at some of the most prestigious university residencies in the United States. As a cosmetic plastic surgeon he has had ample experience in performing Eyelid Surgery, Blepharoplasty, Eyelid Reconstruction, Revision Eyelid Surgery, Eyelid Cancer Reconstruction Surgery, and the Repair of Ectropion and Ptosis deformities.
At the California Center for Plastic Surgery Dr. Younai will review your treatment options for Eyelid Surgery- Blepharoplasty, including pros and cons of each procedure, potential risks and complications, recovery course, pre and post operative instructions, and esthetic outcomes. There are also many before-and-after pictures and high resolution images of Facial Plastic and Eyelid Surgery available in our photo gallery.
Dr. Younai receives patients from the Northern as well as the Southern California region. Some of these cities include Beverly Hills, Los Angeles, Santa Monica, Hollywood, Burbank, Pasadena, Glendale, Valencia, Palmdale, Fresno, and Oxnard.
Dr. Younai performs his surgeries at the Regency Surgery Center which is certified by Medicare, AAAHC, and AAAASF. This state-of-the-art facility is located in Encino, and near Sherman Oaks, Calabasas, Woodland Hills, Thousand Oaks, and Westlake Village.