Plastic Surgery
Dr. Barry Eppley

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

Posts Tagged ‘eyelid surgery’

Case Study: Blepharoplasty in Dry Eyes and Lax Lower Eyelids

Monday, January 23rd, 2012

Background:Aging of the eyes is both an unavoidable eventuality for everyone and the first and most noticeable place on the face that it occurs. The classic findings are heavy or extra skin on the upper eyelids and bags on the lower eyelids. This combination makes for a tired or older appearance that is recognized by everyone since most of how people see and remember our face is in the eye area.

While these findings are typical periorbital signs of aging, why do they occur? Since most of eyelid closure comes from movement of the upper eyelid, its thin skin is prone to become lax and wrinkled. It eventually falls down into the eyelashes obliterating the supratarsal fold and making the upper eyelid heavy. The bags on the lower eyelids come from herniated fat. As the lower support structures between the tarsusand the lower eye socket edge weaken, fat that is normally under the eye as a supportive cushion protrudes forward. As it bulges past the vertical plane of the infraorbital rim, it appears a bag-like protrusion. This combined with the development of wrinkled and sagging skin give the lower eyelid its baggy and sagging appearance.

Case Study: This 55 year-old female from Indianapolis Indiana wanted to make her facial appearance fresher and less tired. She felt her eyes were her biggest problem and wanted to get rid of her loose skin and bags. She had an eye history of having had Lasik surgery two years previously and had some mild dry eyes since. On examination her lower eyelid was lax with a delayed snapback test.

Under general anesthesia, she underwent upper and lower blepharoplasty. On her upper eyelids, excess skin and a small strip of orbicularis muscle was removed along her existing supratarsal crease line. No fat was removed. On the lower eyelids the three fat pockets were removed and a small strip of skin excised. (3mms) A canthopexy procedure was performed because of her lax canthal tendon. The skin was closed using an orbicularis muscle suspension technique prior to a superolateral sweep for the skin closure.

Her skin sutures in the lateral canthal area were removed one week later. It took her a full three weeks for all swelling and bruising to completely resolve. She did return to work ten days later and felt comfortable enough to do so with a little make-up. She had no problems with tearing or dryness of her eyes in her recovery.

While blepharoplasty surgery can make a big difference in the appearance of one’s eyes, it is important to recognize that eyelid function must not be disrupted. Management of the lower eyelid is usually the key to preventing postoperative problems. Not removing too much skin and providing tendinous and muscular support onthe lower eyelid will minimize the risk of ectropion or lower eyelid retraction.

Case Highlights:

1) Aging eyes have extra upper eyelid skin and lower eyelids bags which bother the owner the most.

2) The emphasis of blepharoplasty surgery is removal of skin in the upper eyelid and fat removal in the lower eyelid.

3) Successful and uncomplicated blepharoplasty surgery is based on judicious skin and fat removal with management of a lax lower eyelid if necessary.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Blepharoplasty For Aging Eyes In Men

Monday, January 16th, 2012

Background:  When a man presents for facial rejuvenation it frequently is driven by someone (or many) telling them they look tired. With enough repeated comments and in looking in the mirror, it eventually becomes evident that they in fact are looking tired. This most commonly is due to changes in the eye area.

A man’s eyelids begin to sag and excess skin and fat develop in both of them. The upper eyelid skin hangs down onto the lashes making them feel heavy and obliterating any evidence of a supratarsal fold. The lower eyelid becomes very puffy  and develops a sagging appearance. Dark circles often develop under the eyes which draws extra attention to their changed and aging appearance. Also, the eyebrows may begin to sag and hang below the browbone, creating a ‘hangdog’ or an angry expression. Crow’s feet and other wrinkles develop outside of the actual eyelids.

Blepharoplasty or eyelid surgery is the well known antidote to a man’s aging eyes.While eyelid surgery may seem similar between men and women, there are some subtle and important differences. Men often seek a less obvious and an absolutely natural look compared to women. Eyelid scars are also a major concern, particularly in the lower eyelid as men do not have the option of scar camouflage with cosmetics. (they can use them but usually don’t want to) Men also desire to avoid any periorbital change that would make them look in any way feminine. These include such concerns about too high of an upper eyelid crease/scar, an upward flare to the eyebrow or too tight of a sweep to the tail of the lower eyelid or alteration of the corner of the eye. It is also important to realize that men are not usually interested in getting rid of every single wrinkle around \their eyes, they just want to less less tired and more refreshed.

Case Study: This 52 year-old man from Indianapolis Indiana was tired of being told he looked tired. He was bothered by skin that hung down onto his upper eyelids and eyelashes and the bags under his eyes. His lower eyelid bags were usually fairly swollen in the morning and it took all day until some of the puffiness went down. It took him several years to come to the realization that surgery was the answer.  

Under general anesthesia, he had both upper and lower eyelids treated. The excess skin of the upper eyelid was removed creating a visible supratarsal fold and upper eyelid crease. A skin-muscle flap lower blepahroplasty technique was used removing a significant amount of herniated fat. Minimal lower eyelid skin was removed and the corner of the eye was tightened with the skin closure.

He had the usual amount of swelling and bruising after surgery that took about ten days to look ‘passable’. By three weeks after surgery, he looked non-surgical and was clearly in the benefits phase of the procedure. He did have some mild tearing issues of the left eye which took six weeks to completely resolve due to a slight amount of temporary lower eyelid retraction in the corner. He ended up with a less tired look around his eyes but with an unchanged appearance.  

Case Highlights:

1)      Facial aging in men disproportionately affects the eye area with extra skin, protruding fat, wrinkles and brow sagging.

2)      Blepharoplasty surgery in men must avoid overresection and tightening of eyelid tissues that can look unnatural and more feminine.

3)      Eyelid surgery in men creates a refreshed look but an overall unchanged facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Internet Scams for Plastic Surgeons

Thursday, August 5th, 2010

 As everyone is aware, the internet is full of scams. The easy and no-cost use of  e-mail allows such illegal activities to appear in your inbox without any legal repercussions. You may ask yourself how could anyone fall for these but obviously some do or they wouldn’t keep doing it. The goal of each and everyone of them is to get access to your bank account and it is always in the guise of the need for some form of wire transfer of alleged funds.


Most people remember the ‘original’ e-mail scam…the one with government or family official from Nigeria. There have been many variations of this theme from different African countries and I still get one of these at least once a week.


In the spirit of marketing to niche areas, I just got one just for Plastic Surgeons. It’s the same old scam concept but with a new twist. Read and see if you can figure out the method that they will get access to your back account.

‘Greetings from Milan,

My name is Mr. ****** *******, I am a cosmetic dentist here in Italy. I do smile makeovers, preventive dentistry/maintenance, cosmetic dentistry, cosmetic dentures, etc. I have lots of happy clients here in Italy .

I have been looking for a plastic surgeon for over a week now till I met an old friend last week that referred you to me, She used to live in America before she relocated here with her family. So I decided to contact you to see if you are able to do an Upper and Lower Eyelid Surgery (Blepharoplasty) for this client of mine.

My clients name is Ms. ******** ******, she is a model here in Italy. She will be coming to the U.S in 3 weeks time for a modeling job and will be residing in Indiana  temporarily until the necessary arrangements for her job has been made. Before she leaves, she would be needing a Plastic Surgeon to help her out with her Upper and Lower Eyelids before her next photo shoot.

Please tell me a little more about yourself,  how long have you been a plastic surgeon? Would you be able to give her this surgery by the end of the month?

Please get back to me if you would be available to do the surgery and the amount that you will charge for the job. Let me know if she can pay you with a certified check drawn from a US bank so you can have her booked for the end of the month.

Till I hear from you may you remain blessed.’


Urgency to perform a plastic surgery procedure is not uncommon given the emotional nature of that type of decision. In a known patient where discourse has been established, this is not a concern. But in an unknown patient from afar, urgency is a sure sign of malevolence.


The catch here is when some unsuspecting plastic surgeon asks for payment in advance, which is standard. The switch will be made from sending a certified check to having to wire the money instead. At which point account numbers will be requested to do so.


Internet scams come at us in many ways. They all pray upon the inherent weakness in human nature to believe that money is easily obtained and without much effort. Occasionally that is true but most of the time it’s a recipe for being taken to the proverbial cleaners.


Dr. Barry Eppley

Indianapolis, Indiana  

Chemical Peeling of the Lower Eyelid for Wrinkle Reduction

Friday, February 19th, 2010

Contrary to the perception of many, upper and lower eyelid (blepharoplasty) surgery will not do much to improve wrinkles around the eyes. Eyelid procedures are for removing redundant skin and herniated fat. For wrinkle improvement around the eyes, chemical peels are one good option for wrinkle reduction.

If chemical peeling is to be done at the same time  as a lower eyelid procedure, it can only be done if the lower eyelid technique is transconjunctival. (meaning no formal skin-muscle flap is raised) If a more formal blepharoplasty is being done, one should wait at least 3 months after  before doing so. The combination of the two together will likely result in scarring and ectropion. (pulling down of the lower eyelid)

Chemical peeling is not usually done on patients with any significant skin pigment. This would eliminate many ethnic groups such as most African-Americans, Asians, and Hispanics. There is a real risk of losing some color (pigment) and the risk simply isn’t worth it.

Medium depth and deep peels are commonly used for the lower eyelids because they are effective and have a good margin of safety given that the eyelid skin is very thin. The depth of peeling when using medium peels is directly related to the amount of solution applied, the concentration of the peel, and how the skin is prepared for the peel. Peel concentration alone does not necessarily indicate how deep the peel will penetrate.

The use of medium-depth peels are usually done  in two layers, applying two superficial wounding agents. In my Indianapolis plastic surgery practice, I use a first layer of a Jessner’s solution, a keratolytic agent, before putting on a 35% trichloroacetic acid solution. This enhances penetration and the overall result while retaining a good margin of safety. The peel will develop an immediate frost which is then covered with antibiotic ointment. It can be performed under topical anesthesia in the office.

Deeper eyelid peels are most commonly done with a phenol solution. While full face phenol peels have largely faded since laser resurfacing became popular, they are still a good technique in the lower eyelid when significant wrinkles are present. Concentrations of either 50% or 88% are used which causes injury to the medium depth of the skin thickness. The phenol peel produces the greatest change in skin pigment and wrinkle reduction while also producing some skin tightening. Phenol lower eyelid peels should be done in the operating room because they cause more pain and any tearing into the peel will cause it to penetrate deeper and create a full-thickness burn.

Lower eyelid chemical peels can be done simultaneously with a transconjunctival lower blepharoplasty, as a delayed treatment for wrinkles three months after, or as  stand alone chemical peel when blepharoplasty is not needed. 

Dr. Barry Eppley

Indianapolis Indiana


Common Questions on Eyelid Tucks (Blepharoplasty) and Browlift Surgery

Thursday, January 14th, 2010

1.      What is the difference between eyelid and browlift surgery? Which will make me look less tired?


When considering anti-aging improvements around the eye area, it is important to consider both the eyelids and the brows. Both can contribute to a tired look but they create that appearance differently. Eyelids become aged by having too much skin. In the upper eyelid, this can eventually become hooding with skin that can rest down on the lash line. In the lower eyelids, wrinkles and bags develop some of which is also the result of fat which begins to protrude out from under the eyelid. Conversely, eyebrows create an aged eye appearance by becoming positioned too low off of the forehead. The dropping of one’s brows also creates more excess skin in the upper eyelid which is really just skin that has been smushed together as the distance between the eyebrow and the lash line of the upper eyelid becomes closer together.


Depending upon the anatomy of the problem, some patients just need eyelid surgery alone, a fewpatients may just need a browlift alone, and some will need a combination of both to create the best result. Browlifts tend to be complementary to eyelid surgery.



2.      What is the difference between an eyelid tuck and a blepharoplasty?


They are two different terms that describe the same thing. In 1818 Von Graefe coined the word ‘blepharoplasty’ (greek, blepharon = eyelid, plasty = to shape) to describe an eyelid reconstruction that he performed. Today, blepharoplasty denotes excision of excess skin, with or without the excision of orbital fat, for medical or cosmetic purposes. Blepharoplasty is the word we as plastic surgeons use. Patients commonly refer to it as an eyelid tuck.


3.      Will eyelid surgery leave scars?


All surgery that involves incisions or the removal of skin will leave scars. But the eyelids are unique in that superb scars are almost always obtained. Good scarring on the eyelids is the result of two factors. The eyelid skin is one the thinnest on the entire body. Thin skin will always scar less than thicker skin because there is less dermis to react to the healing process. Blepharoplasty incisions are placed in natural horizontal skin folds in the eyelids. In the upper eyelid this natural crease can be seen as a horizontal crease the in the skin five to 8mms  above the eyelashes. In the lower eyelids, the incision is put right under the eyelashes by 1 to 2mms. When these heal, they can be very difficult to see. (the upper eyelid scar can only be potentially seen when your eyelid is closed!)


4.      How much swelling and bruising will occur after eyelid surgery? How long will I look bad?


There is no question that any surgery around the eyes will cause some temporary swelling and bruising. How much and for how long depends on a variety of factors including how many eyelids were done and your natural tendency to bruise. On average, lower eyelid surgery causes more swelling and bruising than uppers. When all four eyelids are done, most patients will start to look more normal in seven to ten days. It will takes fourteen to twenty-one days to look ‘non-surgical’. When browlifts are combined with eyelid surgery, these time frames may be longer.


There are several thins that a patient can do to help improve the rate of looking better sooner. In my Indianapolis plastic surgery practice, I emphasize three things. First, take the herbal medication Arnica Montana one week before and after surgery. This helps control the amount of bruising and speeds it resolution. It comes in multiple preparations. We prefer the spray delivery system. After surgery, keep your head elevated on ice on your eyes for the first twenty-four hours. You can stop the ice the next day but continue to rest and sleep with your head elevated for the first week after surgery.


5.      How is browlift surgery done?


There are multiple methods of performing browlift surgery and the choice of which technique is used is based on each patient’s differing anatomy. There is no one single way to do browlift surgery that is right for everyone.


For women, the approach to lifting the brows is done ‘from above’. This means the incision is placed somewhere in or along the hairline and the brow and forehead are pulled back. Traditional browlifting is done from an incision way behind the hairline, removing scalp hair, to create the lifting effect. For women with long foreheads, this will lengthen the forehead in an unaesthetic manner and the incision is changed to right at the hairline. This keeps the forehead length the same (it cam also even be shortened) while lifting the brows. These open approaches have the advantage of being able to on the forehead and brow muscles to permanently weaken their effects of forehead wrinkling. …but at the expense of a long scar. When one has a scar concern and the forehead is not severe, the endoscopic approach can be used. Like laparoscopic abdominal surgery, several very small incision are made back in the scalp and the operation is done through a scope and a camera. This shifting technique will lengthen the forehead however so one has to determine beforehand of less scar or a longer forehead are more desireable.


Men do not have the browlift options that women do because of their hairline, or loss thereof, issues. It is rare to ever do any of these superior browlift approaches for that reason. Male browlifts are often done through the upper eyelid using a resorbable implant to push the brows up as they heal. This approach only produces a very mild browlift but the ‘less is more’ approach for men is always better anyway.


6.      I would like a browlift but I am afraid I will have that startled look. How can this be avoided?


A browlift is an easy operation to overdo. Most potential patients are aware of this by looking at many Hollywood and famous people results. It can be a fine line between enough brow evelation to show a visible change and brows that are too high. Do not forget also about the shape of the brow. This is another factor that can make a browlift look unnatural. The best way to avoid this potential problem is to have a thorough discussion with your plastic surgeon beforehand, with a mirror and looking at issues of a new brow position and potential shape change. While browlift surgery is not like doing Photoshop on the computer, there is a surgical art to it that a plastic surgeon uses which is influenced by the browlift approach and other intraoperative techniques. Knowing what you want can help the plastic surgeon modify techniques to help meet your expectations.


7.      Will insurance pay for eyelid and browlift surgery if I have trouble seeing?


In the past, insurance companies did regularly cover upper eyelid and browlift surgery if medical evidence existed that visual impairment existed from the excess eyelid skin and low hanging brows. Such routinue coverage is now increasingly uncommon and much harder to get approved. Whether the insurance option is an avenue to pursue can only be determined on an individual patient basis. Any such procedure on the lower eyelids, however, is never covered as there is no anatomic basis for excess skin getting in the way of seeing. 

Dr. Barry Eppley

Indianapolis, Indiana 

The Anatomy of Periorbital Aging and Rejuvenation

Tuesday, September 22nd, 2009

The eyes have long been described as a window to the soul and their may be some truth to that often stated expression. But they most certainly convey an impression about our state of tiredness and age…and all to frequently people are quick to ask about that tired vs. rested issue. Often (and perhaps appropriately), a person’s eyes are the first feature that we focus on in any type of conversation. As the eyes have such an impact on the impression of our facial appearance, people are understandly concerned about it and that makes treatment of the periorbital area an essential strategy for facial rejuvenation.

But what is it that makes the eyelids and the area around them age? Much of the periorbital aging process is due to skin redundancy or excess. As the tissues around the eye are essentially a sphincter, they open and close frequently. Over time, the thin eyelid tissues get stretched out. This redundancy of the skin of the upper eyelids will begin to appear in the late 30s. Over time, the  skin progressively sags and may eventually come to rest on the upper eyelashes by the time patients reach their 60s.

It usually takes a little longer to see changes in the lower eyelid and around the eyes in the crow’s feet area. By the 40s, fourth decade, wrinkles will begin to appear out from the corner of the eye and lower eyelid folds start to become are apparent at rest. It is also around this time that bags or pooches appear on the lower eyelids. These are the result of herniated fat coming out from underneath the eye as the support tissues that hold it in are weakening. This fat, usually with some swelling and fluid retention (greater in the morning) is what makes up those pesky lower eyelid bags. By the 50s and 60s, the excess skin and bags of the lower eyelid can be quite pronounced.

When you combine the changes of both the upper and lower eyelids, the cumulative effect is a very tired and hooded appearance with loss of the once crisp eye appearance. This look may also be accentuated or worsened in appearance if the overlying brows start to fall as well. This will make the amount of excess skin in the upper eyelid look worse.

When you look at the anatomy of the periorbital aging process, one can understand several concepts about improving their appearance. In my Indianapolis plastic surgery practice, I emphasize to potential patients the following points about periorbital rejuvenation. First, think of the eyelids and brow as an overall unit. Treating just one area will not have as significant effect as treating the entire ‘problem’. They are all connected and the appearance of one influences the other. This is of particular importance as it related to the upper eyelid and the overlying brow. (blepharoplasty and browlift surgery) Secondly, the primary problem in periorbital aging is skin excess. This must be removed to make any appreciable headway. There really is no non-surgical or minimally invasive treatments that will work. The use of lasers or chemical peels is an adjunct, but not a primary treatment method. Third, the lower eyelid is unique due to fat herniation. The fat must be removed or put back from whence it came. Lastly, maintenance treatments after surgery can help prolong the results. (which are not permanent) Botox and chemical peels are easy and very effective office treatments that provide good maintenance to periorbital rejuvenation surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Upper Blepharoplasty and Eyelid Scars

Monday, September 21st, 2009

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

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

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

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

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

Dr. Barry Eppley

Indianapolis , Indiana

Blepharoplasty (Eyelid Surgery) – How Will I Look After Surgery?

Friday, April 24th, 2009

Blepharoplasty, or eyelid tuck surgery, is one of the most common and gratifying anti-aging facial surgeries. As the windows are the eyes to the soul, removing and tightening up loose skin makes them look fresher and better rested. It is a plastic surgery that usually pays great dividends for one’s appearance and the perception by others.

Because blepharoplasty involves the delicate structures surrounding the eyes, patients are understandably concerned about the healing process. They usually want to know how long they will be bruised and swollen or how long they will look ‘bad’. At what point will one be acceptable to be seen in public without having an operated look?

As the eyelids are very delicate, they are prone to a fair amount of swelling and bruising. Such is the nature of blepharoplasty surgery. Usually the lower eyelids will swell and bruise more than the upper eyelids. As most people have not seen such swelling and bruising, it will usually be quite impressive to them. But this abnormal appearance is quite normal and expected.

Typically, it takes a full two weeks or more to look completely normal after blepharoplasty surgery. Swelling is mainly gone by 10 to 14 days, but the final remnants of bruising on the lower eyelids may take slightly longer.

One of the ways to lessen how much bruising and swelling of the eyes that occurs after surgery is to institute the following three measures. First, take Arnica Montana supplements one week before and one week after surgery. They are very effective at lessening the amount of bruising that develops and helping it clear faster afterwards. Keep one’s head elevated for the first 5 days after surgery to help control swelling. For the first 24 hours after surgery, keep the eyes iced with gel eyemasks or frozen vegetables. While these three measures won’t completely eliminate all swelling and bruising, they help lessen the recovery period significantly.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Correction of Lower Eyelid Bags

Saturday, January 17th, 2009

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

The Pinch and Peel Lower Blepharoplasty

Friday, July 11th, 2008

Like all aging processes, changes around the eyes are gradual with an onset and progression over many years. Aging changes often begin in the 30s with a little puffiness or bags on the lower eyelids and the beginning of some fine wrinkles in the crow’s feet. As it progresses into the 40s, excess skin is eventually evident in the upper and lower eyelids as well. Early eyelid aging is usually bothersome in the lower eyelids to most patients as they see the once smooth and pristine skin change. As more and more patients are interested in ‘early onset’ aging surgery so that more major surgery may not be needed later, concerns about the lower eyelids are usually voiced long before the upper eyelids.


In the younger patient who does not have a severe aging issue on the lower eyelids, a traditional more formal lower blepharoplasty (eyelid) procedure is usually not needed. A little removal of fat, tightening up a little bit of skin, and erasing some of the early wrinkles is often all that is need. This can be accomplished by a limited lower blepharoplasty or a ‘pinch and peel’ technique.


In the pinch and peel lower blepharoplasty, an extended skin-muscle flap is not raised as in the traditional lower blepharoplasty. A special instrument is used to pinch up a little excess skin underneath the eye lashes and then it is trimmed. Some lower eyelid fat can be removed from inside the lower eyelid at the same time. Finally the lower eyelid skin is peeled with a chemical solution, usually 25% or 35% TCA (trichloroacetic acid), which is perfectly safe as the skin which is being peeled has not been undermined. This combination of three ‘little’ procedures, when put together at the same time, produces a very noticeable change but without a lot of recovery. There usually is no bruising and minimal swelling. The ‘recovery’ from this procedure is more related to the pinkness from the chemical peel.


The pinch and peel lower blepharoplasty is a procedure perfectly suited to the younger patient with limited aging issues of the lower eyelid. This procedure, combined with Botox treatments in the crow’s feet area, creates a nice rejuvenative effect with very minimal recovery. I have performed this procedure in the office under local anesthesia although it is more ideal if the patient is in the operating room under some form of anesthesia. The pinch and peel lower blepharoplasty truely fits my plastic surgery motto of….match the size of the oepration to the size of the problem.

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