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Archive for the ‘blepharoplasty’ Category

Case Study – Lateral Canthopexies for Changing The Corner Of The Eye

Thursday, March 5th, 2015


Background: The shape of the eye has a significant impact on both facial appearance and expression. Its inner and outer shape is largely created by the overlying eyelids and how they come together and attach to the inside and outside of the orbital bones. The union of the upper and lower eyelids forms the inner and outer corners and this union also creates the aperture or angle between eye corners. The outside corner of the eye is probably the more important half since it controls the horizontal orientation of how eye shape is perceived.

Eye Shape Dr Barry Eppley IndianapolisEye shape most commonly has a neutral axis or a completely horizontal orientation. This means that the inner and outer eye corners are at the same horizontal spot on the orbital rim bones which creates a straight line across the eye when drawn between the two. A downward eye tilt means that the outer corner is lower than the inner corner. Conversely, an upward tilt to eye shape means that the outer corner is higher than the inner.

A horizontal or upward tilt to the outer corner of the eye is seen as most desired. Some women even prefer a more exaggerated or exotic eye cant with the outer corner being much higher than the inner corner. A downward eye tilt, which some people have naturally, is seen as undesired and can also occur from loss of outer corner lid support from any type of lower eyelid surgery.

Case Study: This 22 year-old female wanted to change the outer corner of her eyes slightly to fix their asymmetry and eliminate excessive scleral show. This was her natural eye shape and eyelid position.

Lateral Canthopexy results Dr Barry Eppley IndianapolisBecause she was having numerous other cosmetic procedures, her surgery was done under general anesthesia. Through a 7mm skin incision in the outer skin crease, lateral canthopexies were performed. The outer corners of the eye were sutured up higher on the outer aspect of the lateral orbital rims with small permanent sutures. The skin incisions were closed with very small resorbable sutures. Her six month after surgery pictures show the sustained improvement in her lower eyelid outer corner repositioning.

Lateral Canthiopexy result oblique view Dr Barry Eppley IndianapolisLateral Canthopexy results side view Dr Barry Eppley IndianapolisLateral canthopexies can elevate the outer corner of the eye and can do so without creating a bowstring or tightening effect across the entire lower eyelid. Because it stays on the outside of the bone (rather than inside like a lateral canthoplasty) it does not shorten the horizontal length of the lower eyelid. In addition, it helps to correct prevent rounding of eye shape which is more associated with that of an aging look.

Case Highlights:

1) Improving the upward tilt  of the corners of the eyes can be done by either lateral canthopexy or lateral canthoplasty techniques.

2) Lateral canthopexy vs. canthoplasty have different impacts of eye shape.

3) A lateral canthopexy technique is less likely to round out the eye shape and shorten the horizontal length of the lower eyelid.

Dr. Barry Eppley

Indianapolis, Indiana

Lateral Canthopexy vs Canthoplasty – Implications for Eye Shape

Friday, February 27th, 2015


Changing the outer corner of the eye is done for a lot of different aesthetic and reconstructive purposes. The two main reasons are to help correct a lower lid sag from prior surgery (reconstructive) or to create more of an uplifted corner of the eye to change its appearance. (aesthetic) The procedures used to do so are either a lateral canthopexy or a lateral canthoplasty

Lateral Canthopexy Dr Barry Eppley IndianapolisThe changes that occur between a canthopexy and canthoplasty is often subtle but how they are performed, their indications and the effects that result from their use is very specifically different. Understanding these eye corner manipulations requires an appreciation of eye shape.

The shape of the eye is really determined by how the upper and lower eyelids join at the corner.  This is much more so at the outer corner of the eye than the inner. (at least for Caucasians) A youthful eye is associated with a space between the upper and lower eyelids that is narrow and more drawn out to the side. In some ways it is a tight ‘bowstring’ look provided that the bony anatomy of orbit and cheek is normally developed around it. As one ages the shape of the eye changes as the lower eyelid droops. This creates an eye shape that is now rounder and horizontally shorter. In effect the bowstring effect is weakened.

Lower Blepharoplasty without lateral Canthopexy Dr Barry Eppley IndianapolisThe very frequently performed aesthetic lower blepharoplasty procedure has a high incidence of changing the outer corner of the eye. Careful inspection of many before and after surgery pictures of lower blepharoplasties will show some dropping of the lid margin, even some increased scleral show and an eye that appears slightly rounder. The changes that lie below it can show dramatic improvement with elimination of protruding fat and loose skin but the trade-off in some patients can be a slightly rounder eye and lower lid margin. This phenomenon is well recognized and accounts for today’s trending towards more tissue preservation of the lower lid and the addition of orbicularis muscle suspension support at closing.

Lower Blepharoplasty with lateral Canthopexy Dr Barry Eppley IndianapolisThe role of lateral canthopexy is greatest in lower blepharoplasty surgery for prevention of eye shape change or to restore a rounded corner afterwards. In a cnanthopexy, the point of union of where the upper and lower eyelid meet is changed and fixed to the outer aspect of the lateral orbital rim. in essence the corner is ‘pexed’ outward creating a longer and more narrowed eye shape. This is done with small sutures to the periosteum on the bone.

Conversely, a lateral canthoplasty is more invasive and requires fixing deeper tissues of the lower eyelid (tarsus or muscle) to the inner aspect of the lateral orbital rim. This is usually most effectively done by placing drill holes in the lateral orbital rim where a transosseous suture can be passed to ensure that the new canthal attachment is ‘high and tight’ inside the orbital rim.

While effectively restoring the bowstring effect of the lower eyelid against the eyeball, it does so at the expense of shortening the lower eyelid and giving it a rounder shape. For this reason lateral canthoplasties are primarily used as a reconstructive procedure for significant lower lild retraction. It restores lower lid competence but not necessarily a more youthful looking eye shape.

Dr. Barry Eppley

Indianapolis, Indiana

Cooling Gel Masks After Blepharoplasty (Eyelid) Surgery

Friday, January 30th, 2015


The eyelids are very thin tissues that are well known to swell and bruise easily. Because one’s eyes are so visible, every upper eyelid surgery patient would like their bruising and swelling to go away as soon as possible. For this reason, it is standard practice to do several after surgery strategies including cold compresses, head elevation and the oral intake of Arnica. While no one after surgery strategy is known to be universally effective, it is commonly believed that cooling or cold would be the most important.

Eye Masks for Blepharoplasty Surgery Dr Barry Eppley IndianapolisThe use of eye cooling has led to a wide variety of gel compresses for the eyes for blepharoplasty patients. Most are composed of a gel material that retains cold for a period of time after being removed from the refrigerator or freezer. The historic cooling regime was frozen vegetables (such as peas or corn) but gel pads are lighter and easier to use

In the February 2015 issue of the journal Plastic and Reconstructive Surgery, a paper entitled ‘The Effect of Eyelid Cooling on Pain, Edema, Erythema, and Hematoma after Upper Blepharoplasty: A Randomized, Controlled, Observer-Blinded Evaluation Study’ was published. In 38 consecutive patients who had upper blepharoplasties performed, one side was cooled with an ice pack and the other eyelid was left uncooled. Evaluations were done on the degree of pain, edema, erythema, and occurrence of hematoma one hour, one day, one week, and two months after surgery. Light photography was used one week after surgery to determine the degree of bruising.

The results showed showed no difference in pain between the cooled and uncooled eyelids on the day of surgery. Pain in the cooled eyelids was significantly lower one day after surgery. No differences were seen in swelling, bruising or occurrence of hematoma between the cooled and uncooled eyelids at any time point in the study. The authors conclude that because the majority of patients had no preference for cooling over noncooling, eyelid cooling after upper blepharoplasty is not necessary.

Upper Blepharoplasty Indianapolis Dr Barry EppleyThis study casts doubt on a very long-held and logical treatment after upper blepharoplasty surgery. It just seems so logical that cooling/cold therapy would be beneficial that it is hard to believe that it isn’t. Despite what this study shows I doubt few plastic surgeons will abandon it. Particularly since it is a very low cost treatment that at the least has psychological value for the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: Visual Obstruction Treated By Browlift And Blepharoplasties

Monday, December 8th, 2014


Background: Changes around the eyes are the earliest signs of facial aging. As a result, the ongoing aging effects often creates severe changes around the eyes as one enters their sixties. Besides the excess skin of the upper eyelids and the lower eyelid bags, the eyebrows often sag downward magnifying the hooding effect on the upper eyelids.

Visual Field testing Indianapolis Dr Barry EppleyHooding of upper eyelid skin and brow sagging do have functional effects. By weighing down the upper eyelids there is a loss of a portion of one’s visual fields. A portion or all of the upper visual field may be lost as the position of the upper eyelid acts like a blind over a window. Partial closure of the blind results in loss of one’s ability to see what lies above as one is looking straight forward. This is often confirmed by an historic test known as Goldman’s visual field examination which evaluates the entire range of peripheral vision. But automated perimetry testing today has replaced the traditional Goldman method in many ophthalmology/optometry practices.

To correct these severe eye aging effects and to improve one’s upper peripheral vision, multiple procedures need to be done. With brow sagging, an upper blepharoplasty alone (while helpful) may induce one to remove too much upper eyelid skin and severely shorten the distance between the eyebrow and the lashline. (in essence even pulling the eyebrow down further) A browlift combined with an upper blepharoplasty is needed to not only lift up the low brows but to also reduce the amount of upper eyelid skin that really needs to be removed. Together they create a periorbital effect that is better than a browlift or an upper blepharoplasty alone.

Case Study: This 62 year-old female was bothered by the way her eyes looked and how ‘old’ her appearance. She had such severe hooding that her upper eyelid skin hung below her lashlines. The weight of her upper eyelids, combined with some brow sagging, created a pseudo ptosis look as the level of her upper eyelids enchroached on the iros of the eye.

Visual Field Obstruction Blepharoplasties result front viewVisual Field Obstruction Browlift Blepharoplasties result oblique view Dr Barry Eppley IndianapolisUnder general anesthesia, an initial browlift was performed using a pretrichial incisional approach. An irregular zigzag incision was used along her frontal hairline. A total of 8mms of vertical upper forehead skin was removed for a moderate browlift effect. An upper blepharoplasty was then done using marks done before surgery based on pulling the brows upward. Lastly, lower blepharoplasties were performed with skin and fat removal, orbicularis muscle resuspension and lateral canthopexies.

Visual Field Obstruction Blepharoplasties result side viewHer results at six weeks after surgery showed a significant improvement in the appearance of her eyes but without an overdone look. Her lower eyelids had good contact with the globe and the position of the outer corner of her eyes was maintained. She did have some mild dry eye symptoms during the first month after surgery even though she had no ectropion or eyelid malpositioning problems. This is not rare when upper and lower blepharoplasties are combined with a browlift as this will slow the blink reflex for a period of time after surgery.

Case Highlights:

1) Severe aging around the eyes results in brow sagging and upper eyelid hooding which does impact one’s superior visual fields.

2) Optimal correction of visual field obstruction requires a combined brow lift and upper blepharoplasties.

3) Lower blepharoplasties are often done at the same time to enhance the overall periorbital aesthetic effect but do not provide an improvement in peripheral vision.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Natural Blepharoplasty Results

Saturday, September 13th, 2014


Background: Aging is an inevitable consequence of living and its most recognizable effects are on the face. The first place affected on the face by aging is around and on the eyes. The near constant motion of the eyelids and its thin overlying skin are a set up for wrinkles, loose skin and bags and puffiness caused by extruding fat from under the eye. Given that the eyes more than any other facial feature reveal one’s ‘character’ and are a reported ‘mirror of the soul’,  aging changes of them reflect what most would not want others to see.

Beginning in the late 30s and early 40s, the signs of periorbital (around the eye) aging begins. Botox and other neuromuscular modulator injections do a good job of slowing down this process by decreasing the formation of crow’s feet, but it can not prevent the development of loose skin on the eyelids and the herniation of fat on the lower eyelids. These aging eye effects can be quite variable with some people more genetically prone to developing them sooner and more extensively than others. But inevitably everyone will have more of these eye aging signs than they want.

Eyelid (blepharoplasty) surgery is well known and has been around for almost a century in various forms and techniques. Most patient’s biggest fear about blepharoplasty surgery is that they will look like a different person or will look unusual or very obvious that they have had plastic surgery. They can even point to numerous celebrity examples who show exactly what they fear. How is such a result avoided? Will everyone look like they have had surgery? After all, the eyes are seen by everyone and won’t all changes be seen?

Case Study: This 58 year-old female was tired of her tired looking eyes. She wanted to look less fatigued but was afraid that she might look ‘surgical’. She had a large amount of upper eyelid skin with significant hooding. (skin laying on or near the eyelashes) Her lower eyelids show multiple redundant skin rolls and bags. Here eyebrows were not especially ptotic or has any significant sagging.

Upper and Lower Blepharoplasty result front view Dr Barry Eppley IndianapolisUnder general anesthesia, upper blepharoplasties was performed removing 12mms of skin centrally and sparing the underlying orbicularis muscle. Medial fat pockets were also removed.  Lower blepharoplasties were done using a skin-muscle flap technique. A three pocket fat removal, 5mms of tapered skin removal at the lateral canthus and a lateral orbicularis muscle suspension was done.

Upper and Lower Blepharoplasty result oblique view Dr Barry Eppley IndianapolisHer recovery took about ten days to look ‘non-surgical’ and three weeks to fairly normal. Many blepharoplasties will look a little tight for a period of time but by six weeks after surgery this has usually passed. Her results at six months show significant improvement but a result that retained her natural look.

An overdone or unnatural result from periorbital rejuvenation surgery is caused by numerous factors including aggressive tissue removal and an over elevated or exaggerated browlift. It is the browlift that is often at fault for a perceived abnormal eye look after plastic surgery. The effects of aggressive tissue removal, particularly that of fat, are often not seen until much later when the eye may look skeletonized or more hollow. The key to a natural blepharoplasty result is to not try and work out every excess bit of tissue or get rid of all wrinkles. While patients want the best result possible, they also d not want an over operated look either.

Case Highlights:

1) Aging of the eyes is the first facial area affected and is commonly treated by blepharoplasty surgery.

2) Four lid blepharoplasty (upper and lower eyelid surgery) is the most effective method of partially reversing the effects of aging on the eyes.

3) Natural blepharoplasty results occur when the amount of skin and fat removal is not overdone and lid function is not affected.

Dr. Barry Eppley

Indianapolis, Indiana

The Effect of Upper Blepharoplasty on Eyebrow Position

Thursday, June 5th, 2014


One of the most facial aging surgeries is that of blepharoplasty or the removal of excessive eyelid skin. It is most common because everyone develops redundant skin of the eyelids with enough age and everyone has four eyelids. Even for those patients not driven by a desire for an aesthetic improvement, an upper blepharoplasty is more common than a lower blepharoplasty because it can cause functional symptoms. The weight and hanging of excessive upper eyelid skin can push down on the lash lines, making the upper eyelids heavy and causing upper visual field impairment.

Blepharoplasty (Eyelid Tuck) Dr Barry Eppley IndianapolisBecause skin is taken away from the upper eyelid, and sometimes very aggressively to really get rid of it, the question is often asked if by doing so the eyebrow will be pulled down. Since it is common with heavy eyelids that one use their forehead muscle to lift the eyebrow and help take the weight off of the eyelids (so one can see better), does eliminating the skin reduce this habit which could also cause a drop in eyebrow position? (unmasking the real eyebrow level)

In the May 2014 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery, an article was published entitled ‘The Effect of Upper Eyelid Blepharoplasty on Eyebrow Position’. In this paper, a total of 140 consecutive patients who had upper blepharoplasty due to superior visual field obstruction were studied with before and after measurements of their eyebrow position. In addition, horizontal forehead lines were classified by degree. Their results showed that there was an average very slightdrop in eyebrow position by measurement. (less than 1.5%)  This was not visibly detectable with the exception in some men. In men, one of of six displayed a significant lowering of the eyebrow position. The sample size of men was small (14) compared to that of women. (126) Before surgery lifting of the eyebrows by means of frontalis muscle activity did not influence the position of the eyebrows after surgery, although forehead horizontal lines did seem to diminish significantly afterwards.

Male Blepharoplasty result front view Dr Barry Eppley IndianapolisTo some degree it us understandable why, in most cases, even an aggressive upper blepharoplasty does not pull the eyebrows down. Upper eyelid skin is very elastic and stretchy and allows for large resections of skin. It is not apparent at all during surgery that the position of the eyebrow moves down at all. However, it may have an eyebrow dropping effect in some men because men usually appear later for upper blepharoplasty surgery (they simply wait longer) and may have a strong and well established compensatory frontalis muscle compensation. Once their upper visual field is improved, the real natural position of their eyebrows becomes unmasked (lower) as the lifting effect of the frontalis muscle is no longer needed.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Eyelid Lifts (Blepharoplasty) in the Older Male

Monday, February 10th, 2014


Background: Aging begins around the eyes early in life and continues unabated up through one’s senior years. This periorbital aging is manifested by the creation of extra eyelid skin which is caused by the stretching of the thin eyelid skin due to frequent movement. As the redundant eyelid skin becomes excessive it weighs down the upper eyelid. Known as hooding it essentially creates folds of skin that lie on the eyelashes pushing the lid margin downward.

Older Male Eyelid hooding Dr Barry Eppley IndianapolisBetween of the weight of the eyelid skin and its folding over the lashline, an obstruction of the upper visual field results. This is often not even noticed by the individual because the visual field loss is so gradual. Getting lower and lower over the years, the loss of incoming light from a gradually smaller visual field is just credited to a naturally weakening vision with age.

With this upper eyelid hooding and visual field obstruction comes accompanying forehead wrinkles. While some of these horizontal forehead wrinkles are due to lifelong facial expressions, some of them are due to a constant holding of the eyebrows upward to lift some of the skin off of the eyelids, making one able to see better. Such browlifting is often inadvertent and unnoticed by the individual.

Case Study: This 76 year-old male wanted to improve the appearance of his eyes. He said he was frequently told he looked like he was squinting all the time. He felt he looked old and that some eyelid surgery may be beneficial. He wore glasses and had no symptoms of dry eyes.

Older Male Eyelid Lift Results front view Dr Barry Eppley IndianapolisUnder general anesthesia, a large excisional skin-only upper blepharoplasty was done. No orbicularis muscle was taken. The lower eyelids were treated by the raising of skin-muscle flaps, excision of protruding fat pockets, lateral canthopexies, conservative skin removal and orbicularis muscle suspension suturing.

Older Male Eyelid Lift results oblique view Dr Barry EppleyAfter surgery he had excellent improvement in appearance of both upper and lower eyelids. He felt he could ‘see’ better and that there was more light wherever he went. He did have a minor complication of some lower eyelid irritation and lower eyelid sag at the corners which took about two months after surgery to completely resolve.

Older Male Eyelid Lift results side view Dr Barry Eppley IndianapolisBlepharoplasty (eyelid lifts) in older patients can offer great improvement in appearance and even function. But the lower eyelid must be handled very carefully as it is at high risk for after surgery lid malpositioning. (ectropion) Even when handled well (limited skin removal, tendon tighening and muscle suspension), many older patients will experience  temporary period of lower eyelid lag symptoms.

Case Highlights:

1) Advanced aging around the eyes creates severe upper eyelid hooding, upper visual field obstruction and redundant lower eyelid skin with sagging.

2) When the amount of excessive eyelid skin is considerable, the eyes can look small and one can appear to be continuously ‘squinting’.

3) Upper and lower eyelid lifts (blepharoplasties) can create considerable improvement, opening up the eyes and making them feel less heavy.

Dr. Barry Eppley

Indianapolis, Indiana

Patient Testimonial: Upper Blepharoplasty (Eyelid Lift) Surgery

Tuesday, December 24th, 2013


Blepharoplasty (Upper Eyelid Lift)

Upper Blepharoplasty Eyelid Lift Dr Barry Eppley Indianapolis‘I never thought I would ever have plastic surgery for any cosmetic reason. I had worn glasses for many years but when I retired at age 65 I started to have more trouble seeing because of what was happening around my eyes. Everything just seemed a little more dim and I just can’t see as well. After seeing Dr. Eppley I realized that the skin on my forehead, brow and around the eyes had loosened and fallen to partially obstruct my vision. Trying to strain to see even gave me some issues with headaches. Having having my eyelid surgery by Dr. Eppley I could not only see better but I actually like the cosmetic improvements as well. I was not initially concerned with any cosmetic enhancement but I now see that as a pleasant bonus! Thank you Dr. Eppley for your surgical expertise and kind encouragement to go through the procedure. You were right, it was not as bad as I thought it would be.’


Carmel, Indiana


There is probably no plastic surgery procedure that is more satisfying to a patient than an upper blepharoplasty procedure, also known as an eyelid tuck or an eyelid lift. This is so not only because of its aesthetic effect but because of the removal of the heavy feeling on the upper eyelid and an improvement in one’s visual field if the excessive skin is significant enough. It is its combined aesthetic and functional benefits that makes the upper blepharoplasty a winning procedure for those that undergo it. It is also a fairly ‘simple’ plastic surgery procedure to undergo with minimal pain afterwards albeit with some swelling and light bruising that takes about 10 days to go away completely.

Dr. Barry Eppley

Indianapolis, Indiana

Five Things You Didn’t Know About Eyelid Lift (Blepharoplasty) Surgery

Thursday, October 31st, 2013


Eyelid lifts or tucks are one of the most successful and commonly performed of all the anti-aging or facial rejuvenation procedures. While the number of eyelids outnumber any other facial structure, the number of eyelid surgeries performed is also due to the early onset of bothersome and visible aging which takes its earliest effect on the eyelids with the deveopment of extra skin, herniated fat and wrinkles.

While cosmetic eyelid surgery is common, there are numerous aspects of it that are not know or frequently misunderstood. Here are five things about blepharoplasty you may not know.

The Formal Name for Eyelid Surgery is Blepharoplasty. Coming from the Greek words, Blepheron (eyelid) and Plassein (to form), reshaping surgery of the eyelids is formally known as a blepharoplasty. Many times the procedure is simply known as having a ‘bleph’.

Upper and Lower Blepharoplasty Surgery Is Very Different. Upper eyelid surgery is the ‘simpler’ form of blepharoplasty with lower risks. It is largely a skin removal surgery and there are no concerns about the support or suspension of the eyelid which is largely responsible for the blink reflex and eyelid closure. Conversely, lower eyelid surgery involves removing tissue and tightening a structure that is suspended across the eyeball and largely does not move but must remain tight up against the eyeball. Thus risks of lower blepharoplasty with skin and fat removal are disruption of the lid position (pulling away from the eyeball) and prevention of this potential problem must be factored into the surgical technique used.

Laser Blepharoplasty Is Not Better. Laser blepharoplasty is simply using a laser beam to cut the eyelid skin or remove orbital fat instead of a ‘cold steel’ scalpel. Because of its high tech nature and the magical properties that have been given to anything associated with a laser, it is assumed that a laser blepharoplasty heals faster and gives a better result with less scarring than traditionally performed eyelid surgery. The reality, however, is exactly the opposite. The burn injury sustained by the skin edges from a laser actually increases the risk of visible scarring and heals slower…at the least it does not offer a better result.

Mini-Blepharoplasties Do Exist. Like all facial rejuvenation procedures, the scope of the operation should be based on the extent of the problem. For younger patients, the extent of the blepharoplasty surgery needs to be less. Such mini-blephs are known as pinch blepharoplasties where just a ‘pinch’ of skin is removed. This is often done using a special instrument to remove the smaller amount of eyelid skin. These pinch blepharoplasties are really helped by the concomitant use of skin resurfacing and Botox injections to improve the extent of their results.

Non-Surgical Blepharoplasty Can Offer Some Improvements. There are a variety of non-surgical treatment options for the periorbital region. Botox injections, laser resurfacing, chemical peels, injectable fillers and fat injections can be used to lessen wrinkles around the eyes, improve its skin texture as well as volume enhancement. While effective, such treatments are not technically a true blepharoplasty and certainly don’t create the same effect. While calling these treatments non-surgical is certainly appropriate, it is also important to realize they are adjunctive treatments that can benefit a surgical blepharoplasty or can be used alone.

Dr. Barry Eppley

Indianapolis, Indiana

Injectable Fillers vs Fat Transposition Blepharoplasty for the Tear Trough Deformity

Tuesday, October 29th, 2013


The tear trough is a natural depression that runs from the inner aspect of the eye down along the infraobital rim, usually stopping at about a vertical line drawn down from the pupil of the eye. With aging, it becomes deeper and more visible and then becomes known as the tear trough deformity. Extending from the tear trough is another line known as the lid-cheek junction or palpebromalar groove. Both the tear trough and palpebromalar groove have drawn a lot of interest in reducing their presence primarily through the use of injectable fillers.

Currently there are two known methods for treating the tear trough deformity, injectable fillers and lower blepharoplasty surgery. By far injectable fillers are most commonly used because of their simplicity and immediate effects. But this is not a fool proof treatment and is prone to complications such as lumpiness and irregularities. The filler can be placed right under the skin or under the orbicularis muscle and each location has its own advantages and disadvantages.

Surgical correction through a lower blepharoplasty can be done using a variety of techniques of which the most effective are orbital fat repositioning and orbicularis muscle suspension. What is proven not to work is simple orbital fat removal. Actually removing orbital fat may even make it look worse by causing a depression above the tear trough which can accentuate it. Thus fat distribution rather than removal is a more effective strategy.

Lower eyelid fat transposition has become the surgical method for treating tear trough deformities. In this technique the orbicularis muscle and septum are separated below the arcus marginalis. This creates an infraorbital depression into which orbital fat is used to fill it. The orbicularis muscle is then suspended out at the lateral canthal area as a preventative manuever to lower the risk of lower eyelid ectropion. (pull down of the lid)

The tear trough deformity is a bothersome aging problem around the eyes that makes one look tired due to their dark circle effect. Injectable fillers are a good first treatment approach and one should stay with the hyaluronic acid-based fillers for these injections. If unsatisfactory results occur then a lower blepharoplasty with fat transposition would be the definitive approach.

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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