Explore Plastic Surgery - Dr. Barry Eppley

Blepharoplasty (eyelid rejuvenation surgery) is one of the most common facial cosmetic surgeries. According to the American Society of Plastic Surgeons procedural statistics for 2008, nearly 200,000 such surgeries were performed. Lasik (corrective vision) surgery is done even more frequently with roughly one million done as of last year. It should be no surprise, then, that these two eye-related procedures can cross paths in the same patient. Either someone has had Lasik and presents sometime after for blepharoplasty or one has had blepharoplasty and is now interested in vision correction.

This raises the question of how one impacts the other and does it pose a problem? Blepharoplasty and Lasik are compatible procedures that can, and often are, done in the same patient. But they are never done together. They must be staged and timed so they do not create functional eye problems.

Blepharoplasty can interfere with eyelid closure with the potential for a temporary period of eye dryness as a result. The blink reflex is slowed and the loose amount of eyelid skin and laxity has been removed. In short, the safety net for competent eyelid closure has been reduced…even if it is only temporary. This can be revealed when one sleeps where only a small crack of opening between the eyelids can cause lack of adequate eyeball lubtication. This is evidenced by crusty eyelids in the morning and a feeling of dry or itchy eyes.

LASIK is an elective laser eye surgery that reshapes the cornea (front surface of the eye) to improve vision. It is the most popular vision correction procedure performed in the United States and worldwide. LASIK can correct a wide range of nearsightedness (myopia), farsightedness (hyperopia) and astigmatism. Dry eye is not an uncommon problem after Lasik and an estimated 20% of patients having the procedure suffer some temporary period with it.

While Blepharoplasty and Lasik can be done before or after each other, there should be a sufficient time period between them. If blepharoplasty has been done first, one should wait until their eyelids are completely healed and that any symptoms of dry eye are completely resolved or do not exist. Usually this should be at least a three month waiting period. It will also depend on what type of blepharoplasty has been performed. The issue is really the lower blepharoplasty. ‘Low-risk’ blepharoplasties include those done through a transconjunctival approach (inside the eyelid with no external skin excision) and pinch and peel techniques where minimal lower eyelid skin is removed.

If Lasik is initially performed, one should wait at least 6 months (if not longer) before undergoing a blepharoplasty. This time is need to ensure that the cornea has healed properly and to protect it from any stress from potential dryness. One’s ophthalmologist should be consulted  to get clearance for a blepharoplasty procedure.    

Barry L. Eppley, M.D., D.M.D.

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 12:00 - 1:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the topic of periorbital rejuvenation was discussed. Blepharoplasty (eyelid tucks) now rate as the number one facial plastic surgery performed, exceeding facelifts, rhinoplasties, and chin augmentation. Becuase the eyes are of great social significance, most people feel that they are their most important facial feature. The eye area is the first region of the face which shows aging. Rejuvenation of the eyelids and brows can make a big difference on one’s appearance. Topics discussed with listener questions included blepharoplasty and its many variations for the upper and lower eyelids, browlifts, botox, injectable fillers, orbital implants, micropigmentation (permanent eyeliner), eyelash extensions, and Latisse eyelash growth stimulant.

Free plastic surgery consultation with Dr. Barry Eppley can be arranged by calling his Clarian North office in Carmel Indiana at 317-814-4100 or his Clarian West office in Avon Indiana at 317-217-2200.

Aging around the eye area is one of the first and often most significant signs of facial aging. The areas around the eye that change are the brow and both upper and lower eyelids. All the above sag due to not only loose skin but redundant (extra) skin as well. Most patients have a clear idea of these issues when it comes to the upper eyelid. They can clearly see skin hanging down onto their lashes and loss of the youthful supratarsal crease or fold that previously existed between the brows and the eyelashes.

Correction of the aging upper eyelid, known as upper blepharoplasty, is one of the simplest and most successful of all facial plastic surgery procedures. While it does cause some temporary bruising and swelling, the removal of a strip of the extra eyelid skin helps create an immediate change. The upper eyelid is tightened and the supratarsal fold is immediately restored.

 One of the potential concerns that some patients may have about the procedure is the risk of visible or poor scarring. The good news is that is one issue which is a rare problem. The scarring is so good in this area, and the scar is always hidden when you are awake (with the eye open, the upper eyelid crease rolls back inward), that this is really a non-issue most of the time.

 There are several reasons for the almost always good scarring which occurs on the upper eyelid. First, the upper eyelid has the thinnest skin on the entire body. The thinner the skin (with less dermis), the less tissue there is to produce scarring. Scar formation comes from the skin’s dermis which is paper-thin. Quite frankly, the excellent eyelid scars we see is as much the result of its thin skin as it is surgical technique. Secondly, the scar line is sufficiently above the lashline of the upper eyelid that it is completely covered when one’s eyes are open. To find an upper eyelid scar, you would have to ask the patient to close their eyes and then look carefully up close. Lastly, most poor scarring comes from wounds that are closed under significant tension. As the eyelids spent a significant part of their time being open, the incision closure or scar line is not under much stretch or tension.

In my Indianapolis plastic surgery practice, I have observed that the upper blepharoplasty is a very effective and simple procedure to go through. Most patients report virtually no pain, no matter how it looks to the viewer. Scarring is a very rare issue with blepharoplasty or eyelid surgery.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

One of the most popular and successful facial plastic surgery procedures is blepharoplasty or eyelid tuck surgery. As it is for most the earliest sign of facial aging  is around the eyes.  And as the eyes are seen by all (every human conversation involves a fair amount of time looking into the other person’s eyes.), it is no wonder that how we look is highly influenced by the appearance of our eyes.  This is why I always blepharoplasty a great value based on how much it can change one’s appearance…and other people’s perception of you.

Despite the success and relative simplicity of blepharoplasty surgery (compared to other facial procedures), there remain some basic misconceptions about it. Despite how one may look after eyelid surgery, there is a remarkable paucity of any significant pain.  The eyelids are very thin tissues with skin and a little muscle, but nothing that creates a lot of pain with surgical manipulation. In essence, you look bad but you don’t feel bad. As a result, recovery after blepharoplasty is mainly about how you look and not really about how you feel. It takes about a week or so until one really feels good again about going out in public.

 
Blepharoplasty will not necessarily make you look like you have had a beating. Recovery after eyelid surgery, in terms of the swelling and bruising that occurs, can be influenced by what one does before and after the procedure. Stop any medication that can promote bleeding, such as aspirin and non-steroidal anti-inflammatory drugs, two weeks before surgery. I highly endorse taking Arnica Montana tablets (a homeopathic supplement) beginning one week before and one week after surgery. This will help to prevent some of the bruising around the eyes that will occur as well as help what does appear clear faster. On the first postoperative night, keeping your head above your heart and ice the eye area (frozen vegetables are easiest) are really beneficial. All of these together can make it possible to be publically presentable and relatively ‘non-surgical’ in appearance a week after surgery.

Contrary to the perception of some, blepharoplasty will not usually change the way you look. We have seen photos of famous people who look different (and sometimes worse) after their procedures. This is a function of overdoing the operation which can definitely cause a change in the orbital and eye area. Too much skin removed or blepharoplasties combined with an aggressive browlift can make for an overdone or unnatural look. This is a result of how the procedures were performed, not just because they were performed. While everyone wants the best result and wants it to last a long time, no one wants to look unusual along the way.

Despite the really significant improvements that eyelid surgery can make, the results are not permanent. And as stated before, trying to make them last forever will only result in an undesired outcome. Like all anti-aging facial surgery, the operation treats the symptoms and not the underlying problem. Expect blepharoplasty results to last five to seven years, and sometimes longer. But  a tuck-up years later will eventually be needed to maintain that refreshed look.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

With aging, some people develop not only loose skin on the lower eyelids but ‘bags’ as well. These lower eyelid bags are well recognized and are often referred to as puffiness, bulges or festoons as well. Most do not realize that these lower eyelid bags are not just swollen tissue but is a ballooning out of fat from underneath the eye.

Anatomically, our eyeball is surrounded by cushions of fat so that it can be pushed around without breaking. This fat is held in place inside the eye socket by certain types of tissue that keep in back behind the rims of the eye socket. On the lower eyelid, a wall or partition between the lashline and the lower edge of the eye socket keeps fat back under the eye. With age, this tissue or ligament gets weak and the fat moves forward and bulges out. Simplistically, this represents a hernia of the lower eyelid. The bulge or bags you see on the lower eyelid is usually herniated fat.

The traditional lower blepharoplasty or eyelid tuck deals with this protruding fat as part of the operation. Removing or cutting it out is a mainstay of this eyelid rejuvenation procedure. This is a good approach for many patients but not for all. Removing too much fat or taking fat in someone with a tendency towards a more skeletonized face can create a sunken in look later, which is not ideally helpful in making a more youthful and attractive appearance.

Recent trends in lower blepharoplasty has been towards saving, rather than removing, this protruding fat. This does make sense in that, at one time, one did look youthful with this same fat. Repositioning it back into the eye where it came from seems logical. The fat can be put back by doing a ‘hernia repair’. Push the fat back and secure it by sewing the herniated membrane down to the edge of the eye socket, recreating an effective retaining wall again.

Having performed both approaches to the lower eyelid bag repair, I find both of them effective. Sometimes the quality of the lower eyelid membrane is not very good, so I will simply do removal of the protruding fat. But when it is good, I prefer the hernia repair approach as it always seems better to preserve tissue as one ages.

An unanswered question about lower eyelid hernia repair is how it holds up long-term. Does the fat end up coming out again years later…or does the hernia repair hold up for a long time? This answer will become clearer in the next decade as many more of these are done and followed.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Aging begins to occur on the face around the eyes first. Often the lower eyelid is affected more than the upper eyelid. It begins initially by the development of some loose eyelid skin and wrinkling in the crow’s feet area. As it progresses, more wrinkles appear and the lower eyelid may begin to bulge as fat herniates outward. This aging progression is subtle in the late 30s and early 40s and becomes much more prominent in the late 40s and early 50s.

A lower eyelid tuck or blepharoplasty is a common plastic surgery procedure to improve the appearance of the aging lower eyelid. In its fullest extent, the skin and muscle are lifted up and trimmed and bulging fat is removed. However, the lower blepharoplasty operation can be tailored to the extent of the lower eyelid aging. Early onset eyelid aging does not usually require the full blepharoplasty operation.

Limited lower blepharoplasty procedures are ideal for younger patients. In such ‘mini’ lower eyelid surgery, several millimeters of lower eyelid skin are pinched up with a special instrument rather than making an extended incision and dissection under the eyelid skin down to the orbital rim bone. The pinched up skin is simply trimmed off and the blood supply to the remaining lower eyelid skin is unaffected. This then allows a moderate depth chemical peel to be done using either a 25% or 35% TCA (trichloroacetic acid) solution. The combination of some skin removal and skin tightening helps fresh up the lower eyelid and reduce wrinkling. Because it is a more limited lower eyelid procedure, recovery (looking good with no telltale signs of having had surgery) is usually complete in one week.

When herniated fat is also present, this can be removed by an incision on the inside of the lower eyelid (transconjunctival) This also does not disrupt the blood supply to the eyelid skin so a chemical peel can still be done.

This pinch and peel lower eyelid technique can be done in several variations as well. How much skin is pinched up, whether fat is removed, and the strength of the chemical peel solution are all variables that can be altered and mixed and matched. In the office, pinches of lower eyelid skin and chemical peels can be done under local anesthesia. When fat removal is needed, this then requires a trip to the operating room with an anesthetic.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The development of bags under one’s eyes is a common aging problem. While some younger people have it naturally, most acquire them as a result of time and with increasing age. They are a cosmetic concern for many and certainly helps create a tired and aging facial appearance. Lower eyelid bags are a frequent reason that brings one into a plastic surgeon’s office.

What is the cause of lower eyelid bags? To understand them, one has to realize that the eyeball inside the bony walls of the orbit is encased in a bed of fat. This permits the eyeball to be moved around by pressure on it without causing it to rupture or burst. This cushioning fat is held back inside the bony rims of the orbit by thin ligaments that run from the lower eyelid to the bone. As we age, this ‘ligament’ weakens and fat comes slowly spilling out. Essentially think of the lower eyelid bag as a hernia of fat. You can prove this by gently closing one eye and pressing on the eyeball. Notice that the lower eyelid bag pushes out as you push in.

Understanding this eye anatomy gives you insight into how to fix it. There are several very different surgical approaches . You can remove part of the fat which is sticking out through standard lower eyelid surgery. (blepharoplasty) This is a tried and true method that has been done for decades. More recent approaches include a ligament repair and fat transposition. In the ligament suture method, like a hernia repair, the fat is stuffed back in and the ligament is tightened and sutured to keep it from coming out again. In the fat transposition technique, the exact opposite is done. The protruding fat is teased out and brought over the bone, filling out the area underneath the bag. All three methods hope to achieve a smooth lower eyelid. All methods involve a lower eyelid incision (right below the lashes) with removal of excess skin as well.

In a younger patient without excess skin, the fat bags are generally removed through inside the lower eyelid but the hernia repair and fat transposition methods cannot be done due to the limited space.
Which one of these lower eyelid bag surgeries should one have? The choice depends on the shape of one’s eye, the underlying bone, and how much excess fat and skin one has. In an eye that has bags but with a deep tear trough underneath, the fat transposition method may be better. It helps fill out the tear trough and avoids a sunken eye appearance years later by preserving tissue. The hernia repair method can be used on any protruding lower eyelid bag and debate remains as to whether it is better to put it back or remove it. In the patient with a thin face and deep-set eyes, it is better to keep all of the fat and put it back in.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

As we age, most people will develop lower eyelid prominences otherwise known as lower eyelid bags. Ini addition to the excess skin thaty develops, a big part of these bags is caused by fat coming out from underneath the eye. In plastic surgery, we call this ‘herniated orbital fat’ which has alway been believed to be caused by the weakening of the tissue that runs between the eyelid and the underlying rim of orbital bone. (known as the orbital septum) Much like a hernia, this support tissue becomes weak and allows some of the fat which wraps around the eyeball to come protruding out. As a result, lower eyelid surgery (lower blepharoplasty) has traditionally involved removing this overhanging fat as well as the extra skin to make this area look better and smoother.

A recent study published in the September 2008 issue of the journal, Plastic and Reconstructive Surgery, looked at the progressive development of these lower eyelid fat prominences to try and explain why we see with age. Their objective was to evalute more closely the long-held belief of a fat hernia under the eye. Through MRI studies of forty patients of different ages, measurements were taken of the eye, fat amd surrounding bone. What they found was that the eyeball stayed in the same position throughout life but the amount of fat around the bottom part of the eye actually increased as we age. These measurements suggest that as we age there is actual fat expansion below the eye that accounts for the development of the lower eye bags.

Recent thoughts on aging lower eyelid (blepharoplasy) procedures have leaned toward doing more of a hernia repair rather than relying on traditional excision for management of the lower eyelid bags. These study findings, however, indicate that the removal of lower eyelid fat is still a good thing to do and is an important component of lower eyelid procedures for many aging patients. There is always the concern that removing this fat may make the eye look ‘too hollow’ over time. But this is not something that I have observed nor do I see it reported in the plastic surgery liiterature.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Eyelid (blepharoplasty) and browlift surgery can make a dramatic impact on how well rested you look since eye contact is a big part of every social conversation. It can also relieve the weight of excess upper eyelid skin and get rid of bags on the lower eyes. Any surgery around the eye will cause a fair amount of bruising and swelling after which, although it is fairly painless, certainly looks bad and is socially obvious for a awhile. Here is list of instructions that I provide to my patients after blepharoplasty and browlift plastic surgery.

 
1. Expect considerable swelling and bruising of the eyes, which usually is most severe by the second postoperative day. Most of the swelling and bruising will be gone by 2 weeks after surgery. Keeping your head elevated, on 2 to 3 pillows or sitting/ sleeping in a recliner, will help limit how much swelling will occur.

 
2. Keeping cold compresses on the eyes for the first 24 hours is also very helpful in in keeping down swelling. This can be done with ice cubes or frozen vegetables in a ziplock bag, changing them every 30 minutes or so as they become lukewarm. Continuing these cold compresses for 48 hours, if possible, is even better.

 
3. For eyelid suture lines, antibiotic ointment will be provided to you to apply twice a day. Apply enough to keep them lightly lubricated. The antibiotic ointment is an ophthalmic preparation, so it is safe if it gets in your eyes. (which it almost always does) Also, apply in eyes at bedtime for the first 2 to 3 days after surgery if they feel dry.

 
4. In browlifts, the incisions are in the scalp or at the hairline and there is no need to apply antibiotic ointment to them. This only makes the hair greasy and is difficult to get out.

 
5. In browlifts, there will be a circumferential head dressing to put pressure on the forehead. This may be removed the first morning after surgery.

 
6. Eyelid sutures will be removed 1 week after surgery. In browlifts, the scalp sutures will be removed 10 to 14 days after the procedure.

 
7. In eyelid surgery, you may resume the wearing of contacts 1 week after surgery.

 
8. In browlift surgery, one may wash their hair 48 hours after surgery.

 
9. The use of eye makeup (eyeliner, eyeshadow) should not be used for 2 weeks after surgery. Cover-up or concealer may be used on bruised areas after sutures are removed.

 
10. Exercise and strenuous physical activities should not be done for at least 3 weeks after surgery. Bending over (head below one’s waist) should be particularly avoided within the first week after surgery.

While the anatomy of the upper and lower eyelids is nearly identical, and the aging process which they undergo obviously similar, freshening up the eyelids is different whether you are north or south. Compared to the lower eyelid, the upper eyelid offers a ‘simpler’ procedure that, quite frankly, has fewer risks or complications.

 
In the lower eyelid, because it is suspended like a clothesline from one side of the eyebone to the other, too much skin removal or aggressive surgical handling, may make it pull down after surgery as it heals. This condition, known as ectropion, can cause a lot of eye irritation and tearing as the eyeball really wants the eyelid tucked up close against it. (this keeps it lubricated and allows the eyeball to be washed clean, so to speak, with each blink that we do) Even an infinitely small gap between the eyeball and the eyelid can cause this problem. In older patients, where the ‘clothesline’ is not as strong as in youth, the risk of ectropion is significant and some tightening of the tendon that attachs the eyelid to the bone is often done at the same time to prevent this potential complication.

 
The upper eyelid does not pose the same potential problems as the lower eyelid. There is no risk of the eyelid pulling away from the eyeball with skin removal and, as a result, much more skin can be taken. By comparison, it is usually possible to take three or four times as much skin from the upper eyelid as the lower eyelid. Difficulty with eyelid closure from too much skin removal on the upper eyelid, while possible, is rare. Since the movement of the upper eyelid is primarily responsible for most of eyelid closure (the lower eyelid is pretty passive), its continuous downward movement can also stretch out the eyelid fairly quickly should a tad too much skin be removed. The lower eyelid has no such capability.

 
The intricacies of upper eyelid surgery is all in the placement and design of the incisions and the cutout pattern of skin and muscle. Incisions on the upper eyelid which are placed too low may be visible, incisions placed too high may create an unnatural appearance after surgery. And, of equal importance, incision placements must be identical on both eyelids to make a good matched set.
As an Indianapolis blepharoplasty surgeon, I have learned that an upper blepharoplasty is that it is tremendously effective, fairly simple to undergo, and has few complications. But the real bonus is that it is virtually painless! Yes there will be some mild swelling and bruising, but with a week or two, you will have a result that will last for many years.

Dr, Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis