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  • Skin Quality vs. Quantity: How To Choose the Right Procedure
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Female: One eyelid is wrinkly after an upper bleph. Is a revision in order? Is there a non surgical option? I had upper and lower blephs with an endoscopic brow lift almost five months ago. One eyelid is wrinkly and crepey. At my 12th week check up, my plastic surgeon said to wait and that it should work its way out. It seems to be getting wrinklier, not less. Is there anything nonsurgical that can be done to address this or am I looking at a surgical revision? My eyebrows have relaxed some, but I wish I had not done the brow lift.

Dr. Amiya Prasad: Thank you for your question. You have submitted some very good photos with your question. In your history, you described that you have had endoscopic brow lift with upper eyelid blepharoplasty and that you are concerned that about five months after it's been done that one eyelid is looking more and more wrinkly and crepey, and that you also closed your question with some regret of about doing the endoscopic brow lift. You've asked a reasonable question about the non-surgical options to address crepiness in the skin.

I think that the most important thing, of course, is to keep that open dialogue with your surgeon. Certainly you chose your surgeon based on your research and understanding that your surgeon and you had a good understanding of what to expect, but I'll share with you a little bit of the perspective of what I suspect may be part of what you're experiencing.

First of all, during a discussion about eyelid surgery and brow position, I make it a point to explain to my patients that there's a distinction to be made between skin quantity and skin quality. I've always tried to communicate that very often it is a perception that wrinkled skin equals excess skin. That is rarely the case. There may be some redundancy where there's both wrinkled skin and extra skin. Wrinkled skin is more about skin quality.

Now that being said, the strategy that your surgeon employed most likely was to do the brow lifting procedure, estimate the amount of skin to be removed in the upper eyelids, and then re-evaluate after the brow was elevated, because as you lift the brow, there's less skin over the upper eyelid.

Now as with many brow lifting procedures, especially endoscopic procedures, there's gonna be some regression. Initially the brows look very high and very often it's necessary to actually over-correct with that understanding that there's some regression. Again it depends on a case by case basis, but as the brow descends a little bit, then certainly there appears to be some more skin because that skin wasn't removed at the time of surgery.

In general, it is suggested, I think, by most cosmetic surgeons to allow six months to a year to transpire, so that the brow position is stable, and then you can see how much redundant skin or dermatochalasis there is, that excess skin. If you are concerned of the skin quality, well, skin quality is typically addressed by treatments such as laser or platelet-rich plasma, but I suspect that from your question that you are describing more of a redundancy, which means there appears to be more skin.

As far as nonsurgical approaches, you may get suggestions about heating devices or lasers. I would stay away from the heating devices 'cause in my experience and many, many people in the New York City Long Island area have been seduced by the very aggressive promotion of various heating devices, whether it's ultrasound-based or whether it's radio frequency based. There's a limit for how much you can lift a brow or even tighten skin. What we are seeing is that a lot of times the attempt to tighten or lift results in excess heat, resulting in actually the skin getting thinner. That's why, in our practice, we focus a lot on regenerative treatment such as platelet-rich plasma, as well as limited use of things such as fractional CO2 laser, or in darker skin patients, the use of something like Pelleve, a radio frequency device.

I think you should allow the brows to settle and see how much skin there is in the upper eyelid. If you're talking about redundancy, then an enhancement maybe necessary to get you closer to the ideal that you want to achieve. I can't stress enough; keep the communication with your original surgeon. Your surgeon knows your face and your eyes and was there. I'm sure you feel confident in your doctor's ability to do the work that was done and have this discussion about quantity vs. quality. Sometimes something simple as retinol or retin-A or something in the retinoid family can help improve those crepey quality skin without having an invasive procedure.

Have these discussions with your doctor. I hope that was helpful. I wish you the best of luck. Thank you for your question.

Skin Quality vs. Quantity: How To Choose the Right Procedure

Dr. Amiya Prasad discusses how eyelid skin is first decreased during eyelid surgery, then increased as the procedure regresses. Wrinkling of eyelid skin is actually a skin quality issue, not a skin quantity issue, which can be improved non-surgically