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January 29, 2012

My lower eyelid is sagging after eyelid surgery-what should I do?

Filed under: canthal surgery,cosmetic eyelid surgery,Dr. Steinsapir,eyelid reconstructive surgery,fixing eyelid surgery,revisional eyelid surgery — admin @ 1:42 pm

First take a deep breath.  Things happen after eyelid surgery.  Many things fix themselves with a little time.  Before surgery, your surgeon went through a lengthy list of things that might happen with surgery.  Of course it is human nature to think that none of that will happen to you.  In some cases I think that the surgeon sends a subliminal message that even though all this stuff is in the consent, it is a mere formality.  Having an issue after surgery is an unwelcome shock.  If you trust your surgeon, that confidence should help get you through the rough patches after surgery.

There can be a number of reasons for why the lower eyelid sags after surgery.  In some cases swelling can push the lower eyelid away from the eye.  This can occur in conjunction with a process called chemosis.  Chemosis is the medical term for swelling of the white of the eye or the conjunctiva.  Just as the eyelid will swell after surgery, the conjunctiva can swell.  When it is swollen, the conjunctiva has been described to look like “jelly.”  The best treatment for this is ocular lubrication and time.  This often resolves with tincture of time.

Another cause of lower eyelid sagging is preexisting laxity of the lower eyelid.  Swelling after surgery causes the laxity to be exaggerated resulting in the unsatisfactory position of the eyelid.  In many cases again time is the best treatment.

When the surgeon cuts the skin of the lower eyelid to remove “extra lower eyelid skin,” malposition of the lower eyelid can be more serious.  Under these circumstances the lower eyelid can be short of skin or the muscle that helps hold the lower eyelid against the eye can actually be damaged by the surgery.  Rather than allowing this to heal, surgeons often feel the need to provide an early fix.  That early fix can help resolve the issue or make it worse.

Generally, due to mechanical issues, some of the simple treatments can actually be helpful.  These include steroid injection, mechanical finger winking, and when appropriate a pull up suture placed to support the eyelid corner for a few weeks.   When these measures fail, it is best to let the eyelid heal before attempting revisional surgery.  So often Dr. Steinsapir is called in to fix an eyelid where the original surgeon has made several well meaning attempts to “tuck up” the eyelid early after the original surgery with each procedure making the situation worse.

What will your eyelid need?  It often depends on precisely what factors are contributing to the circumstance.  If your surgeon was not a fellowship trained oculoplastic surgeon, it is often helpful to see someone who is.  The additional training and experience may be precisely what is needed to address the situation.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology. Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA. Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a 

December 9, 2011

I had a midface lift at the time of my eyelid surgery, and now my eyes look different. Will canthal surgery correct my problem?

Filed under: eyelid reconstructive surgery,Eyelid Surgery,fixing eyelid surgery,irregular eyelids,Lateral canthal surgery,midface lift,midface surgery,Plateau Midface Defect — Tags: , , , — admin @ 9:41 pm

The most critical issue here is to understand how your face has changed.

You are absolutely correct to say that your eyes have changed.  However, your analysis of the problem is not correct.  I suspect that very few surgeons you consult will understand the issues.  At the same time I am equally certain that many surgeons would be more than happy to perform a lateral canthoplasty for you.  They will mean well but they are simply going to make your situation worse, not better.

I completely agree that surgery has altered the shape of the eyes.  This is the most obvious change.  The outer corners of the eyes are higher after surgery compared to your preoperative status.  There is also a subtle lower eyelid contour abnormality of the lower eyelids.  It is true that a properly executed lateral canthoplasty has the potential to reposition the lateral canthal angle.  In my many years of repairing prior eyelid surgery, I have found that very few surgeons are capable of actually achieving that type of result in a natural way.  Not impossible, just very difficult as the surgery must be done with the patient at least awake enough to open and close the eyes to judge the effect of repositioning of the angle.  If surgery is performed under general anesthesia, then in my opinion, the likelihood of success is very low.

Canthoplasty, and to a lessor degree, cathopexy, risk over shortening the lower eyelid. It is true that many surgeons will shorten the lower eyelid as part of the canthoplasty procedure.  The procedure is taught this way and this maneuver is important for pathologically lax eyelids.  However, over shortening an eyelid that does not need to be shortened will simply force the lower eyelid below the curvature of the eye.  This will actually make the lower eyelid look more pulled down.  The outcome will be disappointing.

So lets talk about the real issue.  It is interesting how important the eyes are in interpersonal interaction.  Subconsciously, we scan the face of the person we are speaking to.  During conversation, we actually scan a triangle on the face that includes the eyes, the nose and to a lesser degree, the mouth.  This is so profoundly ingrained, that one expects someone listening to you to look at you in this manner.  We are not even be aware of this gaze pattern.  However, we can be acutely aware when the pattern is altered in someway.  What you would experience when you are speaking to someone is the sense that they are not really paying attention to you.  When does this happen?  Studies have shown that changes in the face will alter this scan pattern.  There are some very nice studies of this in the head and neck literature in looking at scan patterns when viewing someone who has a facial lesion or just had surgery to remove a facial lesion.

How does this apply to this situation?  If you look carefully at your after photograph, you face demonstrates a classic facial defect caused by your mask lift.  The forehead dissection has resulted in atrophy of the fat pads that extend from the temple to the orbital rim.  This hourglass hollowing of the temple areas I call the plateau midface deformity.  Essentially the loss of the fat volume skeletonizes the zygomatic arch.  This little bit of facial fat plays a critical role.  This cushion of fat at the side of the face serves to separate the eye aesthetic area from the temple aesthetic area.  This slight cushion of volume helps maintain gaze on the eyes.  Without this fat volume, the scanning gaze is falls off the eyes and is drawn into the temple area.  You are left with the feeling that people are not paying attention to you.  Since the primary reason many women (and men) have cosmetic surgery is to stay relevant, this feeling of being ignored can precipitate a narcissistic crisis.  The fact that your surgeon cannot understand your concerns (and I promise you they really don’t get it) is even more infuriating.  Because like you, they don’t see what the issue is, you get treated like a problematic, ungrateful, impossible to satisfy (insert your own description here) person.  Naturally this can precipitate a break down in the doctor patient relationship.

In the example shown here, surgery was used to correct the problem.  Previously placed cheek implants were removed and replaced with a hand carved ePTFE orbital rim implant.  The lower eyelid was also lengthened using hard palate graft.  Because it is necessary to sew the eyelid closed for a week to allow healing means that only one eye can be done at a time.  For some individuals who only have the plateau midface, fillers can be used as an alternative to facial surgery.

First, there is no substitute for an actual personal consultation.  Generally for this type of problem the best solution for many is adding hyaluronic acid filler to the area where you have lost volume.  These products last quite a while and this can be a workable alternative to corrective surgery.  For some, surgery is necessary.  The most important thing is to avoid having a fix by doctors who do not understand what the issues are. Unfortuately, if you don’t see it, you can’t fix it.

Kenneth D. Steinsapir, MD

About Dr. Steinsapir

Dr. Steinsapir is a much sought after oculofacial surgeon.  He is an innovator in minimally invasive cosmetic and reconstructive procedures and has invented new methods for treating with BOTOX, fillers and cutting edge reconstructive eyelid and midface surgery.  He specializes in high precision eyelid surgery and is a leader in correcting prior facial and eyelid surgery, including multiple revised cosmetic eyelid reconstructions.  He attended medical school at the UCLA and completed ophthalmology residency at The University of Chicago.  He is multiple fellowship trained including three years of fellowship training in oculofacial plastic surgery at UCLA, and a two-year cosmetic surgery fellowship in Rancho Mirage.  He is widely published and lectures to other surgeons nationally and internationally.  He is an associate clinical professor of Ophthalmic Plastic and Reconstructive Surgery at the Jules Stein Eye Institute at UCLA.  His private practice is located in West Los Angeles, immediately serving the Los Angeles and Bevery Hills communities.  Additionally, individuals from all over the country and the world regularly come to Los Angeles for this expert care.

To learn more about Dr. Steinsapir’s specialized Restylane treatments, please contact us today.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

October 27, 2011

Upper blepharoplasty made my eyelids heavier and the skin wrinkled. What is going on?

Filed under: blepharoplasty,brow lift,cosmetic eyelid surgery,Cosmetic Surgery,eyelid reconstructive surgery,Eyelid Surgery,fixing eyelid surgery,forehead lift,oculoplastic surgery — Tags: , , , , , , , , , — admin @ 8:48 am

Dr. Steinsapir specializes in fixing unsatisfactory eyelid surgery.  As a fellowship trained oculoplastic and cosmetic surgeon, and a board certified ophthalmologist, Dr. Steinsapir is experienced in working closely with his patients to create a personalized treatment plan.  If you are experiencing eyelid ptosis and crepey (wrinkled) skin following upper blepharoplasty, it may be that your original surgeon did not have the proper experience to successfully perform your upper blepharoplasty.

Crepey Skin

When performing upper blepharoplasty, simply removing extra skin is not enough to create a desirable outcome.  Successful blepharoplasty requires what Dr. Steinsapir calls a ‘structured’ blepharoplasty.  It is essential to properly support the upper eyelid skin to avoid crepey upper eyelid―platform skin that simply won’t hold makeup.  To correct this problem, your surgeon will need to remove skin from below the upper eyelid crease and anchor the eyelid platform skin and underlying muscle to the levator tendon, which raises the upper eyelid.  This places the upper eyelid skin on a slight stretch resulting in a smooth platform for makeup.

An experienced and skilled surgeon can address crepey upper eyelid skin after unsatisfactory upper blepharoplasty with a carefully planned excision of the excess skin left on the eyelid platform.  With the eyelid open, the upper eyelid skin is anchored to the levator tendon to create a long lasting adhesion to the eyelid elevator.  Recovery is usually somewhat shorter than standard upper blepharoplasty.

An anchor blepharoplasty is an important part of any comprehensive eyelid surgery. This part of your procedure specifically addresses loose skin and drooping eyelashes on the upper eyelid platform.  Excess, wrinkled or loose skin here can give you a tired appearance associated with eyelash ptosis and crepey eyelid platform skin.

While ideally anchor blepharoplasty is a part of every blepharoplasty, unspecialized or less skilled surgeons may not be comfortable offering this important aspect of treatment.  Anchor blepharoplasty is a very technical skill that requires great precision and specialized expertise.  Without great experience, education and an artistic skill, your cosmetic doctor may have difficulty performing an anchor blepharoplasty as part of your upper blepharoplasty; unfortunately, in these cases you may find yourself disappointed after you heal and wish your eyes appeared more alert.

Heavy eyelids

Heavy eyelids following upper blepharoplasty are often the result of a pre-surgical condition that your surgeon failed to address during you consultations.  Before you underwent blepharoplasty, you presumably already had heavy lids and heavy brows.  The brain compensates for the heavy eyebrow by activating the frontalis muscle, the forehead elevator.  The forehead lifts the eyebrow until the skin in the upper eyelid no longer rests on the upper eyelashes.

Clinically, this situation can be detected by looking for lines in the forehead and an abnormally elevated eyebrow.  When upper blepharoplasty is performed in this setting, the excess skin in the upper eyelid is removed. This reduces the amount of forehead muscle activation that is needed to keep the upper eyelid skin off the upper eyelashes.  The forehead relaxes and the eyebrows come down. The net result is that it appears that almost nothing was done surgically.  Of course the forehead is smoother but if the objective was to make the eyes brighter by clearing space above the eyelashes, the net effect can be disappointing.  Under these circumstances the best option is to perform a forehead lift in conjunction with the eyelid surgery.

About Dr. Steinsapir

Dr. Steinsapir is on active staff at the UCLA Hospital and Medical Center at the David Geffen School of Medicine as an associate clinical professor of Ophthalmology in the Division of Orbital and Ophthalmic Plastic Surgery. UCLA is consistently rated the best hospital in the West and ranked at the top with a handful of medical centers in the United States. Many surgeries are performed on an outpatient basis at the Surgery Center at the UCLA Medical Center.  Dr. Steinsapir addresses a broad array of oculofacial reconstructive concerns.  Contact us today to schedule a personal consultation with Dr. Steinsapir.

 

 

 

 

October 5, 2011

I had eyelid surgery 8 days ago and I am certain that my surgeon made a mistake. What should I do?

Filed under: blepharoplasty,cosmetic eyelid surgery,eyelid reconstructive surgery,Eyelid Surgery,fixing eyelid surgery,oculoplastic surgeon,oculoplastic surgery — Tags: , , , , , — admin @ 7:53 pm

Blepharoplasty is an invasive surgical procedure and by definition, requires time to heal.  Eye surgery causes trauma to the tissue surrounding your eyes and it’s difficult to determine how your eyes will look, even after a week or more.  In the grand scheme of things, eight days is not enough time to determine the majority of mistakes.  Even if your doctor did cause a complication, it’s possible it will clear up during the healing process.  However, there are some rare complications to be mindful of and consult your physician immediately if you are experiencing the symptoms.

Immediate post-operative issues

Dr. Steinsapir uses the term “immediate” to describe post-operative issues and complications that last from moments after surgery to up to six months, whereas long-term complications are issues that persist for more than six months.  He uses the six month time frame because a number of concerns related to upper eyelid crease height, difficulty closing the eye, mild lower eyelid retraction or alterations in eyelid shape often resolve spontaneously within this time period.

Dry eye

One of the most common problems after surgery is dry eye.  Swelling and temporary lid dysfunction can exacerbate pre-op dry eye issues.  When the eyelids are swollen after surgery, they do not move the tears around very well and this can cause drying and irritation.  This type of swelling can typically affect eye comfort for ten days or more when there is normal tear production.  When the eyes are dry, eye comfort may be affected by post-operative eyelid swelling for several weeks before resolving.

If, however, the surgery damages the nerve fibers that supply the muscle that closes the eye (orbicularis oculi muscle), the blink mechanism may be permanently affected causing long-term eye surface drying and dry eye symptoms like irritation, sensation of burning, grittiness, and redness. Fortunately, many of these closure issues get better over time. You can treat these dry-eye symptoms with artificial tears and bland ophthalmic ointment.  Additionally, Dr. Steinsapir may choose to supplement this by plugging the tear drainage system, and taping the eyes closed.

Bruising

Bruising is natural and anticipated following surgery; it is a normal part of recovery.  On rare occasions, a much more significant bruise can occur. If this happens deep behind the eye, the bruise can cause blindness. This type of bleeding is called a retro-orbital hemorrhage.  While these cases are very rare, it is this very significant risk that prompts the eyelid surgeon to advise potential patients to avoid medications and herbal products that can thin the blood and predispose to bruises in the first place.

Bleeding that causes bruising after surgery can occur from straining, coughing or other activities that disrupt the clots that normally form from the surgical wounds.  For this reason, it is essential for your potential eyelid surgeon to know if you are taking a blood thinner such as aspirin, coumadin, or Plavix.  In these circumstances, Dr. Steinsapir will advise against elective or optional eyelid surgery.

Superficial bruising may not threaten vision but these bruises can affect the outcome of surgery.  Severe bruises cause swelling that can stretch a healing eyelid. In the upper eyelid, this can produce heaviness in the upper eyelid that might need to be corrected surgically if there is no resolution after 6 months.  When the resulting eyelid malposition does not satisfactorily resolve by 6 months after surgery, revisional surgery may be necessary to address the issue.

Stitches

Occasionally, stitches closing the surgical incision come apart before the skin edges are healed together.  This is called a wound dehiscence.  This most commonly occurs in the upper eyelid where an incision is made to remove excess skin. The raw edges of skin separate and the wound gapes open. This can be unsightly and it is tempting to sew the raw edges back together. This may be the right thing to do, however, there may be a low-grade infection causing the wound separation in which case the best course of action is to simply observe the area, and keep it moist with extra antibiotic ointment. The most surprising thing about wound dehiscence is how well it heals on its own. It has been Dr. Steinsapir’s experience that given time to fully heal, the body pulls the skin edges back together so well that no further intervention is needed.

Swelling

Chemosis is a specific type of tissue swelling. The white of the eye is a specialized tissue called the conjunctiva.  Just like the eyelids can swell following surgery, the conjunctiva can also swell.  It looks like jelly along the edge of the eyelid. Mild chemosis is self-limited; it will resolve on its own.  More severe chemosis is very rare and is almost never seen with standard blepharoplasty.  In this circumstance, the swollen conjunctival tissues balloon to the point where they are not covered by the closed eyelids. When this happens, the conjunctiva is subject to drying that causes more swelling―becoming a cycle.  The best treatment is aggressive lubrication with an ophthalmic ointment and when necessary, occlusion with plastic wrap to prevent drying. Surgical treatments are available for the rare instances when these measures are insufficient.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology.  Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA.  Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

August 27, 2011

My surgeon performed eyelid surgery 6 weeks ago and now my eyes don’t close at night. What should I do?

Filed under: blepharoplasty,eyelid reconstructive surgery,Eyelid Surgery,oculoplastic surgeon,oculoplastic surgery — Tags: , , , , , , — admin @ 10:39 am

Eyelid surgery is a delicate operation that has as many rewards, but it is still surgery and requires adequate healing time.  As you begin to heal, you may notice problems with dry eyes, or your lids not closing properly.  Immediately after surgery and for about ten days following, swelling may cause discomfort and concern about the new position of your lids.  However, as your body heals, your lids may resume a more natural position.  There is a small risk that the nerve fibers that supply the muscle that closes the eye (orbicularis oculi muscle), may be temporarily or permanently weakened causing long-term eye surface drying and dry-eye symptoms.  Six weeks following surgery is too early to become alarmed, but Dr. Steinsapir strongly recommends visiting your original surgeon for a complete assessment of your condition to determine your treatment options. If your surgeon is not a fellowship trained oculoplastic surgeon, you may need to see one or a cornea specialist.

Why won’t my eyes close?

Surgery can produce long-term damage to the function of the eyelids causing dry eye symptoms.  If your surgeon removes too much upper eyelid skin and underlying muscle, your eyes may not close completely, causing dry spots to develop on the cornea.  Depending of the design of the blepharoplasty, the nerves that supply the muscle that helps to close the eye can be damaged weakening the blink reflex.  This means that during a blink there may not be sufficient speed or force to cause the upper and lower eyelids to meet during the blink.  Since the eyelids move tears on the eye surface around, the net result is surface drying.

What are my treatment options?

The first line approach to treating these issues is to increase the frequency of artificial eye drops and, when indicated, ophthalmic ointment at bedtime.  If necessary, your tear drains in your eyelids can be closed temporarily with plugs to see if symptoms improve.  If these measures fail, there are some additional mechanical measures available.  Depending on the corneal status early surgical reconstruction may be necessary.

The extent of the solution depends on the severity of the symptoms and the degree of drying seen on the surface of the cornea.  Although a range of options are available, the key objective is to make the eyelids meet and to create sufficient force of eyelid closure to help spread the tears over the corneal surface.

Is this a long-term issue?

Common post-operative issues can be thought of in two broad categories: immediate and long term.  Immediate issues are post-operative issues and complications that present anytime from moments after surgery up to six months.  Long-term complications are issues that continue to persist beyond six months.  The six-month time frame is useful because a number of concerns related to difficulty closing the eye and mild lower eyelid retraction often resolve spontaneously in this time frame.  In contrast, it is Dr. Steinsapir’s experience that when these types of problems are present six months after surgery and continue to be a concern, then they often need to be addressed with a corrective surgery.

I chose an experienced surgeon, what happened?

No matter how technically superb the surgeon, surgery can tip a marginally compensated dry eye to discomfort.  Unpredictable individual factors may also contribute to a particular situation.  Dr. Steinsapir is acutely aware of the importance of eye comfort after surgery and what steps are needed to make the eye as comfortable as possible. Unfortunately, specialists lacking the training in Ophthalmology can underestimate the impact of these easily addressed issues.  For this reason, Dr. Steinsapir closely follows his patients after surgery.  Your post-operative follow-up schedule is based on how you are actually doing rather than on a scheduled based on how everyone one else has done in the past.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology. Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA. Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

August 6, 2011

Can I visit the United States for Reconstructive Surgery?

Filed under: blepharoplasty,cosmetic eyelid surgery,Cosmetic Surgery,Dr. Steinsapir,eyelid cancer reconstruction,eyelid reconstructive surgery,facial cosmetic surgery,fixing eyelid surgery,oculoplastic surgeon,oculoplastic surgery — Tags: , , , , , , — admin @ 9:32 am

When it comes to reconstructive facial surgery, Dr. Steinsapir has extensive experience with eyelid, midface, and orbital reconstruction including repair of prior unsatisfactory eyelid surgery, removing unsatisfactory facial implants, correcting eye changes associated with thyroid eye disease, orbital and tear duct surgery, and repair of the eyelid after skin cancer removal or trauma.

Many people travel from across the United States as well as internationally to have surgery with Dr. Steinsapir.  He is world-renowned for his leadership in facial cosmetic surgery.  If you are considering traveling to have reconstructive surgery or other cosmetic treatment with Dr. Steinsapir, here are some important considerations that will help you have the best experience possible.

Consult First

Many people who travel for cosmetic treatment feel they should be able to have surgery at the time of their initial consultation.  They want to take care of everything in just one trip, so they may fly or make a long drive to Los Angeles, have their consultation, and have surgery all during the same trip.  This idea may seem appealing because you only have to book a flight and pack your suitcase once, and you may even save a little money—but please reconsider this approach.  Dr. Steinsapir doesn’t believe in performing an initial consultation and surgery at the same time.  Even if you save a few dollars in airfare, in the end this amounts to hasty and high-pressure decisions.  Your choice to move forward in having surgery with the right doctor is important, and it’s not a good idea to cut corners here.

Reconstructive surgery should be something you and your surgeon approach calmly, thoughtfully, and with confidence.  Instead of too much pressure, Dr. Steinsapir strongly advises and encourages you to take the time to make sure you have found the right doctor and right treatment approach.  He wants you to have time to think about the options and be completely comfortable with the proposed surgical plan.

Take Time to Reflect

Consulting now and having surgery later is a sound approach for anyone seeking the right cosmetic treatment with any doctor.  Although admittedly not convenient, slowing down, thinking about your choices and being fully comfortable ensures that you can make a fully informed choice without the pressure of time.  When you consult with Dr. Steinsapir, he won’t pressure you into committing to surgery.  It is better for everyone if you have the opportunity to meet with the surgeon, then have time to think about the issues discussed well before undergoing reconstructive surgery.

Make Thoughtful Decisions

Even if you’re traveling from very far, Dr. Steinsapir will not perform surgery at the time of your initial consultation.  The best surgery is always performed with the utmost of care, consideration, research, and planning.  You should go into surgery comfortable and confident that you have made the right decision.

About Dr. Steinsapir

Dr. Steinsapir is on active staff at the UCLA Hospital and Medical Center at the David Geffen School of Medicine as an associate clinical professor of Ophthalmology in the Division of Orbital and Ophthalmic Plastic Surgery. UCLA is consistently rated the best hospital in the West and ranked third among all medical centers in the United States. Many surgeries are performed on an outpatient basis at the Surgery Center at the UCLA Medical Center. Larger procedures may also be performed on an inpatient basis at the Jules Stein Eye Institute. Dr. Steinsapir addresses a broad array of oculofacial reconstructive concerns.  Contact us today to schedule a consultation, followed by a brief consideration of the more common reconstructive issues that bring people to see Dr. Steinsapir.

July 20, 2011

Droopy Eyes after a Midface Lift

Filed under: Cosmetic Surgery,eyelid reconstructive surgery,facelift,facelift los angeles,facial cosmetic surgery,midface lift,midface surgery — Tags: , , , , , , — admin @ 8:01 pm

Complications following a midface lift are especially disconcerting because they can affect the basic functions of your eyes.  Whether your eyes begin to droop, tear, or fail to blink, any change in the way your eyes and face function is reason enough to contact your doctor.  But sometimes, surgeons panic in these situations and respond with a fix-it mentality and may be encouraging you to undergo corrective surgery immediately.  Your surgeon may just want to take care of the problem as quickly as possible and as a result, you may be receiving mixed messages from your physician about the best course of action.  However, immediately following your facelift may not actually be the right time to fix the problem.

Undergo a consultation

Before taking any action to correct your midface lift complications, carefully weigh your confidence in your current surgeon.  There is no substitute for an in-depth personal consultation because discussing your problem with your doctor over the phone doesn’t allow him or her to see and fully understand the physical issues.  Occasionally, the description of what is going on and the actual physical complications are not the same.

If you are not 100 percent confident in your surgeon and are casting about for opinions from strangers, listen to your feelings.  Do not blindly follow the recommendations your original surgeon or any surgeon if their recommendations do not make sense to you.  While you may not like your appearance and may be experiencing profound disappointment, these issues are seldom a medical emergency.  Don’t commit to a second surgery unless you have a clear understanding of the following:

  • what is going on and why these complications are occurring,
  • what type of surgery your doctor has planned,
  • why a surgical solution is necessary at this time,
  • the risks of a second surgery, and
  • the probability of success or failure.

The risks of midface and lower eyelid surgery and corrective surgery

Lower eyelid surgery and midface surgery have significant risks associated with them.  Your surgeon may not fully understand these risks.  If you’re experiencing complications it does not mean that your surgeon did anything below the standard of care.  However, how your surgeon addresses the problem can make a profound difference and he or she should not rush the process.

The anatomy described in some of the most important and most recent papers in the field of lower eyelid and midface surgery done through a skin incision under the lower eyelashes (infracillary incision) is inaccurate.  Dr. Steinsapir recently reviewed the literature on this subject and presented it before the Fall 2010 American Society for Ophthalmic Plastic and Reconstructive Surgery Scientific Symposium.  Some of the core papers describe anatomic hypotheses rather than proven anatomic fact.  For example, the soft tissue of the cheek is mobile (i.e. it slides when we smile), and the lower cheek is also mobile over the lower half of the face. In this location, the nerves responsible for facial expressions around the mouth travel in such a way that it is possible to safely dissect this plane in the lateral half of the lower face; this is a key aspect to the so-called deep plane facelift.

Similarly, surgeons dissect under the skin and lower eyelid muscle to perform midface lifts.  Published papers appear to support the hypothesis that this midface lift technique can be performed without injuring the nerves that feed the eyelids.  Unfortunately, a hypothesis is a scientific guess, it does not make an established anatomic fact. There is also clear evidence in published papers suggesting that the nerves that supply the lower eyelid orbicularis oculi muscle travel in this so-called glide plane, which is actually just somewhat mobile fat and loose connective tissue between the cheek bone and the orbicularis oculi muscle.

So why do doctor’s still perform this kind of surgery despite the risks?  Despite the inaccurate papers, it is possible to dissect in this plane without significantly altering the nerve supply to the orbicularis oculi muscle in some individuals.  Yet others may not do well.  This may have to do with how aggressive the surgeon is and the exact nature of the distribution of these motor nerves, which do vary somewhat from person to person.  Additionally, when this dissection is carried out laterally into the crowsfeet area, it is also possible to do significant damage to the nerves that provide innervation to the orbicularis oculi muscle in the upper eyelid as well.  This is significant because the elements of the orbicularis oculi muscle near the lower eyelid margin are responsible for blinking the eye closed.  Without this critical blink function, tears are not moved across the corneal surface properly resulting in dry eye and tearing issues.  When the lower eyelid slumps, it does not properly cover the lower portion of the eye and there is increased corneal drying.

The remedy for midface and lower eyelid surgery complications

To address eyelid complications from a midface lift or lower lid surgery, the best answer is to avoid further eyelid tightening and allow the tissues to heal.  In six months or more come back and address the situation with your surgeon if problems persist.  By preserving as much of the lower eyelid and not cutting out tissue―as would be the case if your doctor were to try to fix the problems immediately following your initial surgery using a technique called canthoplasty―there are many more options and increased likelihood of an improved outcome if you allow the tissue to heal.  While in the healing process, keep lines of communication open with your surgeon or look for oculoplastic surgeons for consultation who have as a focus of their practice the repair of unsatisfactory cosmetic eyelid surgery.  Be skeptical of solutions that must be done “urgently” or don’t make sense.  While very few of these complications mend themselves, with time it may improve so that less work may be needed than first thought.

About Dr. Steinsapir

Dr. Steinsapir trained alongside the inventor of BOTOX and has performed thousands of BOTOX treatments in Los Angeles since 1988 and recently patented his Microdroplet BOTOX technique. He is a board certified eye surgeon and fellowship trained in oculoplastic surgery and cosmetic surgery in Southern California where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology.   Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

June 29, 2011

Complications after surgery

Filed under: beverly hills facelift,blepharoplasty,cosmetic eyelid surgery,Cosmetic Surgery,eyelid reconstructive surgery,Eyelid Surgery,lower blepharoplasty,midface lift,midface surgery,oculoplastic surgeon — Tags: , , , , , , — admin @ 7:53 am

Complications following a midface lift and eyelid surgery are especially disconcerting because they can affect the basic functions of your eyes.  Whether your eyes begin to droop, tear, or fail to blink, any change in the way your eyes and face function is reason to be concerned.  But sometimes, inexperienced surgeons panic in these situations (even long-in-practice, but inexperienced surgeons) and respond with a shoot-from-the-hip, fix-it mentality, and may push you to undergo corrective surgery immediately.  Your surgeon may just want to take care of the problem as quickly as possible and as a result, you may feel pressured to have a corrective surgery.  There are certainly times where immediate work is appropriate.  Before you agree to such a fix, ask yourself if you are still comfortable trusting your surgeon.  In his book Blink, Malcom Gladwell describes the process of “thin slicing;” the way our intuition rapidly assesses a situation.  That intuition is ignored at our peril.  If the hair on the back of your neck is standing up because your surgeon wants to hustle you back to surgery, ask yourself: are you comfortable with what is being proposed?  If you are not comfortable, your best course of action is the natural one―dig in your heals.  There are occasional situations that are medical emergencies.  However, these are truly rare.  There is almost always time for a second opinion.

Undergo a consultation

Before taking any action to correct your complications, carefully weigh your confidence in your current surgeon.  There is no substitute for an in-depth personal consultation because discussing your problem with your doctor over the phone doesn’t allow him or her to see, and fully understand the physical complications.  Occasionally, the description of what is going on and the actual physical complications are not the same.  Fixing complications is specialized business.  Even if your surgeon does a lot of primary cosmetic surgery, he or she may be relatively unsophisticated when it comes to repairing surgical complications, especially when this work affects the function of the eyelids.

If you are not 100 percent confident in your surgeon and are casting about for opinions from strangers, listen to your feelings.  Do not blindly follow the recommendations your original surgeon or any surgeon whose recommendations do not make sense to you.  Don’t commit to a second surgery unless you have a clear understanding of the following:

  • What is going on and why these complications are occurring,
  • What type of surgery your doctor has planned,
  • Why a surgical solution is necessary,
  • The risks of a second surgery, and
  • The probability of success or failure.

The risks of midface and lower eyelid surgery and corrective surgery

Lower eyelid surgery and midface surgery have significant risks associated with them.  Your surgeon may not fully understand these risks.  If you’re experiencing complications it does not mean that your surgeon did something that another surgeon might have done in a similar circumstance.  However, how your surgeon addresses the problem can make a profound difference and he or she should not rush the process.

The anatomy described in some of the most important and most recent papers in the field of lower eyelid and midface surgery done through a skin incision under the lower eyelashes (infracillary incision) is inaccurate.  Dr. Steinsapir recently reviewed the literature on this subject and presented it before the Fall 2010 American Society for Ophthalmic Plastic and Reconstructive Surgery Scientific Symposium.  Some of the core papers describe anatomic hypotheses rather than proven anatomic fact.  Unfortunately, a hypothesis is a scientific guess―it does not make an established anatomic fact. Lower eyelid surgery through the lower eyelid skin is one example of this.  Surgery damages the motor nerves that help support the lower eyelid margin leading to complications that can surprise the unsuspecting surgeon.  Naturally, they are not going to say that they are surprised but be assured they would not perform surgery this way if they thought it would cause a problem.

So why do doctors still perform this kind of surgery despite the risks?  Despite the inaccurate papers it is possible to dissect in this plane in some cases without significantly altering the nerve supply to the orbicularis oculi muscle.   Motor nerve damage to the orbicularis oculi muscle near the upper and lower eyelid margin affects the blink and weakens eye closed.  Without this critical blink function, tears do not move across the corneal surface properly resulting in dry eye and tearing issues.  When the lower eyelid slumps, it does not properly cover the lower portion of the eye and there is increased corneal drying.

The remedy for midface and lower eyelid surgery complications

To address eyelid complications from a midface lift or lower lid surgery, the best answer is to avoid further eyelid tightening and allow the tissues to heal.  By preserving as much of the lower eyelid function and not cutting out additional tissue―as would be the case if your doctor were to try to fix the problems immediately following your initial surgery using a technique called canthoplasty―there are many more options and increased likelihood of an improved outcome if you allow the tissue to heal.  While in the healing process, keep lines of communication open with your surgeon or look for oculoplastic surgeons for consultation who have as a focus of their practice the repair of unsatisfactory cometic eyelid surgery.  Be skeptical of solutions that must be done “urgently” or don’t make sense.  While very few of these complications mend themselves, with time it may improve so less work than originally  thought may be necessary.

About Dr. Steinsapir

Dr. Steinsapir is a board certified eye surgeon and fellowship-trained in oculoplastic surgery and cosmetic surgery in Los Angeles where he specializes in balanced facial cosmetic surgery for natural results, with an emphasis on minimally invasive techniques, fast recovery time, and leadership in medical technology. Dr. Steinsapir has a private practice and also serves as an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, at the David Geffen School of Medicine at UCLA. Contact us today to learn how Dr. Steinsapir’s experience and training make him an expert in cosmetic surgery, which can be a vital part of your evidence-based treatment plan.

Services described may be “off-label” and lack FDA approval. This article is informational and does not constitute an advertisement for off-label treatment. No services should be provided without a good faith examination by a licensed physician and an informed consent with a discussion of risks, benefits, alternatives, and the likelihood of treatment success. Only you and your treating physician or surgeon can determine if a treatment is right for you.

March 8, 2011

How long should I wait before having my eyelid surgery revised?

Filed under: blepharoplasty,eyelid reconstructive surgery,Eyelid Surgery — Tags: , , , , — admin @ 8:47 pm

Deciding to undergo reconstructive blepharoplasty is not a decision that should be taken lightly.  However, living with surgery results that make you unhappy with your appearance is not something you should have to do either.  It’s important to consider which symptoms are part of the healing process and which are cause for concern.  Minor bruising and swelling can make it difficult to tell if your surgery has provided the results you were hoping for so it’s important to talk with your surgeon about your concerns as well as what to look for if, by some small chance, something does go wrong.  Complications can occur even at the hands of the very best surgeon and although they’re rare, emergencies happen and it’s important to know the signs.

Common side effects of surgery

Many people become concerned when swelling in the eyelid persists for several weeks after surgery; some amount of bruising is also common following surgery, but neither bruising nor swelling are cause for concern unless they are excessive.  Remember that that it does take time to heal and many issues resolve with time.  For this reason, it is best to give the eyelid plenty of time before considering revisions to your surgery, especially if the issue is mild ptosis.  Dr. Steinsapir usually recommends six to twelve months before considering revisions.  There can be pressing reasons to operate earlier.

Certain lower eyelid surgeries (primarily transcutaneous lower blepharoplasty) have a finite risk of damaging the lower eyelid.  These issues can be complex.  It is often true that when something is not right several months after eyelid surgery, the problem was evident very soon after surgery.  Because many things will show improvement over time, a period of healing is often recommended, even if reconstructive surgery will be necessary.  Treatment with medication such as steroids and simple mechanical treatment such as finger winking can help with the ultimate lower eyelid position.  In this situation especially, it’s important to wait and allow time to heal before deciding on reconstructive surgery.

Causes for concern

There are occasions when immediate action is necessary to correct a problem that may result in a much more complex reconstructive surgery down the road or immediate damage to the cornea.  These situations are unusual.  Worrisome issues that occur within the first 24 hours of surgery include bleeding, bruising that rapidly expands across the eyelid, loss of vision, or persistent or severe pain.  These types of issues should prompt an immediate call to your surgeon.  If you are not able to reach your surgeon, consider calling 911 .  It is better to be seen for something that turns out to be nothing serious than to miss something truly important.  Other issues are much less urgent and may not make themselves clear for several days or weeks after surgery.  Even when it is clear that the issue does not require immediate attention, call your surgeon and discuss the situation with the office.  Most often the surgeon will want to assess you personally and assure themselves of what is going on.

About Dr. Steinsapir

Dr. Steinsapir is board certified in Ophthalmology and has completed numerous fellowships, including three years of Orbit and Eyelid fellowships at the prestigious Jules Stein Eye Institute at the David Geffen School of Medicine at UCLA and a separate two year cosmetic surgery fellowship under the auspices of the American Board of Cosmetic Surgery.  He is widely respected for his work and has published over thirty scientific papers and eight book chapters.   He is a true innovator, having developed Microdroplet™ BOTOX®, a unique patented method for injecting BOTOX®, Deepfill™ under-eye Restylane® treatment to address the dark circle and under-eye hollow for up to a year without the need for retreatment.  Dr. Steinsapir is one of the foremost eyelid surgeons in the world.  He is on staff at the UCLA Hospital and Medical Center where he is an Associate Clinical Professor of Ophthalmology at the Jules Stein Eye Institute.  He is also on staff at Harbor/UCLA Medical Center where he serves as an attending surgeon.  He is in practice in West Los Angeles and is in high demand by discerning individuals from Los Angeles, Beverly Hills, and Southern California.  Many of his patients also come to see him from around the country and the world. Very few doctors offer the level of skill and expertise he brings to cosmetic surgery and aesthetic restorative surgery to address prior unsatisfactory eyelid surgery.  Please contact us today to learn more about evidence-based treatment options with Dr. Steinsapir for proven results.

February 24, 2011

Blepharoplasty Reconstruction

Filed under: cosmetic eyelid surgery,eyelid reconstructive surgery,lower blepharoplasty — Tags: , , , , , , , , — admin @ 6:31 pm

Blepharoplasty, also known as eyelid surgery or a lidlift, is one of the most common cosmetic surgeries and has a remarkable track record for safety.  Because incisions are made along the creases of the upper eyelid, below the lower lashes, or from the inside of the lower lid, scarring is minimal and relatively hidden.  Complications can occur, even when surgery is performed by experienced surgeons.  Complications that can compromise the outcome of eyelid surgery can include hematoma, infection, or eyelid function problems that result from excessive skin or muscle removal, or motor nerve damage.  When the cosmetic or functional result is unacceptable, reconstructive surgery is needed to address these issues.

Potential Concerns

The traditional approach to upper eyelid surgery has been to aggressively remove skin, muscle, and fat.  The result of this outdated philosophy is “the surgical look” with a high sulcus and no upper-eyelid fold.  While some are happy with the cleaned-up appearance created by this type of surgery, a certain percentage of individuals are unhappy with the alterations caused by their changed appearance.  Unfortunately restoring the upper eyelid fold is virtually impossible.  Fillers can help soften the appearance, but restoration of the upper eyelid is not feasible as it is with repair of the lower eyelid.

Other upper eyelid issues are more amenable to corrections.  One such concern is laxity of the skin in the upper eyelid, below the upper eyelid crease.  The skin takes on a crepe appearance.  Crepe skin appears thin and dry and doesn’t hold makeup.   This can be corrected with a precision anchor blepharoplasty.

The indiscriminate removal of skin, muscle, and fat can have more serious complications than just the “surgical look.”  Over-aggressive cosmetic surgery can, result in damage to the muscles that allow the eyelid to close, shortening the upper eyelid and preventing the eye from closing.  The lower lid can also become retracted, pulling the lower lid downward.  Often, individuals come to Dr. Steinsapir with unique issues that require unique surgical solutions.  While there are complications that can’t be fully corrected, many of these issues can be improved functionally and cosmetically by a very limited number of specialized eyelid surgeons who offer these types of reconstructions.  The process starts with a detailed personal consultation.

About Dr. Steinsapir

Dr. Steinsapir is a much sought after oculofacial surgeon.  He is an innovator in minimally invasive cosmetic and reconstructive procedures and has invented new methods for treating with BOTOX, Fillers and cutting edge reconstructive eyelid  and midface surgery.  He specializes in high precision eyelid surgery and is a leader in correcting prior facial and eyelid surgery, including multiple revised cosmetic eyelid reconstructions.  He attended medical school at the UCLA and completed ophthalmology residency at The University of Chicago.  He is multiple fellowship trained including three years of fellowship training in oculofacial plastic surgery at UCLA, and a two-year cosmetic surgery fellowship in Rancho Mirage.  He is widely published and lectures to other surgeons nationally and internationally.  He is an associate clinical professor of Ophthalmic Plastic and Reconstructive Surgery at the Jules Stein Eye Institute at UCLA.  His private practice is located in West Los Angeles, immediately serving the Los Angeles and Bevery Hills communities.  Additionally, individuals from all over the country and the world regularly come to Los Angeles for this expert care.

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