Blepharoplasty: To pinch or not to pinch? (Photo)

Question

After a lot of thought (and unsatisfied results from fillers), I've decided to have the surgery to remove the fat pads from under my eyes. However, after a couple of consultations with different physicians, I find myself confused once more. I was told I should have a skin pinch with the procedure, but I'm petrified of being left with "droopy" eyes. Based on the photos provided, is a "skin pinch" necessary? Would my skin sag if I don't get it?

Timothy R. Miller, MD · Answer

Although the best recommendations would come after an in-office evaluation some suggestions can be made based on your photographs.The first step would be to make absolutely sure that any previous fillers are not causing any of the issues seen in the photographs.  Patients and some physicians are commonly surprised to learn that fillers injected into the lower eyelid are can persist for years (up to 5 years) and migrate.From the photographs it does not appear that you would require a "pinch" technique, and besides if a blepharoplasty was performed without the pinch technique and the results suggested you needed one, the pinch could easily be performed at a later date under local anesthesia and with minimal downtime.I would recommend that the blepharoplasty technique be a fat repositioning technique to avoid a hollowed look and you may consider fat augmentation in the cheek and peri-ornital area as well.The attached link and website provides more information.I hope this helps.

Stephen J. Pincus, MD · Answer

From the looks of your photos and the history you give, it looks like you have "malar edema" or puffiness under your eyelids…not periorbital fat. This can result from fillers being injected into the area and pulling in water. Occasionally, injecting hyaluronidase helps. If, in fact, it is malar edema, there are several possible approaches with variable degrees of success. You should seek the advice of a surgeon experienced in eyelid problems. A skin pinch would not help.

Michael A. Persky, MD · Answer

Hi Chamberlu,It appears that you will benefit from lower lid fat reduction.  I would recommend that alone.  If at some point in the future your lower lids appear to have excess skin, then a skin pinch procedure can be performed under local anesthesia in the office.  Good luck and be well.Dr. P

Mehryar (Ray) Taban, MD, FACS · Answer

Difficult to tell from photos but probably no skin removal is necessary as you are young, but that is something that can be determined better once the fat is removed/repositioned during surgery.  Notice I mention reposition the fat, instead of removal, to preserve youthful lower eyelids, instead of hollowness after fat removal. See link provided.

Kenneth D. Steinsapir, MD · Answer

You have what is known as a negative vector lower eyelid.  There is poor support for the lower eyelid and the top of the cheek.  The little bump at the top of the cheek is not really excess lower eyelid skin that will be corrected by what is called a skin pinch.  The reason is that this festoon is too far away from the lid margin.  A skin pinch is effective for loose skin close to the eyelid margin.  Your lower eyelids may easily be destabilized with almost any type of lid procedure and consideration is needed to performing prophylactic lateral canthoplasties at the time of lower eyelid work.  There is almost no visible herniated fat visible (at least in these photos), so I think you are actually asking for the wrong kind of lower eyelid surgery.  That will lead to a very disappointing outcome.  You are too olive for a chemical peel or laser procedure to tighten this area so I suspect that surgery will be your best option.  They key is which surgery.  To answer that, a detailed consultation is really needed.

Curtis Wong, MD · Answer

because your photos show your puffiness to be more consistent with malar bags.  A lower lid blepharoplasty will not help this.  What was wrong with fillers?  The transient nature or the ineffectiveness?  Regardless, if you have depressions, filler is good and my favorite filler is your own fat, assuming you have a little extra somewhere on your body. Microfat or nanofat grafting has been shown to be safe and with minimal risks for lumpiness.  As for the puffiness itself, if your lower lid fat pads are not prominent as your photo suggests, resurfacing of the puffy part can flatten it for the time being if you're accepting of the risks of laser.  Microfat liposuction has been also tried on the those pesky malar bags with some success and more recently, Thermitight has been effective as well.  Pinch blepharoplasties are reserved for those with excess skin and the patients willingness to accept a scar, albeit minimal.

Christine A. Petti, MD · Answer

Eyelid surgery-lower lid puffiness, dark color lower lid, some skin excess upper lid, more cheek fullness would help final lookI appreciate your comments.  I am basing my answer on your comments and also your photos, but I highly recommend a full plastic surgery consultation.  Based on the above data, I would recommend you have a lower eyelid transconjunctival approach--contouring the fat pads so there is a normal and natural contour and not the puffy appearance that currently exists.  There would be no external lower eyelid scar and no removal of skin in my opinion.  I would not remove any skin from the lower eyelid.  Skin can be tightened and made more youthful with peels at the time of the eyelid lifts, and this makes for a very natural outcome and no scars or lower eyelid distortion or pull down, scary post-surgery appearance.  You may also consider an upper eyelid lift, but from the photos - it is difficult to assess the amount of fat in the upper lid.  You would need a complete examination to assess this.  The upper eyelid skin is not very excessive--it may be removed surgically or it may be tightened with a fractional laser peel at the time of the eyelid surgery.  The peel can be used to tighten the skin of the entire eyelid region-upper, lower, crows feet and polishes the skin that remains after the surgical alterations.  It is very natural and as long as you have a skin prep with Retin A and Hydroquinone, you should be fine as far as pigment.  You appear to have olive skin complexion so that is why I am mentioning this.  This can be discussed at time of consultation.    Your brows always need to be assessed, and from the pictures appear to be in a normal position on or above the brow bone, so this is good.What I do see from the photos is that your eyes may look better with some added cheek volume.  Not to look like a freak, but just to add some support and projection to the cheek under the lower lid and in the area of what I term the C-sweep--the beautiful curve where you would put highlighter on the cheek bone in the upper cheek-eyelid area.  This is my assessment and I hope this is helpful to you.  You have beautiful eye, whether you have surgery or not.  Be careful, as you want to preserve a natural look.  Less is more!

George Sanders, MD · Answer

Hi!Your frontal photograph shows the white of each eye beneath the iris, known as scleral show. You also appear to have relatively weak cheekbones, and that may be the source of your scleral show. Because of this, I would recommend that you be very careful with a skin pinch. You may find that your lower eyelids pull down even morethan they do now because of your tendency to lower eyelid droop = scleral show. As far as the "fat pads" beneath your eyes, those may be areas of residual filler or evenareas of swelling known as malar bags. You need to make sure that they are really dueto fat before having surgery.

Kristina Tansavatdi, MD · Answer

From your pictures it does not seem you have enough excess skin to warrant a skin pinch. However, a thorough examination of the your lid contour, the amount of laxity, the amount of excess skin and the position of your eyeball in relation to the position of your cheek are all important findings to determine which surgery will leave you with the result you are looking for and yet prevent any "drooping" of the eyes.

William Portuese, MD · Answer

The photograph demonstrates herniated fat pads in all 3 compartments of the lower lids. The fat is removed through trans--conjunctival approach with the incision placed on the inside of the eyelids. When there is excess skin on the lower lids, a pinch technique is performed to remove a few millimeters of excess skin.This would only remove excess skin if there are wrinkles at rest, not upon animation. We close this incision with tissue glue.

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