Both information points are correct regarding approaches to a blepharoplasty. What is most important however is for you to chose the best blepharoplasty surgeon and not the technique. That is their job. Expert Eyelid surgeons include Board Certified Plastic Surgeons, Facial Plastic Surgeons (ENT), and ophthalmology. There is no such thing as a "eyelid fellowship". The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon. See the below link on how I would research the identity of the best plastic surgeon for your eyelid surgery.#BestEyelidSurgeon
Based on the photo you provided, it appears that there's no need for an external incision under your lashes. In fact, you might not need any incisions at all. Of course, it's sort of a glamour shot and you're smiling somewhat so it's hard to say for sure.
You appear to have hollowness under your eyes. This can be corrected either with fat transfer surgery or Restylane injections. Whatever you do, do not have any fat removed under your eyes (you don't appear to have any!)
I would need to examine you in person to know for sure if this preliminary evaluation is accurate.
This is an impossible question to answer without an examination. The "best" procedure depends on your clinical examination. If you have received different ideas from different surgeons you should either go see another plastic surgeon or even an oculoplastic surgeon (specializes in eyes) to get a third opinion!
You need to be comfortable and understand your decision before you proceed....
I prefer doing most blepharoplasties from the "inside" or through a tranconjunctival approach. I agree with Dr. Berkowitz regarding the benefits of this approach. If the over lying skin requires tightening, then I use Fraxel re:pair fractionated CO2 laser; sometimes I will use the older traditional CO2 laser.
Mixto is a good fractionated CO2 laser. Whether it is right for you is difficult to answer without examining your skin, and knowing what your expectations are. Good luck and be well.
Lower eyelid blepharoplasty can be performed from both the outside (transcutaneous) or inside (trans conjunctival) of the eyelid. 99.9% of the 3000 cases I have performed as an Ocular Plastic Surgeon in Sterling Hieghts, Michigan have been transconjuctival. The advantage of my technique is: NO stitches; NO skin incision, and NO Scalpel blade. I perform the procedure with the MIXTO laser.
This carbon dioxide (CO2) laser allows me to gently remove the fullness ( fat) from the inside of the eyelid. The beauty of this laser is that it stops bleeding as it removes this tissue so the surgery is faster and my patients have less swelling (than traditional methods) and get back to work faster. Instead of removing skin which can leave a tell tale scar line underneath the lashes, I tighten the skin with the Mixto laser! The Mixto is phemomenal to resurface (refresh) the skin. Smoothing of the skin with the laser is a perfect accompaniment to lower eyelid surgery.
I have found in most patients that removing most of the fat from the inside and then tightening the skin on the outside works the best. In some patients who are young I don't tighten any skin or make an external incision but these are patients under 40 who I think the stretched skin from the fat will shrink back into position. So to answer your question both is a good option. Without looking at you in person it is hard to tell how much fat you would need removed if any and what the best technique is for you in particular. A non smiling photo (mug shot style) is better to evaluate you in rather than the photo you have submitted.
Each and every surgical procedure should be individualized to the specific patient that is being treated. No single surgical technique is suitable for all patients. Having said this, my most common approach in the lower eyelids is through a transconjunctival incision (made on the inside of the eyelid so that there is no visible scarring). The surgical technique I prefer involves repositioning both the fat and muscle of the lower eyelid. Occasionally, the skin must also be removed in the lower eyelids. In the upper eyelids, a combination of removal of skin, muscle, and fat is commonly used. The most effective technique is always individualized for each patient.
The lower eyelids must be evaluated in terms of excess skin, protruding fat pads (bags), and laxity of the eyelid. Only after properly assessing these issues, can the best approach be determined.
It appears that your concern may be fullness of the lower eyelids without excess skin. Fat transposition is a good option because it does not result in a hollowed out look and uses the local fat to fill in the depression beneath the bags. In essence it decreases fullness in one place and fills another, therefore you get 2 benefits with this technique. Fat transposition may be performed through either the inner or the outer approach. Because you don't require removal of excess skin, the inner eyelid approach may be better for you.
Your photo is difficult to analyse but I can tell you that there is rarely a need to do a lower blepharoplasty for fat repositioning or fat removal with an external incision. If there is a need to remove skin then you do need an external incision but it does not appear that you would require that. You can have your lower eyelid skin tightened with a chemical peel or fractionated co2 laser if it is slightly crepey or loose.
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