Article by Hisham Seify, MD, PhD, FACS
Los Angeles Plastic Surgeon
Occuloplastic Surgery involves cosmetic and reconstructive surgery of the eyelids. This includes a large number of post surgical, post traumatic, and congenital conditions. The cosmetic portion of Occuloplastic surgery deals with upper and midfacial aging using advanced techniques in Blepharoplasty, Midface Lift, and Endoscopic Brow Lift.
Different Occuloplastic Procedures:
BLEPHAROPLASTY (Eyelid Surgery)
Upper and lower eye lid surgery is one of the most common cosmetic surgery procedures performed by Occuloplastic surgeons. This information is put together as to help our patients understand the different aspects of this highly technical procedure.
Droopy eyelids can make you look older and can also impair vision. In many cases it is the first sign of facial aging. A tired, staring or stressed look are one of the main complaints voiced by our patients.
Upper Eyelid surgery (Upper Blepharoplasty) deals with the excess skin and fat in the upper lid. The skin is accurately measured and trimmed, the fat is conservatively excised. In select cases, the upper lid levator muscle could be tightened and the crease is well sutured.
Asian upper eye lid surgery recreates the absent crease if needed. Excision of excess skin without crease modification is also possible.
Upper eye lid surgery could be combined with brow lift or corrugator muscle release (permanent Botox effect). A browpexy could also be done through the same upper eye lid incision.
Upper eye lid ptosis (lazy eye lid) is divided into different groups based on the initial cause. The two main groups include congenital and acquired. Most cases encountered in the adult population are acquired and include a dehiscence of the muscle aponeurosis and not a functional muscle problem.
Lower Eyelid Surgery (Lower Blepharoplasty) removes the excess skin and redrap the fat pads over the upper cheek area, eliminating the deep eye lid/cheek lines. Different approaches and techniques exist e.g. Transconjunctival blepharoplasty, transcutaneous Blepharoplasty (with or without Midface Lift), Lower Blepharoplasty with canthal reconstruction.
A. Transconjunctival Blepharoplasty
This technique leaves no incisions on the skin surface. The fat pocket is approached from the inside of the eye lid. It is an ideal technique for patients with minimal skin laxity and moderate fat pads. Laser or peel resurfacing could be combined with this technique to insure skin tightening.
B. Transcutaneous Blepharoplasty
This is an open technique that allows exposure to the lid structures and redraping of the fat, muscle and skin. Despite the external skin incision the final scar is well concealed and is very difficult to detect.
C. Transcutaneous Blepharoplasty with Cheek Lift
A very popular technique that reverses the aging of the lower eye lid and the midface lift. A near full facial rejuvenation could be achieved through this approach.
D. Transcutaneous Blepharoplasty with cheek lift and fat grafting
If there is marked loss of facial volume, the addition of micro fat injection allows a 3-D restoration of the face.
E. Canthal reconstruction
The medial and lateral canthi together with the supporting ligaments act as a framework for the lower eye lid. This insures stability and efficiency in protecting the eye. Canthal support is added to lower blepharoplasty cases to avoid any post operative complications.
Revision and reconstruction of the Lower lid following cosmetic blepharoplasty:
The lower eye lid is a highly specialized and delicate structure. The ultimate goal of the upper and lower lids is to achieve protection and proper hydration of the cornea.
The following are the possible problems encountered and their management:
Ectropion: Retraction of the lower eye lid from scar formation leads to exposure of the cornea, dryness and subsequent perforation potential. This could be a surgical emergency that requires immediate attention.
Mild cases respond to lower lid massage, night ointment and eye drops. Moderate and severe cases require surgical intervention with canthal support, alloderm reconstruction and muscle flap.
Lower lid reconstruction following tumor excision or trauma:
Lower lid cancer excision could lead to the creation of a defect that requires reconstruction .The procedure of choice depends on the extent of the resection and the availability of local tissues. Different flaps are available to rebuild the skin, muscle and conjunctiva (inner lining) of the eye lid.
Are you a good candidate for eyelid surgery?
As with all plastic surgery procedures, good health and realistic expectations are prerequisites. Blepharoplasty removes the excess fat, muscle, and skin from both upper and lower lids. The results can be a refreshed appearance, with a younger, firmer eye area. People with severe circulatory, ophthalmologic, or other serious medical conditions must rely on the diagnostic skills of their own personal specialists to determine whether blepharoplasty is an option to consider. Consultation with a board certified plastic surgeon can help you decide whether any additional, complementary surgery would increase the success of the surgery.
Choosing your plastic surgeon
Whether the surgery is desired for functional or cosmetic reasons, your choice of a qualified plastic surgeon is of paramount importance. Board certification, proper training, hospital affiliation, society membership etc... Are among the main things that we advise our patients to check before requesting a consultation.
During the pre-surgical consultation, you will be examined or asked to answer queries concerning vision, tear production, use of lenses, and your desires for surgery. Your surgeon will explain what you can expect from blepharoplasty and take a complete medical history. Factors to be weighed include age, skin type, ethnic background, and degree of vision obstruction. Furthermore, you can expect an open and honest exchange between you and your surgeon, which will establish the basis for a successful outcome.
After a mutual decision is made by both you and your surgeon, the technique indicated for your individual surgery will be discussed. The type of anesthesia, the surgical facility, any supportive surgery, and the risks and costs inherent in the procedure will be outlined.
Understanding the Surgery
In upper eyelid surgery, the surgeon first marks the individual lines and creases of the lids in order to keep the scars as invisible as possible along these natural folds. The incision is made, and excess fat, muscle, and loose skin are removed. Fine sutures are used to close the incisions, thereby minimizing the visibility of any scar.
In lower eyelid surgery, the surgeon makes the incision in an inconspicuous site along the lash line and smile creases of the lower lid. Excess fat, muscle, and skin are then trimmed away before the incision is closed with fine sutures.
Newer techniques involving redraping the fat rather then complete excision are preferred. Proper knowledge of different factors related to eye lid tone and closure insures a safe outcome. Special training in Occuloplastic surgery is a plus.
Eyelid puffiness caused primarily by excess fat may be corrected by a transconjunctival blepharoplasty. The incision in this case is made inside the lower eyelid, and excess fatty material is removed. When sutures are used to close this kind of incision, they are invisible to the eye. They are also self-dissolving and leave no visible scar. Under normal conditions, blepharoplasty can take from one to two hours.
What to Expect After the Surgery
Immediately after the surgery has been completed, your surgeon may apply tiny sterile bandages. This is not done for transconjunctival blepharoplasty. It is not crucial that the eyes be covered. However, an ointment to prevent dryness of the eye area may be used. A certain degree of swelling and bruising is normal. Cold compresses, as well as head elevation when lying down, will enhance healing and relieve discomfort. Your surgeon will prescribe medication for discomfort.
For a week and a half following blepharoplasty, you will clean the eye area (the eyes may feel sticky, dry, and itchy). Eye drops may be recommended. Your surgeon will also list activities and environments to avoid in the weeks immediately following surgery. Permanent stitches will be removed in five to seven days after surgery. Self-absorbing stitches will dissolve on their own.
Insurance does not generally cover surgery that is done purely for cosmetic reasons. Surgery to correct or improve vision or surgery for eye deformity or injury may be reimbursable in whole or in part. It is the patient's responsibility to check with the insurance carrier for information on the degree of coverage
Plastic surgery makes it possible to correct many facial flaws and signs of premature aging that can undermine self-confidence. By changing how you look, facial plastic surgery can help change how you feel about yourself.
Special topics related to eyelid surgery:
1. Ptosis: Droopy eye lid due to abnormal muscle or other tissues is a common finding during blepharoplasty consults. Special attention to this finding during surgery is of paramount importance to insure a good outcome free of complications.
2. Cheek lifts (midface lift): A commonly used technique in conjunction with lower lid surgery to insure proper redraping of the mid face and restoration of a smooth eye lid –cheek junction. No additional incisions are required for this approach .The degree of midface dissection is related to the degree of the deformity.
3. Fat grafting: An important part of the mechanism of aging is loss of facial volume. We like to ask our patients to bring old photographs to the consultation to study the facial changes and the need for adding volume through injection of fat. (Please refer to the section on fat grafting for more details).
1- Seify, Hisham MD; Hester, T Roderick MD. The Use of Micro fat Grafting in Periorbital Rejuvenation: Review of 100 Consecutive Facelifts: 24.Plastic & Reconstructive Surgery. 116(3) Supplements: 31-32, September 1, 2005.
2- McCord, Clinton D. M.D.; Seify, Hisham M.D.; Codner, Mark A. M.D. Transblepharoplasty Ptosis Repair: Three-Step Technique. Plastic & Reconstructive Surgery. 120(4):1037-1044, September 15, 2007.
3- Seify, Hisham MD; Hester, T Roderick MD. The Use of Micro fat Grafting in Periorbital Rejuvenation: Review of 100 Consecutive Facelifts: 24.Plastic & Reconstructive Surgery. 116(3) Supplements: 31-32, September 1, 2005.
4-The American Society of Plastic Surgery (ASPS)
5-The American academy of facial Plastic & Reconstructive Surgery.
6-The American Society for Aesthetic Plastic Surgeons.(ASAPS)