Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘blepharoplasty’ Category

Tear Trough Fat Grafting During Lower Blepharoplasty

Saturday, June 10th, 2017


Lower eyelid aging creates a number of well known aesthetic deformities. From excessive skin, herniated orbital fat, malar-palpebral grooves to tear troughs, the anatomic changes to the lower eyelid have been well chronicled. Tear troughs and the correction of this nasojugal groove have been treated by both injected fillers and fat as well as different surgical blepharoplasty techniques.

The surgical correction of the tear trough deformity has included orbital fat transposition, release of the orbitomalar ligament and tear trough implants….or some combination of them. While these can be done using an external skin or an internal conjunctival approach, the most consistently effective is the external approach or the skin-muscle flap technique. Its enhanced visibility allows for the redistribution/rearrangement of local tissues to a reproducible autologous rejuvenation effect.

In the June 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘Micro Free Orbital Fat Grafts to the Tear Trough Deformity during Lower Blepharoplasty’. In this paper the authors report their results of 32 lower blepharoplasty patients who had their tear trough deformities treated by the addition of micro free fat grafts with an average followup of one year. In their technique they minced any removed orbital fat pockets into small 2mm to 3mm grafts. (micro free fat grafts) These are then placed into a space created by the release of the orbitomalar ligament. Their results showed consistent good improvement of the tear trough deformity. No patients developed infection or lid deformities. One reoperation due to sclera show was needed (3%) while temporary conjunctival swelling occurred in just over 10%.

Traditional lower blepharoplasty techniques in the face of tear trough can often leave them looking worse by exacerbating the appearance of the preoperative hollows or dark circles. The concept of not merely discarding herniated orbital and reusing it either through pedicled flap transposition or free fat grafts is a logical one. What is appealing about free fat grafts is that they are more versatile than a peddled flap. They can be placed more consistently, in greater volumes and with more precise placement. Such solid small fat grafts have been known to survive for as long as thirty years ago with reports of the use of ‘pearl fat grafts’ in the face.

Free fat grafting of the tear trough during lower blepharoplasty can be done with fat harvested from anywhere not just the use of orbital fat. Small grafts taken from the buccal fat pad is a good example of a regional fat donor source. Whether its survival is as good as orbital fat can not be determined but there is no reason go think that it would be less.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Z-Plasty Medial Epicanthoplasty

Monday, May 22nd, 2017


The shape of the eyes is affected by many anatomic structures. While much focus is on the larger eyelids, the inner corner of the eyes has a significant impact on eye appearance. While they may the small the inner and outer corner of the eyes affects eye width as well as the angulation of the eyelids.

The epicanthal fold or epicanthus refers to a visible skin fold that covers the inner corner of the eye. While everyone has some degree of an inner eye skin fold, the prominent epicanthal fold is most commonly associated with the Asian eye. (although many other ethnicities have it as well) They can also occur in Down’s syndrome as well as fetal alcohol and Turner’s syndrome. The height of the bridge of the nose is also a factor in its occurrence. Low nasal bridges have a high association with the epicanthal fold while high nasal bridges do not, presumably due to the stretch of the skin between the eye and the nose.

The epicanthoplasty is a procedure done to change the shape of the epicanthal fold. While it is most commonly associated with double eyeliod surgery, it can also be done as an isolated procedure in patients with a distinct upper eyelid fold. In these patients the most common technique is a z-plasty. This eliminates the downslanting fold as well as creates a horizontal orientation of the inner eye.

The inner eye z-plasty is carefully marked with its long axis along the fold and the back cuts at 45 to 60 degrees. The limbs must be marked so the switch of the skin flaps creates the change of the fold. Once cut the skin flaps need to be released of any fibrous attachments to the medial canthal tendon. Small dissolvable sutures are used for the skin closure.

The medial epicanthoplasty has a role to play in the non-Asian eye. It can effectively change the inner eye corner from a down slanting to a horizontal orientation.

Dr. Barry Eppley

Indianapolis, Indiana

Upper Eyelid Corrugator Muscle Resection

Sunday, April 30th, 2017


The frowning expression creates the well known ‘11s’or vertical wrinkles of the forehead. This is caused by the corrugator muscles drawing the eyebrows down and inward. It is partially a protective function for the eye from the glare of the sun and bright lights but also commonly appears when one is concentrating as well as ‘suffering’. Botox is a most common and highly aesthetic effective treatment for glabellar frown lines. The injections are targeted towards the corrugator supercilii, procerus and depressor supercilii muscles.

The corrugator supercilii are small paired muscles with a pyramidal shape which are located along inner edge of the brow bones at the nose. They are located beneath the overlying orbicularis oculii and frontalis muscle but do send fibers that pass through them to attach to the underside of the skin. An understanding of this anatomy has lead to their surgical treatment through a direct or upper eyelid incision for their resection leading to elevation of the medial brow and reduction of glabellar frown lines. This direct muscle resection approach also come in useful in the surgical treatment of frontal migraines.

In the February 2017 issue of Aesthetic Plastic Surgery, a paper was published entitled ‘Transpalpebral Corrugator Resection: 25-Year Experience, Refinements and Additional Indications’. In this paper the senior author discusses his experience and expanded techniques from the transpalpebral corrugated muscle resection technique that he introduced in the early 1990s. He lists the modifications of his eyelid approach as follows: 1) a thin layer of depressor supercilii muscle is removed to expose the corrugator supercilii muscle, 2) a medial branch of the supraorbital nerve is used to trace a path through the muscle down to the periosteum, 3) a portion of the muscle lateral to the nerve is removed, 4) a superior segment of the muscle is removed by electrocautery, 5) a lateral  segment of the procerus muscle is also removed, 6) for migraine surgery the supratrochlear and supraorbital arteries are cauterized as well as a foraminotomy if the nerve is fully encased by bone, and 7) fat injections are done to restore lost volume from the tissue resections.

The small size of the corrugator supercilii muscle and the limited access of the upper eyelid incision mandate a precise surgical technique for its resection if it is to be effective. Such refinements in the technique has described by this paper have led to improved results and addtionalk indications for its use.

Dr. Barry Eppley

Indianapolis, Indiana

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

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.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits