Dr. John Hilinski
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Eyelid Surgery

An eyelid lift, also known as blepharoplasty, is a procedure to recontour the upper and/or lower eyelids. Most blepharoplasty patients are unhappy with bagginess along the upper eyelid and puffiness below the lower eyelid. These types of changes involving the eyelids contribute to a tired or prematurely aged look.

Aging changes involving the upper eyelid typically reflect too much skin that appears to hang over the eyelid margin. When this occurs, you lose the normal crease just above the eyelid and this leads to that baggy, tired look. Many women are also frustrated by the inability to apply make-up to the upper eyelid because of excessive skin folds. Whenever upper eyelid blepharoplasty is being considered, one must also assess whether the eyebrow has descended enough to contribute to the problem. If this is the case, a browlift may need to be performed in conjunction with upper eyelid blepharoplasty to achieve optimal results. The upper blepharoplasty incision is designed to blend in with the existing but hidden natural skin crease. Redundant skin is removed and excess fat is taken out as needed. The incision is closed with the end result being a sharper, well-defined upper eyelid crease with a refreshed new look.

In contrast to the upper eyelid, lower eyelid blepharoplasty emphasizes removal of excess fatty tissue. Only in certain instances is it necessary to remove lower eyelid skin. Typically, there are no external incisions with lower lid blepharoplasty. The incision is usually hidden on the inside of the eyelid (termed transconjunctival blepharoplasty). In rare cases where an external incision is required (for excess skin), it can be readily hidden just below the eyelashes. Excess fat is removed from the individual fat compartments below the eye and the incision is allowed to heal from the inside out. The result is restoration of a smoother, more youthful lower lid contour.

Healthy men and women who are looking to improve aging changes of the upper and/or lower eyelids may be good candidates for blepharoplasty. Upper blepharoplasty is typically performed on patients complaining of heaviness of the upper eyelid and/or decreased d

efinition of the skin crease extending across the upper lid. Lower blepharoplasty is typically performed on patients bothered by unwanted bags or puffiness along the lower eyelid, which may also be accompanied by dark shadows or dark circles under the eyes.

Blepharoplasty is usually performed under local anesthetic with sedation as needed. The procedure typically takes place in an outpatient surgery setting, though the upper eyelid lift can be performed in the office setting with just local anesthesia. Upper blepharoplasty generally takes less than an hour to complete while lower blepharoplasty may take up to one and a half hours to complete.

Patients are able to go home soon after the surgery is completed. Swelling and bruising can be minimized by elevating the head while sleeping and applying cold compresses. Any pain that patients experience can be controlled with low-dose prescription medication. The sutures are removed within four to seven days after surgery. Swelling subsides within a few days and patients are usually presentable in public and able to return to work within seven to ten days. By 2-4 weeks, it is difficult to tell that you ever underwent surgery.

Lower Eyelid Lift – Case Example

This is an example of a lower eyelid lift, or blepharoplasty, to address unwanted shadowing around the eyes. This particular patient exhibits what many patients classically refer to as ‘bags’ under the eyes. Others describe eyelids like this as being excessively puffy. Most lower blepharoplasty patients like this one present to the facial plastic surgeon complaining that they look excessively tired all the time, despite feeling just fine. In many cases, patients are more bothered by other people constantly asking them if they got enough sleep the night before. Since we typically interact with others while looking at their eyes, issues like this can be quite distracting.

The puffiness under the lower eyelid really represents abnormal protrusion of the fat that originates underneath the eye. In fact, most patients have three different pockets of fat under each eye. As shown in the adjacent photo diagram, you can see where the three different fat pockets are situated under the eye. Some plastic surgeons describe this protruding fat as acting like a hernia does in that tissue pokes out through an abnormal opening in a wall. However, this is not entirely accurate when it comes to lower eyelid fat. It is technically called ‘pseudoherniation’ because the fat does not come through an opening under the eye. It actually pushes against a weakened thin wall called the orbital septum that normally has enough strength to keep the fat back underneath the eye. When the orbital septum can no longer contain the fat underneath the eye, it pushes forward and creates this unwanted puffiness. The orbital septum can be congenitally weak, as in this case example, contributing to onset of eyelid puffiness at even a young age. In other cases, the orbital septum becomes weakened due to aging changes with onset of eyelid puffiness later in life.

There are two main options for removing this type of excess lower eyelid fat. One involves making an incision in the skin just under the eyelashes. The other, which was used in this blepharoplasty case example, involves making an incision inside of the lower eyelid (called a transconjunctival blepharoplasty incision) to avoid any external scarring. The conjunctiva refers to the lining around the eye and the inner surface of the eyelid. Transconjunctival implies that we are making an incision across (trans) this lining during the eyelid lift. In this particular San Diego eyelid lift patient, we opted for the transconjunctival incision since the goal was to remove only the excess fat and there was no need to trim any of the eyelid skin given her young age. As you can see in the adjacent blepharoplasty diagram, the lower eyelid is pulled outward and down to allow exposure of the conjunctival surface where the incision is made (see red arrow showing the surgical approach). The excess fat is then exposed by very careful surgical dissection. In many cases, like this one, the excess eyelid fat is simply removed. In others, we actually will redrape the fat into a new position. This is called a ‘lower eyelid fat repositioning’ procedure. This option is used in cases where the fat can be ‘recycled’ by placing it in an adjacent area next to the cheek to help provide a smoother lower eyelid contour. Once the fat has been reshaped under the eyelid, the incision is allowed to close.

This type of eyelid lift can be done under IV sedation (or a general anesthesia if you prefer) in less than an hour typically. Most patients look fairly presentable in the public eye within 7 days with only mild swelling and bruising noted during the first few days of recovery.

Here are the before and after photos of this particular lower eyelid lift patient. As you can see, she has a fairly marked visual improvement in her lower eyelids. She no longer has the bulging contour under her eyes and the abnormal lower eyelid shadowing has been greatly diminished.

Do you have additional questions about Eyelid Surgery? Click here to visit our frequently asked questions or contact our office to schedule a consultation.

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