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Dr. Barry Eppley

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Posts Tagged ‘blepharoplasties’

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 – Upper and Lower Blepharoplasties with Endoscopic Browlift

Sunday, July 7th, 2013


Background:  Changes around the eyes is the first part of the face that shows signs of aging. The development of excess skin on the eyelids and protruding eyelid fat makes the eyelids heavy and tired looking. But the eyes do not age in isolation, above them sits the eyebrows which are not immune to the effects of time. Aging of the eyebrows is primarily seen as they fall lower, often off of the bony brow ridges.

When considering corrective eyelid surgery, the standard and very effective approach are blepharoplasties. (eyelid lifts) While effective, the best result may not be obtained if the consideration of the brow position is overlooked. Whether a browlift is also beneficial can be tested before surgery by lifting the eyebrows and seeing if it also makes the eyes and the forehead look better. If a browlift is going to be performed with the blepharoplasties, this necessitates a smaller amount of skin removed from the upper eyelids. (a browlift recruits eyelid skin upward)

Browlifts have many different options than blepharoplasty surgery. They can be done from behind the scalp through a long open incision (coronal type), small incision scalp approach (endoscopic type), at the hairline (pretrichial type) and through the upper eyelid. (transpalpebral) Which technique is used depends on how much browlifting is needed, the vertical length of the forehead skin and how much muscle deanimation of the forehead is needed. The endoscopic browlift is one of the most common methods due to its smaller incisions but still having a powerful upward lifting effect.

Case Study: This 52 year-old female was tired of people telling her she looked tired or mad. Her eyes had a lot of excessive skin and herniated fat. But her brows were also heavy, low hanging and were asymmetrically positioned. She had very thick and heavy skin throughout her face.

Under general anesthesia, the first procedure done was an endoscopic browlift. Through four small incisions in the central and temporal scalp, the periosteum over the brows and across the nose was released through an endoscope. Muscle was removed from the supraorbital and supratrochlear neurovascular bundles and the brows lifts and secured to the outer cortex of the cranial bone by resorbable Lactosorb screws and sutures. The upper eyelids were done next, removing less skin than originally marked to prevent any potential risk of incomplete eyelid closure. The lower eyelids had skin and fat removed and the orbicularis muscle resuspended during closure.

The time required for all swelling and bruising around the eyes to completely go away after surgery was three weeks. By one month after surgery she showed a significant improvement with more open and refreshed eye look…no longer having a mad or angry appearance.

Combining a browlift with blepharoplasties creates the most complete amount of periorbital rejuvenation. While the change can be dramatic, the patient should anticipate a significant period of time for a complete recovery as the eyes are visible to all and even small amounts of swelling or bruising may be noticeable.

Case Highlights:

1) Aging of the eye area must not only consider the eyelids but the position of the eyebrows as well. Some of the excess skin on the upper eyelids can be due to yhe downward push of the eyebrows as well.

2) Total periorbital rejuvenation consists of upper and lower blepharoplasties as well as a browlift.

3) If the forehead is not vertically long, an endoscopic browlift can raise the eyebrows without making the forehead too long.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Combined Browlift and Eyelid Lifts in Severe Periorbital Aging

Wednesday, April 17th, 2013


Background: The aging process around the eyes is classic. The near continuous motion of the eyelids creates loose skin and, with enough time and motion, the eyebrows will fall over the supraorbital rims and sag downward.. For many patients today, they have eyelid surgery early in life and never progress to see the extreme aging changes that can occur around the eyes.

But in its most extreme form, eyelid aging will develop hooding where the loose and excessive skin will fall down and even over the eyelashes. The eyebrow can even lie completely under the brow bone further accentuating the hooding effect of the loose upper eyelid skin. While such severe changes are usually seen in the elderly, it can occur in younger patients due to their natural genetics.

When there is a large amount of loose upper eyelid skin, it is tempting to think that a dramatic change can occur with its excision alone. But this does not take into account the powerful negative effect of a low brow position and its influence on obscuring the vertical space between the lashline and the brow. Without such a space a supratarsal fold can not be created no matter how much eyelild skin is removed.

Case Study: This 57 year-old female wanted to improve the aging appearance of her eyes.  She has severe upper eyelid hooding, a low eyebrow position and significant obstruction of her upper visual field. While she initially resisted the idea of a browlift with her blepharoplasties, she eventually resigned herself to the fact that failing to deal with her eyebrow position would limit how much of a blepharoplasty result would be seen.

Under general anesthesia, a pretrichial (hairline) browlift was initially performed with a beveled incision along the frontal hairline. Eleven mms of forehead tissue was removed from the center of the hairline tapering out into the temporal area. The browlift was secured into position with suture fixation through outer cortical skull bone holes and sutures to the galea. An upper and lower blepharoplasty was then done, removing skin only in the upper eyelid and skin and fat from the lower eyelid.

Her postoperative course had the typical swelling and bruising around the eyes which ensues with some expected temporary foehead and frontal scalp skin numbness. She looked fairly normal at three weeks after surgery and completely normal by 6 weeks after surgery. She not only looked more refreshed by had a dramatic improvement in her field of vision.

With severe periorbital aging, oen has to consider a more comprehensive surgical approach around the eyes. This would include a browlift as well as the four eyelids. the choice of browlift is based on the existing length of the forehead and the degree of brow ptosis.

Case Highlights:

1) Severe upper eyelid hooding and brow ptosis produces an combined aesthetic and functional obliteration of the eyes.

2) When the brow is low, even aggressive upper eyelid skin removal will not produce an adequate result.

3) A combined browlift and 4-lid blepharoplasties is needed to open up the eyes in severe aging changes.

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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