How Eyelid Surgery Works [Part 1 of 2]

Announcer (00:01):
You are listening to Head On with your host, board certified plastic surgeon, Dr. Bahman Guyuron.

Dr. Guyuron (00:07):
The most common reason that patients ask for our opinion about the eyelid surgery could be the redundant skin of the upper eyelids or bags within the lower eyelids. Although when we examine the patients commonly we find some other aspects of the aging that can influence the upper or lower eyelids. The other reason that some patients actually ask for help in their lower eye is a discoloration or dark circles under the eyes. Dark circles under the eyes are complicated matters. It could be related to the hyperpigmentation, meaning pigment, deposits in the lower eyelids, or they could be actually because of the bags under the eyes and hollowness that cause the discoloration of the eyelids. And it is actually not uncommon problem, and we do have a solution for each one of these. There are rare occasions that darker discoloration onto the eyes can be treated with hydroquinone, which is a bleaching cream, but most of the time that doesn't work so well.

(01:32):
And often it is the laser treatment or combination of laser treatment and fat injection or fat injection alone. It's amazing actually how often injection of fat in the lower eyelids cannot change the color of the skin and make it lighter. Some of the available and scientifically proven medication that may have some benefits in the lower eyelids includes the RetinA, which can actually improve the eyelids to some degree, but not a great extent. It doesn't replace the surgical treatment. What I'd like to talk about also actually the combination of things that can happen in the lower is as a result of aging. Aging is the process in the lower eyelids that produces combination of changes in the lower eyelids including redundant skin, hollowing of the upper eyelids, hollowing of the lower eyelids redundant skin in the lower eyelids loosening of the ligaments that hold the lower lid up, or even a pigmentation change, meaning darkening of the lower eyelids.

(02:59):
And when we do analyze the eyelids for the plasty, which is the medical term for correction of the aging eyelids, we actually look at every aspects of the aging that can influence the eyelids. And because of the multifactor and nature of the eyelid aging, we have to individualize eyelid surgery. There is no single solution for that is appropriate for every patient. So we may remove redundant skin, we may remove fat from the lower eyelids and we may inject fat in the upper eyelids, lower eyelids, we may tighten the muscles, we may tighten the ligaments, tendons that are holding the lid up in order to take away the looseness of the lower eyelid that can result in eyelid being pulled down. One of the most common changes that we see on the eyelids actually is called the eyelid ptosis. Eyelid ptosis means loosening or a stretch of this muscle that opens the eyelid.

(04:22):
Over 50% of the individuals beyond age 50 have this condition in a variety of degrees. Some patients have a mild version of it, some patients have severe version of it. The reality is that correction of that is an integral part of achieving a successful eye surgery. And this has a surgery that not only improve the eyelids, opens the eyelids, make the patients look more awake, more energetic. It also is a functional surgery because patients who have eyelid ptosis, they're not opening their eyelids wide enough to see the entire visual field. And if they have a test that is called visual field exam, most likely it is going to reveal a degree of blockage of the visual field. And when we open up the eyes, they actually see more of the room, more of the view. They more have a bigger view than they used to have.

(05:38):
So it is a combination of functional and aesthetic surgery. If the visual field exam shows that there's indeed substantial, substantially enough blockage of the visual field, the insurance may cover actually that part of the surgery, meaning eyelid ptosis correction. And if the skin drapes over the eyelashes enough to block the visual field, again, the insurance may cover the upper eyelids surgery. Ironically, there is no specific age for the eyelid surgery, meaning that I have done eyelid surgery on teenagers. Those who have genetically disposition to have fat on their back under the eyes, and even at age 16, 17, they look like they're tired, but they're not tired. And what we do is actually through a small incision inside the lid removes those back and it really makes the eyelids look very different and more energetic, less tired. But obviously as we get the third and fourth decade of life, the indication for the surgery changes and that group of patients, it is the beginning of the aging.

(07:13):
Again, bags may appear that they were not there. That again, is a genetic disposition. Not everybody actually shows bags under the eyes, fat packs, and usually it runs in the families. So commonly the patients come to us and tell us, I don't want to look like the way my dad looked, the way mom looked at older age. They have a lot of bags under the, yeah, usually that's genetic and we just remove those bags. Part of the reason that the eyes are in a position that they are and their eyes open the way they are is a combination of volume in the eye socket. Some of that volume is fat, and fat is absorbed or dissolved. As a result of emaciation, the eyes are going to look hollowed and that can happen as a result of aging as well, and the eyelids can look depleted.

(08:28):
That is why the contemporary eyelid surgery includes injection of some fat in the upper or lower eyelids to restore the volume that is lost. If fact, if you look at the pictures of a lot of young attractive individuals, they have fuller eyelids than those who have aged. And that used to be actually a part of aging that we could not for a while correct it. But for the last two decades, we've been able to improve that part of the eyelid. Also invariability today, those of us who specialize in the face and eyelid area do not do eyelid surgery without some fat, restoration of the fat. So fat can be lost because of weight loss can be lost because of aging, and we can restore that. And it may actually sound like oxymoron that we are actually removing fat from one point and adding fat. The reality is that fat bags are in the wrong place where we remove from that wrong place and we add fat below where they were creating the fullness because of fullness, they were creating the hollowing and that way we can actually create a smoother lower lid.

(10:03):
Again, fat contains the stem cells and the stem cells also rejuvenate. The skin fat that we use to inject in the eye usually comes from the lower abdomen where generally there is accumulation of fat that we don't need it. We remove with a dull cannula or needle and remove from the abdomen, inject it in the area with a dull needle. So for fat injection in the eye, we actually don't need any cuts to be made anywhere. It is just the injection in general is a very safe operation. And what we do is make it even safer by injecting the eyelids with agents that will shrink the vessels because one of the complications, serious complications of fat injection in the isles and fat can get into the vessels and can damage the vision. But those of us, again, have a lot of experience doing this and know how to minimize that potential.

(11:14):
In fact, I've been doing fat injection the eye for over 25 years. Fortunately, I've never seen any visual loss in the eye. But there are reporter cases in the literature that we know that that's the possibility that fat can get into the vessel. So again, we shrink the vessels with the epinephrine, Neo-Synephrine and inject the fat, which will minimize the potential for fat getting into the vessels. Fat also can potentially be lumpy, meaning take irregularly. If it happens, it's correctable or can be absorbed. We know that part of the injected fat goes away. So what we do is inject it a little bit more than what we need. And generally, those of us, again have a huge experience in this area, have figured out how much we need to inject to accomplish the intended goals. In general, the patients who need eyelid surgery, one of the areas that we have to look at in the position of the eyebrows, because if the eyebrows are too low can actually create fullness in the upper eye or redundant skin in the upper eye.

(12:37):
That actually is because the eyebrows are too low rather than eye is having too much skin. So again, those of us who are experiencing this area, we take that in consideration and there are patients that may just need an eyebrow lift rather than eyelid surgery. The patients that they need eyelid surgery, the patients who need combination in order to have the optimal results. So that's an integral part of what we analyze. The other fact that the other combination surgery that we do with the eyelid operation is facial rejuvenation. Other parts of the facial rejuvenation, meaning tightening of the skin of the face, tightening of the neck, removal of fat. And sometimes again, we do use laser in the lower eyelids or the entire face to improve the quality of the surface of the skin. The function of the laser is almost like what we get from painting of the building after renovation.

(13:52):
If you renovate the building, and you don't paint, it is not going to look great. So in the eyes also we have the same factor and if we make it smoother but it is discolored or has fine line wrinkles, laser is going to take care of that. Most of us specialize in the face area, have variety of lasers, and depending on what the condition is, our choice is going to be different. And for the low, right, generally the need for the laser is because of the discoloration or fine lines. The best laser for that is the CO2 laser. We can get obviously improvement from the Sciton HALO ProFractional, and even from Morpheus8, but they don't accomplish exactly what the CO2 laser is going to do in the lower eyelids, which is combination erasing the discoloration and removing the fine wrinkles. And the laser can actually be used at the time of eyelid tightening and or removal of bags as long as we don't do what we call skin flap technique.

(15:09):
They're two major surgical ways of tightening the skin of the eyelid. One is raising the skin and muscle, which is muscle that closes the eyes called orbicularis muscle. And the other one is raising the skin alone and lifting and draping, removing the redundant portion. As long as we don't do the skin flap, only laser can be used. But if your skin flap is raised as a separate entity, delivery of the laser will be slightly more risky in terms of delayed healing and loss of skin. So it is something that we don't commonly do. The benefits of not dividing laser delivery and surgeries, that there is only one surgery, one recovery because usually for the eyelid surgery we need some anesthesia and we do, if we also deliver CO2 laser, we need anesthesia. So if we divide them, there'll be two recoveries, two procedures and two startup anesthesia facility costs that they can be combined if we do them at the same time.

(16:27):
When you think about the eyelids next to the brain, they're the two most important organs in our body. So we have to protect them for by any price. So we carefully examine the patient well before even I operate on the patient or even consider operating the patient. I'm going to know more about the patient's overall health, blood pressure, heart condition, lung condition, and eye exam. My first question to the patient is actually when was the last time you had an eye checkup? Because the more I know about the eyelid health, the safer the operation is going to be. And if they didn't have any eye checkup within a year of the surgery, I'm going to insist on having an eye checkup before I do the surgery and after that, and then after I make sure that the patient is ready, good candidate for the surgery.

(17:34):
And I'm going to examine the eyes. And again, I'm going to look at the entire face. I'm going to look at the eyebrow position, eyelid position, eyelid function and tone of the eye is that we have a specific test that we do to insure that the operation is going to be safe and sound. Or I may have to again remodel my procedure in order to give the patient the best result that I can. Assuming that the patient is good candidate, the surgery is going to be done as an outpatient operation under anesthesia. Can it be done under local anesthesia? Yes, specifically if it is the upper eyelid, redundant skin alone. But if it's a combination of upper eyelid surgery, low eye surgery, fat injection, I prefer to do it under general anesthesia. Usually general anesthesia in our facility means light anesthesia, which it boils down to the fact that the patient is not paralyzed. The patient receives enough medications not to know what's going on. And at the end of the operation, the minute they shut off their medications, patients wake up and go to the recovery room for 45 minutes an hour, then go home. And if they're from out of town, out of country patients, they're going to go back to the hotel room. The upper eyelid surgery is done through an incision that is placed in the eyelid crease. And we conceal that in such a way that often after everything heals, you can't tell that the patient has surgery.

(19:27):
Fortunately, the eyelids are the most forgiving part of our body in terms of healing. On the other hand, they are one of the unforgiving part of our body for any error in the calculation of what we need to do. So we are extremely precise in what we do, measure exactly what we are going to be removing and how much of skin we're going to be leaving behind. So when the patient's asleep, the upper eyelid would not remain open. Unfortunately, I have seen that in earlier stages of my career. Fortunately very, very few. But I have seen also being the person who does this routinely, I see complications from other colleagues also, but most of our colleagues know what to do to minimize the complications. So we remove just the redundant amount, measure it while the patient is lying down, confirm it while the patient is sitting up, and again, place the incision in such a way that would heal inconspicuously.

(20:49):
We have a number of patients who have allowed us to use their pictures in my website. However, we have more pictures in my office because some patients only allow us to show their pictures to the other patients in the office setting. And we respect the patient's privacy rights and we do not ever show any pictures of patient to somebody else, even their friends or family members without the patient consent. For consultation about blepharoplasty, you can call my office (440) 461-7999. Again, 4 4 0 4 6 1 7 9 9 9 or go to our website. That is DrBahmanGuyuron, one word, .com, and we'd be happy to offer in person or virtual consultation. Overwhelming majority of my practice is from out of town, out of country patients.

Announcer (22:00):
Links to learn more about Dr. Guyuron and anything else mentioned on this podcast are available in the show notes. Head On is a production of The Axis, T-H-E-A-X-I-S.io.