Lower Eyelid Surgery (A.K.A. Lower Blepharoplasty)

Before and After Lower Blepharoplasty

Eyes are the focal point of one's face. They are the first thing people notice and are the key to facial expression. This is the main reason why so many people seek cosmetic eyelid surgery. We hear over and over again, My eyes always look tired and old even when I feel wide awake. This is very profound because often if you look old and tired you will feel the same way. How many times have you dressed up and prepared to go out feeling good about yourself only to look in the mirror to see that your eyes look older than you feel. The reason for this is that during the aging process the region around your eyes shows the effects of aging much sooner than other areas.

In the attractive, youthful lower eye lid, the lateral canthus should be higher than the medial canthus. The lower lid should just touch the colored part of the eye.

Aging affects the entire face but usually affects the eye region earliest. The reason for this is because early in life there is a large amount of fat surrounding the eyes. You can verify this yourself by looking at the cheeks of a newborn. They are round and full of fat. As we age, this fat will either descend downward on the face or may go away completely. When this happens, it exposes the underlying facial skeleton resulting in the familiar gaunty appearance that we recognize as aging. Also, the fat and underlying muscles act as a filler creating the volume seen in the cheeks of youth. When this filler descends or goes away we see wrinkling. This process is similar to a grape which turns into a raisin when the water is removed.

Skin With Aging

Muscles With Aging

In the past, eyelid rejuvenation was based on tightening the skin via skin excision. This has changed dramatically in the past decade. Today, well trained plastic surgeons realize that skin excision is just a piece of the facial rejuvenation puzzle. In fact, there are four major components that make up the face. 1) Skin. 2) Fat. 3) Muscle. 4) Bone.

When Dr. Cruise examines a lower eyelid during consultation he evaluates all four components. Drawing on his experience, he determines which component or components is/are causing the problem and what is the best way to correct it.

The importance of the underlying fat and muscle has been revolutionary in the field of plastic surgery over the last 10 years. It is no longer acceptable to think of eyelid rejuvenation as merely a procedure to tighten the skin.This is why Dr. Cruise feels it is so important to correct the problem itself and not just the effects of the problem. He advocates not removing fat but rather repositioning it back to where it once was. Reposition cheek fat is called a Cheek Lift and it can be done at the same time as a lower blepharoplasty. Once again, not everyone needs a cheek lift. This is determined during your consultation.

Fat With Agingtext to prevent overlaping

Another contributing factor to the appearance of old age within the eye region is the fact that the lower eyelid, especially toward the temple region, begins to descend. This gives a depressed, sad appearance. This is much different than the appearance that one had when he/she was younger. The lower eyelid of youth has a bright, elegant appearance with the lateral aspect being higher than the nasal aspect. Dr. Cruise feels that it is important to address this issue. Often, he will elevate the lateral portion of the lower eyelid to re-create that youthful, almond-shape appearance. This is a powerful and very effective maneuver and is well worth the additional time.

Eyelid surgery alone will not correct crow's feet. It will help but often a concurrent brow-lift and/or face-lift is necessary. Dr. Cruise, however, is able to reduce it significantly during his eyelid surgery by repositioning the underlying fat and muscle into a more youthful position.

It is often very useful to perform fat transplantation, as well as either chemical peeling or laser skin resurfacing, in addition to eyelid surgery. This allows Dr. Cruise to address all the components associated with aging around the eye. Remember, the aging eyelid is a result of problems within the skin, muscle, and fat.

Dr. Cruise's philosophy regarding Eyelid Surgery

Plastic surgery has made significant progress in the understanding and treatment of eyelid rejuvenation. Personally, I have studied the peri-ocular region at length trying to understand how the various components effect the eyes appearance. It has taught me that eyelid surgery is much more than just skin tightening.

Each component (skin, fat, muscle, and bone) each have a significant contribution to the eyes appearance and, therefore, must be evaluated individually. Skin can be removed; muscles can be elevated and tightened; fat can be added, removed, or resuspended; and bone can be augmented. It all depends on what the patients wants and what is causing the problem.

I find it very satisfying to be able to address the various causes that create an aged appearance to the eye. Instead of treating it with a one size fits all procedure I can specifically address each problem. This allows me to more effectively rejuvenate the eye region in a way never before possible. This is the artistry of plastic surgery.

During consultation, I will take digital photographs of you so that we can look at them together and determine what are the best treatment options. We will look at the skin, the muscle, the fat, and the facial skeleton individually, and as a group, to see what is necessary to create the look you desire. It is very helpful to bring pictures of what you would like to accomplish. Of course, guarantees are not possible, but it does help me to understand what you would like to achieve.

My philosophy is to try and accomplish the desired results with the least invasive procedure available. This, however, should not be done at the expense of failing to achieve the desired look. Often, it is necessary to combine eyelid surgery with other procedures. The most common ancillary procedures are brow lifting, cheek lifting, lateral canthoplasty, fat transplantation, cheek augmentation, and chemical peeling.

Benefits

There are many benefits to eyelid rejuvenation surgery. The key is to determine exactly what the problem is.

Upper eyelid surgery benefits.

• Removes excess fat and skin of the upper eyelid.
• Creates a sculpted, more attractive upper eyelid.
• Creates a double lid and removes excess eyelid fat in Asians.
• Elevates the upper eyelid to give a more bright, and youthful expression.
• Repositions upper eyelid fat into more youthful position.
• A temporal browlift or formal brow lift can can be performed at the same time.

Lower eyelid surgery benefits.

• Tightens and smoothes out bags underneath the eyes.
• Repositions lower eyelids into a more elegant, almond-shaped appearance.
• Repositions underlying fat to get rid of the sunken, aged appearance.
• Repositions skin and underlying muscles to smooth out wrinkles.
• Markedly fills out the deep crease known as the tear-trough between the eye and nose.
• Eliminates circles underneath the eyes.
• Improves dark discoloration within the lower eyelid.
• Improves fine wrinkles.

Possible complications

The most common complication is inadequate correction of the problem. If this is the case, correction can usually be made with a minor additional procedure. Other complications include ectropion, or downward pulling of the lower lid, asymmetry, and dryness of the eyes. Complications that can occur with any surgery include infection, blood or fluid collection, and unfavorable scarring.

Are you a good candidate?

Most people as they age can obtain improvement from eyelid surgery. Specifically, good candidates include people with the following problems around the eyes:

• Bags and loose skin.
• Sad or tired appearance.
• A deep crease circling underneath the eyes.
• Excess skin and wrinkles.
• Dark discoloration underneath the eyes.
• Crow's feet within the lateral eye area.
• Sunken appearance to the eyes.
• Sagging cheek fat.

Prior to surgery

• Medications. Certain medications thin your blood and should not be taken within three weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery. Dr. Cruise will go over this more thoroughly prior to the procedure.

• Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask Dr. Cruise for something to help you sleep.

• Smoking. Do not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, makes anesthesia much more difficult.

• Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with Dr. Cruise and the anesthesiologist.

• Washing. It is a good idea to wash your face and eyelids thoroughly the night before and the morning of surgery. Wash your hair and comb it straight back. Do not apply makeup.

• Arrival. It is best to arrive on time so things go smoothly. Please be sure to have someone else drive you.

• State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned. Dr. Cruise and ICRS are both well trained and experienced. Excessive worrying can actually be detrimental and you should discuss this with Dr. Cruise prior to surgery so that something can be prescribed to make sure you remain calm.

Consultation For Lower Eyelid Surgery

• General Health

• Past Surgical History

• Medications

• Allergies to Medications

• Skin

Do you have an excess of skin? Usually, this will result in wrinkles. If so, then skin removal may be needed.

How is your skin texture. If you have dark circles or age spots then some type of textural rejuvenation will be necessary such as laser or a chemical peel. Often, proper skin care with Retin-A and/or glycolic acid will help tremendously. Other types of treatment such as IPL, and micro-dermabrasion are helpful but often take many treatments. They will not obtain the significant improvements that laser and chemical peeling can but they also do not have as much, if any, down time.

Example of lower blepharoplasty that required skin excision to diminish wrinkles from excess skin.

Muscle

Youthful Eyes. Muscles around the eyes are circular in shape.

Lower blepharoplasty incision runs just under the eye lashes until it gets to the lateral canthus. It then cants downward. It becomes hidden in a natural skin crease with time.

The incision remains red for about 6 weeks but then becomes essentially unnoticeable unless there are wound healing problems.

Anesthesia

ICRS uses only board certified anesthesiologists to make sure you have the best anesthesia possible. The anesthesiologist will discuss with you what type of anesthesia is best for you. He/she will take into consideration your medical history, the procedure, and your personal wishes.

Eyelid surgery can be performed under general anesthesia or under local anesthesia with or without sedation. If several procedures are being done at once then general anesthesia is the better option. This will be discussed during your consultation with Dr. Cruise and the anesthesia team.

After the procedure

The procedure itself will take about 2 hours. If other procedures are also being done then, obviously, the operative time will be longer.

Immediately. Right after the operation you will be watched by a nurse for 1 or 2 hours and encouraged to walk around. Dr. Cruise is a strong advocate of good pain relief so you will be given as much pain medication as necessary both immediately after the operation and for the next week. You will have ice packs over your eyes. It is very important that you keep your head elevated to decrease swelling. Still, you can expect that your eyes will swell and there will be bruising. You will be able to eat and drink when you get home.

That evening. It is recommended that you take it easy. You can walk around, eat, but not much more. Eyelid surgery has surprisingly little pain. You look worse than you feel. Still, you should take as much pain medication as necessary and try to go to sleep early. It is very important to keep your head up the first 3 days. This will markedly decreased the swelling and bruising. The eyes tend to swell and bruise quite easily, so do not be concerned by this. It will go away. If you have general anesthesia you may become nauseated. It is very important not to vomit as this increases bruising and swelling. You will be given anti-nausea medication. You should take it at the first sign of nausea.

First 48 hours. You can take a shower the day after. Just be gentle. Use cool water to hit your scalp and then trickle over your eyelids. Do not wash your eyelid with anything, merely, allow water to trickle over it. Afterward, dab dry. Mild oozing will continue for about 2 to 3 days. Dressings are not necessary. Your first post operative appointment with Dr. Cruise will usually be 1 week after surgery.

First week. At about day 3, the swelling will be at its maximum. The majority of the bruising and swelling will go away in about 2 to 3 weeks. It is not uncommon for the lower lid to start to pull downward the first few weeks after eyelid surgery. Do not be concerned. This is normal. It will go back up as healing occurs.

Beyond. Swelling will not completely resolve for about 6 months but, as mentioned above, the majority of it will be gone by 2 weeks. The final result will not be evident until at least 3 to 6 months when all the swelling has resolved and skin contraction is complete. Patients who have fat transplantation or cheek lifting tend to swell more.

Recovery time

Usually, people are off work for about 1 to 2 weeks depending on how self-conscious a patient is about the swelling and bruising. Once again, patients who have had fat transplantation tend to take longer for the swelling to subside.