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Archive for the ‘blepharoplasty’ Category

Case Study – Wider Eye Blepharoplasty

Tuesday, March 28th, 2017


Background: The desire for wider or more open eyes to improve one’s expression is not uncommon. Most of the people who seek such eye surgery have an abnormal eye appearance known as ptosis. This is where the upper eyelid hangs down lower than normal and covers up some of the iris or the colored part of the eye. The position often gets lower later on in the day as the eyelid muscles get more tired. Technically the upper eyelid margin should fall no lower on the iris than about 1mm. Anything lower gives the eye a tired or sleepy appearance.

Surgical repair of eyelid ptosis is well known and the exact surgical treatment depends on how much ptosis exists and its cause. Surgical techniques include levator resection, muller muscle resection and a frontalis sling procedure.

But a few select patients do not have true eyelid ptosis or it is very minor but still want a more open eye appearance. This raises the question of whether a ptosis like upper eyelid procedure can be performed on a normal eyelid without ptosis. Technically the procedure is the same even if the eyelid has a normal position. The more relevant question is whether by raising up a normal upper eyelid margin if this will have any negative effect on lid competency and adequate globe lubrication. (incomplete lid closure can create eye dryness)

Case Study: This 21 year-old female felt her eyes were not open enough. She felt her upper eyelids were too low and wanted them more wide open. She did have about 2mms of ptosis and a long upper eyelid vertical skin distance.

Under general anesthesia she had an ptosis repair blepharoplasty procedure done through an upper eyelid skin crease. Five levator-tarsal sutures were placed to raise the upper eyelid margin. Under general anesthesia this was more challenging as no dynamic eyelid motion could be done.

Wider Eye Blepharoplasties result Dr Barry Eppley IndianapolisHer after surgery results showed better elevation of the central part of her upper eyelid with increased iris exposure. She had no eye dryness issues.

Creating more wide open eyes usually involves the treatment of ptosis whether the patient recognizes they have this eyelid condition or not. As long as the upper eyelid margin does not create a scleral gap as a result of the ptosis repair there is no risk of eye dryness or creating an unusual eye appearance. (startled) Wider eye surgery involves increasing the vertical distance between the eyelids and is a form of ptosis repair to do so.


  1. Ptosis repair is generally reserved for use in patients that have actual upper eyelid ptosis.
  2. A wider open eye in the vertical dimension can be created using a ptosis repair blepharoplasty technique. (levator-tarsal suture fixation)
  3. The upper lid margin should sit no higher than the top of the iris.

Dr. Barry Eppley

Indianapolis, Indiana

Aesthetic Vertical Orbital Dystopia Correction Strategies

Saturday, January 21st, 2017


orbital dystopia_edited-2Vertical orbital dystopia is a frequent feature of many facial asymmetry patients. When facial asymmetry affects the midface region most of the time some form of globe dystopia will be present. It is perceived most easily by the difference in the horizontal level of the pupils.

Orbital dystopia is always most clearly seen in pictures as the eyes look ‘off’. This is where patients will notice it the most as well as when looking directly in the mirror. (or in selfies)  There will be one good eye and the affected eye will usually be sitting lower. It is rare that the affected eye is the higher one. For unknown reasons in my experience vertical orbital dystopia occurs much more frequently in the right eye.

The most important step when the eyes appear at different levels is to make the proper diagnosis. This will require a 3D CT scan of the entire face and not just the orbits. Aesthetic (non-craniofacial) orbital dystopia usually has other facial asymmetries as well particularly of the superior brow bone and the inferior cheeks. The entire orbital skeletal box is lower. As a result, the eyebrow and brow bone will also be lower, the upper eyelid may have some mild ptosis and the cheek will be flatter and asymmetric.

Hydroxyapatite Cement Orbital Floor Reconstruction Dr Barry Eppley IndianapolisMild cases (2 to 5mms) of vertical orbital dystopia can be treated by numerous extracranial techniques. Augmentation of the anterior orbital floor (and in some cases the inferior orbital rim), a brow lift and cheek augmentation are the three main skeletal techniques. While numerous implant materials can be used for the orbital bone, including autologous bone grafts, I find the use of hydroxyapatite cement (HA cement) to be very effective. It is easy to apply and shape to the orbital floor and up over the inferior orbital rim if needed.

Orbital Floor Lowering Dr Barry Eppley IndianapolisIn uncommon cases an adjunctive strategy can be to lower the opposite eye as well. If the affected eye can not be adequately raise due to the amount of horizontal pupillary disccrepancy (4mms or greater) the opposite eye can be slightly lowered. This is done by removing part of the bone on the anterior orbital floor. Short of a full orbital decompression, the goal is to achieve a 1 to 2mm lowering of the globe. This dual approach raises the lower eye and very slightly lowers the opposite eye.

In the correction of vertical orbital dystopia, it is also important to be aware of what may happen to the upper eyelid-globe relationship. In most cases of congenital orbital dystopia the upper eyelid follows the eye to maintain a normal appearing upper eyelid to globe relationship. But as the lower eye is surgically lifted, the eye can be come more buried under the upper eyelid. Ptosis repair may be needed to get the eyelid back up higher on the iris.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Asian Double Eyelid Surgery

Sunday, January 8th, 2017


Background:  The double eyelid surgery is a well known blepharoplasty technique that creates an upper eyelid crease in the typical Asian monolid. While the supratarsal fold is present in many ethnic groups around the world, it is missing in many Asian patients. The operation per we does not really create two upper eyelids or removes a single eyelid per se. But the placement of a crease creates two discernible upper eyelid sections which make it appear more interesting and even energetic.

While often called ‘westernizing’ the eyelid, this is not really the objective of the surgery nor is what most Asian patients want. Rather it makes the eye area more interesting than a monolid and is also a cultural sign of beauty. This accounts for its tremendous popularity in eastern Asian culture particularly amongst younger people.

There are a lot of variations in the Asian upper eyelid. It is common to see patients who have a hint or partial upper eyelid fold. Having some fold dictates where the new fold will be in most cases. Setting the new fold position can widely vary from its location above the lashline to its shape across the upper eyelid. There are numerous different techniques for creating the fold from no to a full incisional approach…each with their surgeon advocates.

Case Study: This 21 year-old female wanted double eyelid surgery to enhance her appearance. Her right eyelid was a monolid while the left eyelid had an incomplete crease, most promienently seen in the outer half of the lid.

asian-double-eyelid-surgery-intraop-dr-barry-eppley-indianapolisUnder general anesthesia, she had a full incisional double eyelid procedure using 5 points of levator-tarsal-dermal fixation for each eyelid. The crease height used was based on the of her incomplete crease level of the left upper eyelid. She declined medial epicanthoplasties. The immediate intra- and postoperative appearance can be striking with what appears to be creases that are too high.

asian-double-eyelid-surgery-results-front-view-dr-barry-eppley-indianapolisHer six months after surgery results show a pleasing upper eyelid appearance with defined creases and good symmetry between them.


1) Double eyelid surgery is an Asian eyelid procedure to make the upper eyelid more defined. (monolid to two distinct sections of the upper eyelid)

2) Many double eyelid procedures include treatment of the epicanthal fold as well. (medial epicanthoplasty)

3) Recovery from double eyelid surgery takes 3 to 4 weeks to see the final result

Dr. Barry Eppley

Indianapolis, Indiana

Double Eyelid Surgery with Epicanthoplasty

Tuesday, May 24th, 2016


Double Eyelid Surgery Dr Barry Eppley IndianapolisIn Asian blepharoplasty, more commonly known as double eyelid surgery, the influence of the fold at the inner eye (epicanthus) can affect the aesthetic outcome. As a result many double eyelid surgeries are combined with a medial epicanthoplasty for an improved aesthetic appearance. While the epicanthus is a small structure, there is a large number of operations described for its correction. There does not appear to be a universally agreed upon method for the epicanthoplasty which suggests that all of them have some downside.

Z-Epicanthoplasty Dr Barry Eppley IndianapolisHistorically, some surgeons have avoided epicanthoplasty because of the fear of visible scar formation at the inner eye. But the Z-epicanthoplasty has proven to be a safe and effective technique for eliminating the epicanthal fold during double-eyelid operations without problematic scarring at the medial canthal area. They are numerous small variations of the Z-epicanthoplasty most of which focus on  hiding the scar line in the inner cants area.

In the January 2016 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘A Modified Method Combining Z-Epicanthoplasty and Blepharoplasty to Develop Out-Fold Type Double Eyelids’. In this paper the authors describes his technique for combining double eyelid surgery with a Z-epicanthoplasty in over 1100 women. The goals of the surgery was to create a parallel double eyelid fold with an exposed inner canthus and lacrimal caruncle. The upper eyelid incision is carried out to the new inner canthus location and the skin excised. The muscle fibers that adhere to the inner canthal ligament are severed to release any tension on the epicanthal skin flap. A small z-plasty is then performed on the inner canthal skin flaps. The revision rate was eight patients. (less than 1%)

Double Eyelid Surgery and Lower Eyelid Love Band Surgery Dr Barry Eppley IndianapolisThe Asian upper eyelid has a characteristic single fold with an epicanthus and saggy skin. When an epicanthus is not present, a double eyelid surgery alone can suffice. But with an  epicanthal fold present, double eyelid surgery will create a short and narrow double fold appearance. Thus combining double eyelid surgery with an epcanthoplasty is now common practice. This allows for a smooth connection between the double fold eyelid and the inner canthus. The goal of the Z-epicanthoplasty is to relieve the tension on the medial cantonal area which contributes to the epicanthal fold being present and prevent any adverse scarring in this highly visible area.

Dr. Barry Eppley

Indianapolis, Indiana

Double Eyelid Surgery Recovery

Tuesday, January 19th, 2016


Double eyelid surgery is one of the most common facial surgeries in Asian patients. Changing a monolid to one that has two distinct eye areas by making a distinct crease creates a more appealing eyelid shape. It is not done with the attempt to make a Western eye appearance but to give the Eastern eyelid a better and more defined shape.

There are many techniques in double eyelid surgery so it can be confusing to patients. But they fundamentally can be divided into non-incisional (suture only), limited incisional (three to five small incisions) or a full incisional approach. Each double eyelid surgery has its advantages and advocates. But it is generally agreed that the incisional technique is the most reliable method of achieving a consistent and permanent eyelid crease.

Double Eyelid Surgery swelling Dr Barry Eppley IndianapolisPatents who consider undergoing double eyelid surgery can expect some temporary swelling and bruising after surgery. That is particularly with the complete incisional method technique. Since the eyes are such a focal point of human interaction, prospective patients can anticipate that it will take several weeks for most of the swelling and bruising to resolve and they can look non-surgical in appearance. This is an example of a young female who is one week after double eyelid surgery with epicanthoplasties. She will look normal in a few more weeks.

Patients for double eyelid surgery should anticipate that it will take nearly a full month after surgery to have a full recovery. And six weeks until  the eyelids relax and look natural. While the full incisional technique takes longer to recover, its more consistent and defined upper eyelid creases make it worthwhile in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Eyelid Surgery for Indistinct Creases

Saturday, January 2nd, 2016


Background: Double eyelid surgery is one of the most common Asian facial surgeries. Many Asian upper eyelids do not have an upper eyelid crease and can be seen as a single or monolid. (single eyelid) This specific Asian blepharoplasty procedure is to create an upper eyelid crease that is very distinct, hence making visibly apparent upper and lower eyelid regions. (double eyelid)

Asian monolidWhile some Asian upper eyelids have a double eyelid, many do not or have an incomplete upper eyelid crease. Some have just a faint line for a crease that is barely discernible while others only have a portion of the eyelid crease present. (size of the double eyelid) Besides the variability of the presence or depth of the upper eyelid crease, there is great variability in exactly where it is located. The vertical position of the upper eyelid fold can be anywhere from a few millimeters to 10mms above the lashline.

The partial presence of an upper eyelid crease takes the guesswork out of where it should be. The trick in completing the partial upper eyelid crease is to not make it too deep or more visible than the portion that is already present.

Case Study: This 19 year-old Korean female wanted to have a more complete upper eyelid crease. She also wanted to get rid of the fold on the inner corner of her eyes. (epicanthal fold)

Under general anesthesia (as she was undergoing multiple other facial procedures), the entire upper eyelid crease was created. This was done by excising 2mms of skin and orbicularis muscle and suturing the eyelid skin edges down to the tarsus and levator muscle. Medial epicanthoplasties were also performed by an L-shaped skin fold technique.

Double Upper Eyelid and Lower Eyelid Love Band Surgery Dr Barry Eppley IndianapolisHer postoperative results at 6 months showed a more visible and complete upper eyelid crease. No portion of the upper eyelid crease was more apparent or deeper than the others. Her epicanthal folds were also partially removed.


  1. Double eyelid surgery strives to make a discernble upper eyelid crease that breaks up the upper Asian eyelid into two distinct areas.
  2. Double eyelid surgery creates an attachment of the dermis of the skin down to the levator muscle.

3. Double eyelid surgery can help create a more distinct incomplete upper eyelid crease.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Lower Eyelid Ectropion Repair

Wednesday, October 28th, 2015


Background: The lower eyelid is uniquely different from that of the upper eyelid. Besides being on the lower half of the eyeball, it has much less movement than that of the upper eyelid. The lower eyelid is largely static and is best thought of as a ‘clothesline’ running across the lower half of the eye. Being attached by the canthal tendons to the inside of the eye socket bones on each side, the lower eyelid is held tightly against the eyeball. By being right up against the eyeball, it serves to help keep the eye lubricated and provides a pathway for tear drainage.

Any surgery that involves the lower eyelid always runs the risk of disrupting its intimate and important relationship to the eyeball. While there are different eyelid incisional approaches, all have the potential to cause scarring and retraction pulling the eyelid down and away from the eyeball. (known as ectropion) Besides the obvious adverse aesthetic effects, loss of lid-eyeball contact leads to irritation, dryness and excessive tearing.

Reconstruction of lower eyelid ectropion can be challenging. It is almost never as simple as just ‘releasing the lower eyelid and pulling it back into place’. The lower eyelid layers are scarred and may be now short of supple tissue. Tissue grafting may be needed to overcome the scarred tissues and to prevent the pull down of the lower eyelid from recurring.

Case Study: This 40 year old female had a prior history of a left cheekbone fracture that was repaired by another surgeon. Six months after her repair the original surgeon removed her plates and screws used to fix the fracture and attempted to fix a lower eyelid ectropion. The eyelid ectropion repair was unsuccessful and actually became worse.

Left Lower Eyelid Reconstruction result front view Dr Barry Eppley IndianapolisLeft Lower Eyelid Reconstruction result submental view Dr Barry Eppley IndianapolisUnder general anesthesia a tranconjunctival and lateral canthal incisional approach was used. The lower eyelid tissues were released of all scar from the infraorbital rim. This created and internal conjunctival lining defect which was grafted with buccal mucosa. A lateral canthoplasty was performed using a double hole technique through the lateral orbital rim. Adjunctive procedures including fat injections to the cheek were also done to built up the tissues below the eyelid for typical fat atrophy that occurs after trauma.

Left Lower Eyelid Reconstruction result side view Dr Barry Eppley IndianapolisHer 6 months results that she achieved restoration of a competent lower eyelid that relieved all of her eye symptoms. The result is far from perfect as her lateral eyelid aperture ended up being slightly horizontally shorter than the opposite side.


1) Lower eyelid retraction can occur from a variety of surgical endeavors including cosmetic blepharoplasties and orbital and cheek bone fracture repairs.

2) Severe retraction with vertical shortening of the lower eyelid indicates a loss of eyelid lining os one or several lamellar layers.

3) Severe lower eyelid ectropion repair usually requires multiple surgeries with tissue grafting to achieve an improved horizontal lower lid position and good adaptation back against the eyeball.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Double Hole Lateral Canthoplasty for Ectropion Repair

Saturday, October 3rd, 2015


Background: The position of the lower eyelid against the eyeball (globe) is of critical importance. To maintain good lubrication of the globe and to prevent the eye from drying out, the lower eyelid must be tight up against it. Like a clothesline spanning between two poles, the lower eyelid must have no slack in it and be relatively taut. Unlike the upper eyelid which opens and closes, the lower eyelid is fairly still.

The position of the lower eyelid is well known to be adversely affected by surgery due to the creation of scar and loss of lateral support. This can create a downward pulling of the lower eyelid known as ectropion. Lower eyelid ectropion deformities cause a downward and outward roll of the eyelid making it lose contact with the eyeball. When this happens the eye develops dryness ad irrigation due to exposure. Also the natural gutter effect of the eyelid position is ‘reversed’ and tears may run out the side of the eye as opposed to being directed towards the inner lacrimal drain. (punctum)

lateral canthoplastyCorrection of lower eyelid ectropion can be challenging and a variety of techniques exist to do it. All are based on using the lateral canthal tendon, or some remnant of it, to create outer support to the eyelid by attaching/resuspending it to the lateral orbital bony rim. Techniques differ based on whether it is attached to the inner or outer aspect of the lateral orbital rim. Accompanying techniques with the lateral canthoplasty are also often used including cheek lifts and in more extreme cases even skin and mucosal grafting.

Case Study: This 50 year old female developed ectropion of the right eye from prior lower blepharoplasty and other procedures. She has persistent dryness and itchiness of the eye and chronic tearing. She had failed two prior lower eyelid resuspension/elevation procedures.

Under general anesthesia she had a double hole lateral canthoplasty procedure. Above the desired point where the outer corner of the eye was desired to be, two transosseous burr holes were placed. A suture was passed from the outside in, attached to the lateral canthal tendon and then brought back out the other bone hole. The suture was then tied down pulling the outer corner of the eye upward and inside the lateral orbital rim.. Resuspension of the orbicularis muscle was done to complete her ectropion repair.

Lower Eyelid Ectropion Repair front view Dr Barry Eppley IndianapolisLower Ectropion Repair oblique view Dr Barry Eppley IndianapolisLower Eyelid Ectropion Repair side view Dr Barry Eppley IndianapolisAt six months after surgery, her ectropion remained repaired with complete resolution of all of her eye symptoms.

The double hole lateral canthoplasty procedure is as very effective procedure that solves the attachment problem. Besides a point of fixation one of its other best attributes is that it brings the attachment of the tendon inside the lateral orbital rim where it naturally is located. In moderate to severe ectropion this is my go to technique.


1) Lower eyelid retraction due to scar contracture is known as ectropion.

2) Manipulation of the lateral canthal tendon is a key element in lower eyelid ectropion repair.

3) Using bone holes place in the lateral orbital rim, a place of firm fixation for lateral canthal tendon repositioning is assured.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Upper Eyelid Lifts under Local Anesthesia

Tuesday, August 25th, 2015


Background: Upper blepharoplasty surgery, more commonly known as an eyelid lift, is the most common cosmetic eyelid surgery. It is tremendously effective and is associated with a very low risk of complications. While eyelid tissue is very thin and swells significantly after surgical manipulation, the recovery is fairly quick. The results of blepharoplasty surgery is sustained for years although its results are not permanent.

Blepharoplasty surgery is commonly done as part of other aesthetic facial surgeries such as facelifts and browlifts. As a result the swelling and bruising is seen as significant in the context of the overall face and the recovery is comparatively prolonged. But this composite facial rejuvenative surgery belies the otherwise relative ‘simplicity’ of the upper blepharoplasty procedure.

The upper blepharoplasty procedure relies on skin and some orbicularis muscle removal to create its effect. There is a debate as to whether any muscle should be removed along with the skin removal and its effect is primarily believed to help redefine the upper eyelid crease. Proper marking and not excessive tissue removal are the keys to an uncomplicated and satisfactory upper eyelid lift.

Because the upper eyelid is a small structure with thin tissues it can be fairly easily anesthetized by local anesthesia injections. Since the surgery can be done with the surgeon standing above or to the side of the patient and with the upper eyelid closed, the surgery can be performed out of the patient’s field of vision. This further promotes patient comfort.

Case Study: This 42 year old female felt her upper eyes were getting tired and heavy. She felt she had developed some hooding of skin that no amount of eyelid creams or Botox injections around the eyelids could solve.

Upper Blepharoplasty (Eyelid Lifts) under Local Anesthesia Dr Barry Eppley IndianapolisUnder local anesthesia injections into the upper eyelids, a tapering 7mm crescent of skin and muscle was removed along presurgical markings made with a caliper. The tissue segments were removed by scissors which minimized any bleeding. Small dissolveable sutures were used to close.

Upper Blepharoplasty (Eyelid Lifts) under Local Anesthesia oblique view Dr Barry Eppley IndianapolisUpper Blepharoplasty (Eyelid Lifts) under Local Anesthesia side view Dr Barry Eppley IndianapolisWithin one week after surgery she looked essentially no-surgical and had no bruising. Most of her upper eyelid swelling was gone by ten days after surgery. She described the experience as relatively painless and had no discomfort during the procedure and even afterwards.

An isolated upper blepharoplasty can be comfortably and safely performed under local anesthesia in the office. Its effects are immediate and the recovery is very short. Such an office procedure provides the most economic approach to having an upper eyelid lift done.


1) The upper blepharoplasties (eyelid lift) improves upper eyelid shape by removing hooding and redefining the upper eyelid crease.

2) An isolated upper blepharoplasty can be safely and comfortably performed under local anesthesia as an office procedure.

3) An upper blepharoplasty has a quick recovery with only moderate swelling and bruising.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Asian Love Band Surgery

Sunday, August 2nd, 2015


The Asian eyelid is very different from that of Caucasians both in anatomy and in aesthetic appearance. For the upper eyelid the ‘double eyelid’ blepharoplasty procedure is well known to create a crease which does not naturally exist. But for the lower eyelid aesthetic enhancements are less well known or requested.

Asian love band surgery indianapolisOne newer lower blepharoplasty aesthetic enhancement procedure is that known as Asian Love Band surgery. In this procedure a fullness is added to the lower eyelid just below the lashes. This is intended to enhance the underlying orbicularis muscle which in youth is fuller and more developed. (orbicularis roll) With aging the orbicularis muscle stretched and thins losing its fullness. To illustrate cultural differences in facial aesthetics,   an orbicularis roll in Caucasians would be considered undesireable and often requested to be removed. The Love Band operation is also perceived to make the eye look larger and more open, an optical illusion created by dividing the lower eyelid into two visible parts which is similar to what  “double eyelid” surgery does for the upper eyelids.

The Love Band lower eyelid surgery is done by placing small strips of grafts or implants under the skin through two small incisions at the inner and outer edges of the lid just below the lash line. Traditional materials used include allogeneic dermis (Alloderm) or Gore-Tex. The procedure can also be done non-surgically (albeit temporarily) by using hyaluronic-based injectable fillers.

Lower Eyelid Love Bands Surgical Technique 1 Dr Barry Eppley IndianapolisLower Eyelid Love Bands Surgical Technique 2 Dr Barry Eppley IndianapolisLower Eyelid Love Bands Surgical Technique 3 Dr Barry Eppley IndianapolisThe surgical technique that I have developed for Asian Love Band surgery uses temporalis fascia. This is a natural material that is harvested from small incisions in the temporal area. (although Alloderm can also be used) A small fat injection cannula is passed from one side of the eyelid to the other. The strips of temporalis fascia have a suture pass through them of which the ends are passed into the length of the cannula. The cannula is then removed leaving the suture on the other side of the eyelid. The suture is then used to pull the fascial graft through the lower eyelid tunnel, trimmed and closed with a tiny dissolveable suture.

The Asian Love Band procedure requires a method to pass a graft or implant right under the lash line through the tiniest of incisions. This cannula passing method provides a simple and effective method to do so.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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