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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘lower blepharoplasty’

Technical Strategies – Asian Love Band Surgery

Sunday, August 2nd, 2015


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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Techniques for Fat-Preserving Lower Blepharoplasty

Sunday, August 25th, 2013


The lower eyelids are just one component of the management of the peri-orbital facial area. While browlifts and removal of excessive skin from the upper eyelids (upper blepharoplasty) are well known and established anti-aging treatments, lower eyelid surgery has evolved in its techniques over the past decade.

Traditionally, lower blepharoplasty was all about the removal of skin and compartmentalized fat to get rid of bags and loose skin. While immediately effective, some patients suffer long-term consequences of this substractive approach to the lower eyelid with a more aged and skeletonized appearance. Thus such tissue removal does not always create the appearance of youth.

As a result a different approach to the lower eyelid has evolved towards tissue sparing methods, preserving fat and removing less skin. Rather than aggressively removing fat from the three lower eyelid fat compartments (medial, middle and lateral), it is preserved and used as soft tissue fill for the tear troughs and elimination of the lid-cheek junction.

Conversely another approach is to harvest fat from elsewhere in the body and use it as a fat injection technique for filling in the tear trough and eliminating the lid-cheek junction. Because an open lower blepharoplasty technique does not allow for containment of injected fat one, does not see open blepharoplasty combined with fat injections unless it is with a transconjunctival (closed) lower eyelid approach.

The basic manuevers of a fat-repositioning lower blepharoplasty is based on moving vascularized pedicles of fat from the inner (nasal) and middle (central) protruding fat compartments. These stalks of fat are teased out and moved over and below the lower eye socket rim. (inferior orbital rim) They are used to fill in the hollows and lines of the lower eyelid-cheek region. When done through an open approach, the release of the tear trough and orbicularis retaining ligaments can also be done creating a two-pronged treatment of the tear troughs and the line of the lid-cheek junction.

As the technique of fat-repositioning lower blepharoplasty evolved, it was applied through a transconjunctival rather than an open blepharoplasty approach. The desire to not disrupt the orbicularis muscle and decrease the risk of lower lid ectropion was the primary motivation. But not exposing the transferred fat presumably improves their chance of survival as well. But the limited exposure through the inside of the lower eyelid and the difficulty in releasing the orbital ligaments may lead to persistence of the tear trough groove.

While technically challenging, fat repositioning with the transconjunctival approach can be successfully done and encompasses several important technical steps. The plane of dissection is between the orbicularis muscle and the orbital septum, meticulous release of the tear trough and orbicularis retaining ligament, septal windows for nasal and central fat pedicle release and repositioning, securing the fat pedicles over the orbital rim with transcutaneous sutures, free fat graft (from lateral pocket) placed between the two fat pedicles and a pinch external blepharoplasty and skin resurfacing (laser vs peel) if needed.

Lower eyelid rejuvenation that preserves fat produces a better aesthetic result than a traditional subtractive lower blepharoplasty in many cases. Fat transposition through the lower eyelid is technically challenging and can also be done by transconjunctival fat removal combined with external fat injections with comparative results in many cases.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Transconjunctival Lower Eyelid Bag Removal in Women

Thursday, June 20th, 2013


Background:  Aging of the eyes takes on many predictable changes and one of those is the development of herniated fat. As the name implies, this is fat that has been historically believed to be once was under the eye that has relocated out onto or bulges over the lower orbital rim. Known as eye bags, it is associated with an aging and tired appearance. Since most human eye contact ends up on the face, their development can not be missed and they usually make an undesired impression.

The anatomy of lower eyelid fat is perceived to be three distinct fat pads that come from an intraorbital location. Recent anatomic studies, however, have evaluated this belief and have come up with a different anatomic explanation of their origin. These cadaver studies have shown the lower eyelid pads are discrete fat compartments that are not in continuity with the more posterior intraorbital fat. Rather they may be more accurately described as being both partially intraorbital and partially extraorbital in location. This may seem like a trivial difference in anatomic description but has relevance when considering their removal.

Removal of bulging lower eyelid fat can be done from either inside or outside of the lower eyelid. The choice of approach depends on whether lower eyelid skin needs to be removed and tightened and the concurrent management, if any, of lower eyelid wrinkles.

Case Study: This 42 year-old female wanted to improve her tired looking eyes. She was bothered by the bulges (bags) that had formed on her lower eyelids. She felt they made her older and more tired than what she was. Her darker and thicker skin allowed for few wrinkles despite having the bag.

Under general anesthesia, a transconjunctival approach was taken to her lower eyelid bag problem. Through the inner eyelid, the medial central and lateral fat pockets were identified and removed. No sutures were used to close the transconjunctival incisions. No external skin or incision was used

Her recovery was very rapid with no bruising but some swelling. By two weeks after surgery all swelling was gone and improvement was seen. By six weeks after surgery, she looked great and no longer had a tired appearance.

Blepharoplasty of the lower eyelid most commonly is done through a transcutaneous approach. (external skin incision) With this exposure all contributing aging factors can be treated including skin and fat removal and, in some cases, tightening of the tendon at the outer corner of the eye. But in some younger patients or in those who have few wrinkles or excessive loose skin despite their age, this cosmetically bothersome orbital fat can be removed from inside the eyelid . By placing the incision below the tarsal plate, the fat pads can be exposed and removed. This not only eliminates any external scar but results in a faster recovery with little risk of causing a lower eyelid sag. (ectropion)

Case Highlights:

1) One of the most common signs of aging around the eyes is the development of lower eyelid protrusions or fat.

2) Lower eyelid bag are herniated fat pads that can either be removed alone or in combination with a traditional lower blepharoplasty in which excess lower eyelid skin is removed as well.

3) Removing lower eyelid bags can make a dramatic difference in making the eyes look less tired.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Removal of Lower Eyelid Bags in Men

Monday, February 25th, 2013

Background: Aging affects all areas of the face but not more profoundly than the periorbital (eye) area. Because of the thin tissues of the eyelids, they are prone to display wrinkles, loose skin and lower eyelid bags even early in the aging process. Because most human conversation is done by looking in the eyes, and they are the first thing we usually look at in the mirror, aging changes in the eye are very noticeable and usually disturbing.

The male periorbital area ages just like that in females and responds equally well to blepharoplasty (eyelid tuck/lift) surgery. But there are several unique aspects of a male blepharoplasty. Men tolerate aging changes better than women and as a result they often appear later in the aging process with more profound eyelid tissue issues. The upper eyelids usually have significant hooding and the lower eyelids have bags. Usually the lower eyelid bags are of a bigger concern because they contribute more to a tired and aging look.

The aging lower eyelid bag is caused by a combination of herniated fat, excess skin and sometimes a lax or loose lower eyelid. The biggest anatomic contributor is the fat component. The fat is the result of a protrusion or displacement from its normal under the eyeball position. Normally held into position under the eyeball by ligaments between the eyelid and the bone, aging or a genetic weakness in them allows the fat to come forward creating the ‘bag effect’. This is known as a herniation, much like that of a defect in the abdominal wall.

Case Study: This 48 year-old male wanted to improve his tired looking lower eyes. He had fairly pronounced bags, loose skin and wrinkles. What bothered him the most were the protruding bags which was worse in the morning and after eating salty foods. He had a fair amount of hooding on the upper eyelids but this was not a concern to him.

Under general anesthesia, a transcutaneous approach was used with an incision under the lashline with an extension into a crow’s feet skin crease. A skin-muscle flap was raised down to the lower eye socket rim. A large amount of protruding fat was found and the three fat pockets (medial, central and lateral) were reduced back behind the orbital rim. The lower eyelid skin flap was elevated in a superolateral direction and redraped up over the eye. A pilot cut was made at the lateral canthal area and a 5mm to 6mm skin trim was done along the lashline and a triangle of skin removed over the lateral canthal area. Orbicularis muscle suspension sutures were placed and the skin closed with dissolveable sutures. No dressings was applied at the conclusion of the surgery other than some antibiotic eye ointment along the incision lines.

At one week after surgery he had the typical eyelid bruising and swelling but the elimination of the bags was already evident. By three weeks after surgery all swelling and bruising was gone. When seen at three months after surgery, he had no bags, no lower eyelid malposition and he looked perfectly natural.

Lower eyelid bags are an undesireable aging feature that no topical or laser therapy is going to improve. Even if they could produce a mild improvement in lower eyelid bags the male patient is usually interested in a more efficient and effective therapy. Lower blepharoplasty surgery is the most effective treatment known and the only question is whether it is done with a transcutaneous (outer eyelid incision) or a transconjunctival (inner eyelid incision) approach. This depends on how much loose lower eyelid skin is present.

Case Highlights:

1) One of the common aging concerns for the middle-aged male are lower eyebags.

2) Lower eyelid bags are the result of herniated fat from under the eyeball that sticks out beyond the lower orbital rim.

3) A transcutaneous lower blepharoplasty can very effectively remove herniated fat and loose skin from the lower eyelid, creating a less tired look.

Dr. Barry Eppley

Indianapolis, Indiana

Rejuvenation of the Aging Lower Eyelid and Cheek

Wednesday, December 19th, 2012


There are many signs of facial aging but most people are usually concerned with what happens around the eyes first. The classic presentation of periorbital aging is a progression of tissue changes including excess lower eyelid skin, protruding orbital fat (bags), lower eyelid instability and the falling of the adjacent cheek tissues. (malar descent) While the upper and lower eyelid ages similarly in any person, the scope of the lower eyelid is actually bigger if you include the surrounding cheek regions. Thus the lid-cheek region is a frequent target for facial rejuvenation efforts.

Traditionally, these aging changes were managed by a standard lower blepharoplasty operation which involved an elongated lower eyelid incision and removal of skin and fat. While this basic operation still works well for many lower eyelid concerns, it is known to have potential lid malpositioning problems with risks of ectropion (lid sagging) and separation of the globe-lid intimacy. The precarious suspension support of the lower eyelid is prone to being disrupted by incisional placement, delamination of the lower eyelid tisues with lack of orbicularis muscle integrity near the lid margin, unrecognized weakness of the lateral canthal tendon and over-resection of lower eyelid skin.

One lower eyelid rejuvenation trend that has become commonly used over the past decade, partially as a response to the risk of ectropion, is the transconjunctival approach. Avoiding skin resection and an external lid incision, herniated orbital fat can be removed or repositioned through button hole sized incisions on the inside of the lower eyelid. While protruding orbital fat was once uniformly removed, it is now frequently being preserved and used as a filler for tear troughs, nasojugal grooves and creating rim augmentation to smooth out the lid-cheek junction. Because the blood supply to the overlying lower eyelid skin is preserved, skin resurfacing for wrinkles can be done with lasers or chemical peels.

One evolution of lower eyelid rejuvenation, which is the opposite of a transconjunctival blepharoplasty, is the extension into simultaneous cheek rejuvenation as well. These so-called cheek or midface lifts are a collection of procedures whose technical differences can be as diverse as the surgeon who performs them. Lifting up sagging cheek tissues through a full lower blepharoplasty incision and securing to some location along the zygomaticorbital bone, or even higher to the temporal and forehead regions, allows them to sit back up or higher on the cheek bone. But because it is a more invasive and extensive procedure with much wider tissue dissection than a lower blepharoplasty, it ironically has an even higher risk of ectropion and lower lid scarring problems if not executed to technical perfection.

While it can cause it, these cheek lifts can also be used to treat lower eyelid retraction problems as well. Lifting and supporting the surrounding cheek tissues can relieve the tension on the repositioned lower eyelid at the lateral orbital wall. Releasing the lower eyelid scar, retightening or remaking the lateral canthus and some cheek tissue release and resuspension can be very effective for getting the outer aspect of a retracted lower lid back up against the globe.

Dr. Barry Eppley

Indianapolis, Indiana

The Tear Trough Deformity – Its Anatomy and Surgical Correction

Friday, June 8th, 2012

One facial area that has caught a lot of attention over the past few years is that of the tear trough deformity. Technically known as the nasojugal grove, it is a skin indentation that begins at the inside of the lower eyelid and extends obliquely downward to the lower rim of the eye socket. While some people have it naturally, most do not and it is usually appears with aging. As the fat of the lower eyelid herniates or becomes protrusive, the depth of the tear trough becomes more apparent and deeper. This leads to the dreaded ‘dark circles’, which often drives patients to some form of treatment.

While the tear trough has been around for a long time and is a well acknowledged  deformity, why does it exist and what causes it? On this surface this question may seem somewhat irrelevant, but effective treatments relay on correcting the underlying anatomic problem.

In the June 2012 issue of Plastic and Reconstructive Surgery, a study evaluated the anatomic basis for the tear trough deformity. Through cadaveric facial dissections, an osteocutaneous ligament was found on the upper part of the maxilla which extends up into and through the orbicularis muscle on the inner aspect of the lower eyelid. This is why tear troughs exist and is know going forward as the tear trough ligament. How much of a tethering effect that this ligament has is one major determinant on how prominent the tear trough deformity appears. Other factors creating or exaggerating its appearance is bulging orbital fat above the ligament and infraorbital/maxillary bony retrusion below it.

The most common treatment of the tear trough deformity are injectable fillers, usually hyaluronic-based materials. (e.g., Restylane, Juvederm) By adding volume beneath the tear trough, the soft tissues containing the ligament are pushed outward, softening its appearance. This volumetric approach works best when the tear trough is mild and is very technique-sensitive. Injecting into the ligament and above it just under the skin will actually worsen its appearance.

A similar effect is seen with medial orbital rim or tear trough implants. Placed beneath the ligament and on the bony rim, they add a permanent volumetric outward push. The placement of implants is also assisted by the subperiosteal dissection used to place them. This inadvertently releases the maxillary origin of the ligament thus eliminating the tethering effect.

In cheek lift procedures, dissection should be carried across to the medial orbit rim to release this ligament. This will help soften the tear trough through the pull of the tissues lateral to the orbit over the cheek. Transposing orbital fat into the released tear trough space will help create a more permanent effect.

The tear trough deformity is more than just a simple skin indentation in the lower medial eyelid area. It is there due to the tethering effect of an actual ligament, which is why it changes in appearance with smiling and squinting. Injectable fillers temporarily efface it by adding volume. This is usually a good place to start for more mild tear troughs. Lower blepharoplasties with fat transposition is useful when substantial lower fat herniation (bags) exists. Tear trough implants can be used when one is younger with deep tear troughs and a flatter midface profile. Cheek lifts and ligament release are used as part of a more extensive facial rejuvenation approach in more advanced stages of aging.

Dr. Barry Eppley

Indianapolis, Indiana

A Modified Lower Blepharoplasty To Prevent Postoperative Lid Retraction

Thursday, September 8th, 2011

Aging of the eyes is the most recognized and often the first area of facial aging. It happens to everyone and is seen as excessive skin and hooding of the upper eyelids and bags and wrinkles of the lower eyelids creating a tired and aging look. This makes the desire for eyelift lifts and tucks, known as blepharoplasties, one of the most requested facial plastic surgery procedures. It is also one that I can call a ‘great value’ because its effects are seen with a more rested look to the highly visible and viewed eye area.

While improving the appearance of the upper and lower eyelids seems on the surface to be similar, they are significant differences that must be appreciated. The upper eyelid is the more dynamic of the two and is responsible for much of eyelid closure. It is a downward moving structure that has little risk of adverse lid position with skin and fat removal. (possible with disruption of the submuscular levator but this is out of the traditional surgical plane of dissection)

The lower eyelid, however, is a suspended structure that has relatively little closing motion and is held tightly against the eyeball through its tendinous attachments from the inner and outer corners to the orbital bone. Removing skin and fat of the lower eyelid can easily affect its horizontal position, creating a postoperative risk of lower eyelid retraction and undesireable eye symptoms such as tearing and irritation.

This has led to many modifications of the traditional lower blepharoplasty procedure to limit the risk of lid retraction and expedite recovery. The emphasis on skin removal and tightening (which is still needed for some patients) has been replaced by greater emphasis on limiting disruption of support structures and less skin removal. The focus has also changed to improving the shape and contour around the lower eyelid and cheek, not just how tight or wrinkle-free one can make the lower eyelid. This not only leads to less postoperative complications but a more natural and less risk of an ‘operated look’.

Some basics of the modified lower blepharoplasty include fat removal though the inside of the lower eyelid (transconjunctival approach), pinch skin excision (2 to 4mms removed), and a lower eyelid chemical peel. This works well in most younger patients who are generally under the age of 50. Older patients will likely need some additional components to the procedure including fat injections to the malar fat pad (for upward support and contouring), release of the orbicularis retaining ligament and lateral canthal support. (both for prevention of lower lid retraction from skin removal)

For those patients who have ever suffered a lower lid retraction after blepharoplasty, they can testify how uncomfortable and problematic it can be. It would have been far better to have a little extra skin and wrinkles on the lower eyelid than these problems. A more conservative approach that disrupts less of the support structures of the lid is a sound anatomic approach to lower blepharoplasty. Patients should be aware and counseled that the result will not be a perfectly smooth lower eyelid but a more naturally refreshed one.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Transposition For Correction of Tear Troughs

Tuesday, May 24th, 2011

Aging of the lower eyelid is typified by excessive skin and wrinkles and herniated infraorbital fat. It is this fat that often gives the appearance of lower eyelid bags and puffiness which is always greatest in the morning. This fat is typically removed, in varying amounts, in the commonly performed lower blepharoplasty. While making a dramatic improvement in the short-term, aging and further fat atrophy can create a diametric aesthetic result long-term with a sunken or skeletonized appearance if aggressive fat removal is done.

Today’s lower blepharoplasty surgery places an emphasis on three considerations; more fat retention with redistribution, less skin and muscle removal, and attention to lateral canthal tendon support. It is the idea of redistributing the infraorbital fat rather than simply removing it that has multiple aesthetic benefits. By removing the bulging areas of fat and moving it into the tear trough indentation below, a smoother lid-cheek junction results.

The newer lower blepharoplasty technique uses a transconjunctival approach. By making an incision on the inside of the lower eyelid, the orbital fat is exposed. All three compartments of fat, medial, central and lateral, can be either removed (if no tear trough exists) or transposed into an existing tear trough below. Fat is sutured to the rim of the lower eye socket by suturing through the lower eyelid skin with tie-over bolsters. These visible bolsters stay on for only 5 to 6 days after surgery. This moves the herniated fat over the edge of the bone, thus effacing the tear trough deformity

If one is young and herniated fat is the only issue, then fat removal and transposition is all that is done. If not, then some skin excision is done below the lash line fora few millimeters but no muscle is removed. This allows a good blood suply to be maintained to the lower eyelid skin. Once this incision is closed, then a 30% Trichloroacetic acid (TCA) peel is done. The peel is applied from just beyond the lid-cheek junction up to lose to the suture line under the eyelashes.

Only in those patients with some laxity to the lower eyelid, or some scleral show, get treated as the last step with a lateral canthopexy or tendon tightening procedure. This is usually older patients greater than 60 years of age.

Treatment of the tear trough with the creation of a smoother lid-cheek junction is an important goal in lower blepharoplasty today. This newer transconjunctival approach to the lower eyelid has much less risks for complication such as ectropion. (lower eyelid pulling away or down from the eyeball) It also produces a more natural result as the goal is not to see how much skin and fat can be removed or to make the lower eyelid as tight as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Getting Rid Of Lower Eyelid Bags with Blepharoplasty Surgery

Wednesday, July 21st, 2010

One of the earliest and most recognizeable signs of facial aging is what occurs around the eyes. Because of the constant movement of the eyelids, the sphincteric action of the surrounding muscle units, and the thinness of the eyelid skin, the effects of time (and sun exposure…and lack of a good skin maintenance program) first become noticeable in this area. These aging effects  are recognized as lines, wrinkles, and bags.


Wrinkling of the skin is easy to understand because it occurs all over the face. It is the eye bags that are harder to figure out why they are there. Everyone knows eye bags occur in many people but why they are there is more of a mystery to the general public. I know it is a mystery because of all the eye creams and potions that are marketed to improve it. Once one understands the cause of eye bags, it is easy to appreciate why they are impossible to eliminate with any cream.


The development of fullness under the lower eyelids is the result of fat…fat that was originally under the eyeball. Our eyeball is encased in a surrounding sea of fat and muscle. The fat serves as a natural cushion to protect it from outer compressive forces. It allows the eyeball to be moved around without risk of injury. The fat under the eye is naturally held back by a thin film of tissue that runs between the lower eyelid (tarsus) and the rim of the lower eye socket. With age this tissue weakens, allowing the fat it constrains to protrude out. In some ways, it is like a hernia which is why it is referred to as lower eyelid fat herniation.


Since fat is largely composed of water, it can get bigger or smaller based on one’s water content. Eyebags are well known to be bigger in the morning (being horizontal all night) or if one has eaten a lot of salty foods the night before. (water retention) The size of a lower eyebag can be slightly improved by cold compresses (or cut pieces of cucumber) and some type of topical astringents. But no type of cream can get rid of the protruding fat in any significant amount.


Eyebag removal can be done through two types of  eyelid (blepharoplasty) techniques. If there is a lot of extra lower eyelid skin, then a more traditional open bkepharoplasty is done. By making a fine incision just beneath the eyelashes, the skin can be lifted away from the eyelid, the protruding fat removed, and the extra skin removed as the eyelid incision is closed. Most men and women over age 50 need this type of eyelid surgery to make a real difference.


If one is younger and excess skin is but a minor issue, an internal approach can be used. By going through the inside of the eyelid (no incision on the outside), the protruding fat is removed through this scarless route. The little bit of extra skin can then be safely tightened through a medium-depth chemical peel on the lower eyelid.


‘Debagging’ the aging lower eyelids is an important part of making the eye area look better for many patients. How much skin you have determines whether the incision to remove the fat is done from the inside or the outside.


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


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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