Plastic Surgery
Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘lower eyelid lift’

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 The emphasis on skin removal and tightening (which is still needed for some patients) has been replaced by greater emphasis on limiting disruption of support structures and less skin removal.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

Treatment Options for Dark Circles Under The Eyes

Sunday, January 25th, 2009

Dark circles under the eyes is a frequent request for treatment by patients coming in to see for many different issues. The plethora of available treatments on the internet from vanishing and bleaching creams to laser surgery is a testament to the commonality of the problem. It also suggests that most of these treatments are not effective because they simply don’t work or are used on the wrong type of dark circle problem.

By anatomic location, lower eyelid skin is darker than the skin on the rest of the face because it is very thin (and can show the color of the underlying muscle) and due to shadows from the overhanging brows. When exaggerated dark circles are present, there are several reasons why they may be there including thinness of the lower eyelid skin, hyperpigmentation, hemosiderin staining,  deep set eyes, and the arcus deformity.

Diagnosing which of these causes of dark circles is obviously critical to selecting what may work. In general, dark circles are hard to treat and there is no magical solution. The goal of dark circle treatment should be improvement but do not expect a complete cure. (no matter what the marketing hype says)

If the problem is thin skin, there is little that can be done to substantially thicken it. Vitamin A and C creams and pulsed light treatments may provide some improvement over time. But these are really unlikely to make significant improvements.However, camouflaging the dark with concealers or mineral makeup-based foundations is the most effective and cost efficient approach for thin skin.

Hyperpigmentation is a common cause  and is often seen when substantial lower eyelid bags are present as well. It is a very common cause in dark-skinned patients. When large eyelid bags are present, standard lower blepharoplasty (eyelid tuck) should first be done. This will not make all the hyperpigmentation go away but it will help. A secondary chemical peel, such as 25% or 35% TCA can also be done although there is the risk of causing hyperpigmentation by doing a chemical peel also in some patients. The key is to use melaniin-suppressing creams before and after a chemical peel.  Lower eyelid hyperpigmentation can also be treated by topical creams that contain retin A (exfoliating) and hydroquinone (bleaching) agents. My current favorite is TriLuma cream (available by prescription) because it contains Retin A, hydroquinone, and steroids all in one. This has to be used for several months before any improvement can be expected. In very resistant hyperpigmentation, the use of intense pulsed light (BBL, Broad Band Light) may also be tried but the power setting should be low and careful eye protection done. It will require several BBL treatments to get much improvement.

There are also some cases of dark circles that are due to leaching of blood products (hemosiderin) into the thin lower eyelid skin. Once has to look very carefully to separate this from hyperpigmentation. Topical Vitamin K or creams that contain arnica may be helpful. Pulsed light that is filtered for 560 or 590nm wavelengths may also be effective.

Deep set or hollow eyes as a cause of dark circles requires a surgical solution. The bone on the lower rim of the eye is deficient or flat causing the lower eyelid to indent in. This pulls the lower eyelid in, exaggerating the natural shadowing effect. The area under the eyelid must be built out using either fat grafts, orbital rim implants or fat transposition. Lower eyelid fat transposition is the simplest and most reliable method. By releasing fat from underneath the eye and bringing it out over the rim of the bone, the lower eyelid is better supported and the depth of the hollow is decreased. (as well as the shadowing) Implants also bulk up the bone but the thin skin of the lower eyelid may make it possible to feel or even see them. Free fat grafts are soft and pose no potential problems of infection or feeling them but they are unreliable as to how much will survive after surgery.


The arcus deformity is an often undiagnosed dark circle cause. It is caused by an abnormal attachment of the lower eyelid to the bone which makes the lower half of the eyelid dip in while the upper half is loose and filled with fat which bulges out from under the eye. As one ages, this lower eyelid look worsens creating darker and darker circles. This arcus deformity can be released through a transconjunctival (inside the lower eyelid) approach, allowing fat to balloon out into the dark circle area. In some cases, fat grafts can be added as well to further bulk up the area.


As the many causes of dark circles suggest…there is no one magical solution. That is why there are some many products and methods out there. The key is to knowing why the dark circle are there. Otherwise one is throwing darts at a target…blindly. Improvement in dark circles of the lower eyelid is possible but identifying the cause is critical…something internet products and home remedies do not do.

Dr. Barry Eppley

Indianapolis, Indiana

Medical History in Plastic Surgery at IU Health West Hospital

Sunday, December 23rd, 2007

Joint Gynecological and Plastic Surgery makes Medical History at IU Health West Hospital with Dr Barry Eppley

Plastic Surgery is commonly performed as the reconstructive part of an operation with many surgical disciplines from General Surgery, Urology, Pediatric Surgery, Neurosurgery, Orthopedic Surgery as well as Obstetrics and Gynecology. It is rare, however, that cosmetic plastic surgery is done at the same time, on a different part of the body, with other surgical disciplines.

Such was the case on December 19, 2007 at IU Health West Hospital in Avon, Indiana. A 45 year-old female underwent a combined Gynecologic and Plastic Surgery operation. Dr. Kelly Kasper of IU Ob-Gyn performed a laparoscopic hysterectomy. During the one hour that it took her to complete the procedure, Dr Barry Eppley performed cosmetic surgery of the eyelids including removing excess skin and fat and tightening of the lower eyelids with a chemical peel. (lower eyelid lift) Both Gynecologic and Plastic Surgery were done at the same time in a one hour time period.

While neither operation is unusual, performing both at the same time is and, in my experience, has never been done at the same time before. Such coordination between surgeons allows wonderful benefits to be gained by patients in a cost-effective manner.

Dr Barry Eppley

Indianapolis, Indianapolis

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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