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.

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.

Treating Syringomas

Syringomas are difficult to permanently remove because they originate from the deep dermis level of the skin.  The most common forms of removal include shaving, chemical peel, electrocautery, and lasers.  All of these methods are intended to superficially flatten the bumps caused by syringomas.  These treatments often have to be repeated regularly.  Smaller growths are easier to remove using these methods.  Although this is not a long-term solution, it carries less risk of scarring, permanent tissue damage, and slow-healing.

Deep Dermis Treatment

In order to completely remove syringomas, the treatment needs to penetrate the deep dermis under and around your eyes.  There are many different opinions among physicians about which method is the most effective.  Some physicians use CO2 lasers, while others prefer the deeper laser resurfacing of a Fractional CO2 laser.   Likewise, deep electrocautery may also effectively remove the lumps, however, all of these methods carry a risk of scarring.  Even after the syringomas are removed from the deep dermis level they can still return.  The overgrowth of eccrine sweat glands is not related to any external causes, but is a genetic trait that can’t be treated with skin creams.

Factors for Successful Removal

Smaller syringomas are easier to remove so the earlier you address the problem the better results your doctor can achieve.  Although the bumps can always be removed using chemical peels or shaving, there is a substantial risk of scarring.  Electrocautery and CO2 lasers can damage the delicate tissue around your eye and the deeper the penetration, the more damage can be done.  Removing syringomas requires a skilled hand and experience with lower eyelids.  Dr. Steinsapir utilizes his advanced understands the structure of the lower lid and skin healing to minimize skin damage that can be associated with the treatment of the syringoma.  Generally he will recommend removing one or two syringomas to learn how your skin responds before performing a larger scale treatment.

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.

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.

How doe sutured eyelid surgery work?

Double fold surgery with a threaded suture works by using stitches to create and maintain an eyelid fold.  The crease is created by burying permanent, non-reactive sutures and pinching the undersurface of the eyelid skin to the deep soft tissue of the eyelid.  The problems arise when the sutures break over time or start migrating through the skin.  The recently developed method called Double Sutured and Twist (DST) technique purports a solution to this problem, however it does not solve the other problems created by this technique.

Problems with sutured eyelid surgery

Sutured double-fold surgery is often performed very quickly.  In some parts of the world non-medical providers will do the work.  As we have said so many times before on this blog, it is important to find an experienced medical professional to perform any cosmetic procedure, no matter how simple someone advertises it to be.

Sutured double-fold surgery and DST double-fold surgery are not a permanent solution.  Not only do the sutures have a record of breaking or migrating, but the fold is often less distinctive than a fold created using an incision technique.  Many patients who have undergone sutured double-fold surgery notice that their crease begins to lose definition over time and due to the lack of control this procedure is known for, asymmetry in the lids is also common.

The best double-fold surgery technique

To make a lasting crease, it is necessary to perform a surgery to make a strong attachment between the skin at the crease and the levator aponeurosis, the tendon that raises the upper eyelid.  Although this method occasionally fails and the crease loses integrity, for most people, the result of surgery lasts a lifetime.

Although cosmetic surgery textbooks recommend the placement of the crease 2 millimeters to 4 millimeters higher than experience dictates.  Physicians who specialize in Asian eyelid surgery are informed by experience; and experience indicates that the incision tends to migrate upward as the eyelid heals.  For the best Asian blepharoplasty results, you need a minimally invasive treatment plan that preserves as much natural tissue as possible. A less aggressive, yet highly controlled surgery creates the fastest recovery time, natural improvements, and precise results.

Restoring the eyelid fold

When sutures fail, the defined upper eyelid crease begins to disappear.  There can be changes to the fold that are unsatisfactory with asymmetry between the two eyelids.  Careful incisional anchor blepharoplasty can be performed to restore the appearance of the eyelids despite prior suture procedures.  Since these types of situations can present unique issues, there is no substitute for a personal consultation with an eyelid surgery expert like Dr. Steinsapir.

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.

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.

How does invisible eyelid surgery work?

According to the doctor who “invented” this procedure, invisible eyelid surgery involves both “subconjunctival blepharoplasty” (usually called transconjunctival blepharoplasty) and a simultaneous “advanced” laser treatment performed by a dermatologist.  Using a micro-fractional CO2 resurfacing laser to treat lower eyelid skin by “tightening” the area following removal of fat through an incision made on the inside of the lower lid (transconjunctival incision), this procedure touts a younger and refreshed appearance of both the upper and lower lids without cutting surgery.  And all this has a recovery period of about a week and no one will be able to see any evidence that you’ve had surgery!  Now that sounds too good to be true.

Why the skepticism?

When you break down the idea of “invisible eyelid surgery” into its basic parts, all you’re really left with is lower eyelid blepharoplasty and CO2 resurfacing; two procedures that have been offered by cosmetic and oculoplastic surgeons for years.  Invisible eyelid surgery isn’t a new idea as the advertising physician would have you believe.  It’s simply two existing procedures packaged together and given a brand new name!  No surprise this is often how “new” things are invented in Beverly Hills all the time.

The risks of transconjunctival blepharoplasty

The idea behind the transconjunctival blepharoplasty is to remove the lower eyelid fat pads to eliminate puffiness around the lower lid that makes you look tired and aged.  But transconjunctival blepharoplasty is not without some serious risks that, if performed without skill or experience can result in permanent damage.  This approach of permanently removing eyelid fat is an old approach to lower eyelid surgery.  It can be effective for a small number of people.  The more current approach is preservation of this fat using a procedure called an arcus marginalis release.  Simply throwing away the fat can cause a hollow lower eyelid.

The risks of CO2 laser resurfacing

Deep CO2 laser resurfacing has fallen out of fashion because of the negative experience many have had healing from these treatments.  There is a very real risk that your skin will suffer from permanent depigmentation, and that the scarring caused by such treatments will likely affect the texture of your face.  This is because the treatment depth needed to improve deep facial lines makes post laser resurfacing scars, particularly skin texture changes, relatively common.  In fact these types of skin texture changes and skin depigmentation are so common that many surgeons think that this is the expected outcome of the service!

Micro fractional C02 laser is an effort to reduce this damage.  These treatments do provide freshening of the skin but generally are not powerful enough to reduce lower eyelid lines.  Chemcial peels, although they require much more training than a laser treatment are still the preferred methods.  In some cases, the chemical peel was all that was needed for the lower eyelid contour to be much smoother even without lower eyelid surgery!

What kind of eyelid surgery will work for me?

Dr. Steinsapir says this a lot, so it should come as no surprise: the best lower eyelid surgery is customized for the individual and designed to meet his or her particular features, goals, and medical needs.  This means that the lower eyelid surgery ideal for one person may be a specialized type of blepharoplasty while for another it may be a midface lift designed to correct tissue descent and return it to its proper anatomical location in the lower eye area.  Once you and your oculoplastic surgeon determine the best procedure, together, you and your surgeon must customize it even further to fit your features and obtain natural results.  Dr. Steinsapir observes: “people don’t do well with a one size fits all, cookie cutter approach.”

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.

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.

Because it is a versatile procedure, upper eyelid surgery can also accomplish other goals, such as creating an upper eyelid crease, opening heavy eyes, improving lash ptosis, and smoothing the skin of the eyelid platform making it more suitable for makeup. In addition, the upper eyelid lift procedure effectively leads to a reduction in skin tissue above the eye, allowing for better peripheral vision for some individuals.

Where is surgery performed and what type of anesthesia will my surgeon use?

Some doctors, like Dr. Steinsapir, maintain a dedicated procedure suite in his or her office and for healthy patients, many eyelid surgeries can be performed under local anesthesia in the office setting.  Others need to have surgery in a surgery center and this is typically done at a center or the outpatient wing of a larger hospital facility.  Dr. Steinsapir often brings his patients who need this level of service to the Surgery Center at The Ronald Regan UCLA Medical Center.  The location of your procedure varies based on the resources available to your surgeon and your unique health needs.

Eyelid surgery is very comfortable and most procedures are easily performed under local anesthesia with or without intravenous sedation.  Dr. Steinsapir advises against having eyelid surgery under general anesthesia.  To get the best possible result it is essential that the eyes can open and close to command during surgery.  If you are asleep, this is impossible and the surgical results will be compromised.  As an alternative, Dr. Steinsapir recommends having surgery under intravenous sedation where the anesthesiologist controls the level of sedation.  You would be minimally aware but still able to cooperate during surgery.  Because of the drugs used, you may not form memories of the surgery and yet you are able to cooperate during surgery, which is ideal.

What are the physical restrictions following surgery?

Before you undergo surgery, a reputable oculoplastic surgeon will ask about your medical history and perform a detail examination of the eyes and eyelids to ascertain your risk level and special considerations.  If you must be on a medication like Plavix or aspirin for medical reasons to thin your blood, your surgeon may advise you that you are not a candidate for cosmetic eyelid surgery, or may recommend a less extensive eyelid surgery.

During the first part of your recovery, you will need to take it easy, avoid bending over, and immediately call your surgeon should you experience any pain, bleeding, or impaired vision after surgery.  After 24 hours, Dr. Steinsapir will encourage you to go for a walk.   Bruising and swelling are normal after surgery.  However, many find that large sunglasses hide these bruises making shopping possible even in the first week after surgery.  Most people take a full week off from work.  However, many find that within a day of surgery, they are able to handle phone calls and email without a problem.  It will be about 10 days before most people may not notice that you just had something done.  We generally advise people to wait about this long before going back to the gym.  However, because workouts vary so much, it is best to discuss your workout with your surgeon to get advice that is tailored to your particular workout.  When you see your cosmetic surgeon, he or she will go over your pre-op and recovery plans in depth, giving you instructions and making sure you have the opportunity to ask all of your questions.

What are some complications from surgery and how they are addressed?

If anyone tells you that you can’t go blind from eyelid surgery like blepharoplasty, they aren’t being honest with you.  The truth is, while this is an extremely rare complication, there is a risk of blindness from eyelid surgery.  Of course no doctor thinks this will happen to them, but the best oculoplastic surgeon will acknowledge it’s a possibility, be honest with you about this, and take precautions to minimize the risk as much as possible.

Loss of vision after eyelid surgery is general due to bleeding behind the eye called a retrobulbar hemorrhage.  If someone tells you that they have never this type of problem after eyelid surgery, then they probably have not seen enough cases, or simply lack adequate training in eyelid surgery.   Avoiding medications and herbal products that thin the blood, like aspirin and Ginko help reduce this risk.

Your doctor will have you avoid blood-thinning medications to significantly decrease the already-low risk of retrobulbar hemorrhage.  This means that, with the consent of your general practitioner or family doctor, you won’t be able to take certain prescription medications as well as over-the-counter medications like Aspirin, Ibuprofen, Advil, and Motrin.  You will also need to abstain from most herbal products for a while.  If you have been prescribed a medication by a physician specifically for the purpose of reducing the risk of clotting, such as Plavix, coumadin, or aspirin, do not stop these medications on your own.  This needs to be done under direct medical supervision.  In some circumstances, your doctors may decide that these medications cannot be stopped and this will have a bearing on going forward with elective eyelid surgery.

Other issues may be more common but are less serious.  Dry eye after eyelid surgery is very common.  This is typically because your eyes were on the dry side before surgery and eyelid swelling makes this a bit worse.  As the swelling settles down, typically the dry eye symptoms settle down to what they were before surgery.  Some complications are very specific to the type of eyelid surgery you are considering.  For this reason, it is incumbent upon your surgeon to discuss these possibilities with you at the time of consultation.  If they spend 5 minutes with you, you are being short changed of this discussion.  A detailed surgical consultation appropriate for eyelid surgery can last an hour or more.

What is the time frame before full recovery?

Generally the bruising and swelling that is common after eyelid surgery rapidly diminishes.  Most people are comfortable returning to work and social activities within seven to ten days following surgery.  Complying all your surgeon’s post-op care procedures will ensure your recovery is as swift as possible.  Generally it is about 8 weeks before the swelling in the eyelids won’t be obvious to you when you look in the mirror.

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.

I already have permanent makeup, can I have eyelid surgery?

If you already have permanent makeup, this won’t prevent you from having eyelid surgery.  Generally the permanent makeup is placed within the eyelashes and eyelid surgery typically does not require an incision along the lashes.  Occasionally, the permanent lower eyelid makeup extends beyond the lower eyelid lashes.  The portion of the eye line that extends beyond the lower eyelid lashes may be affected by lower eyelid surgery, but a skilled surgeon can work around this issue and many lower eyelid procedures do not require a lower eyelid incision.

I have permanent eyebrow makeup, can I have a facelift?

Permanent makeup for the eyebrow generally fills-in or darkens your existing eyebrows.  As a result, a forehead lift that moves the eyebrow will also cause your permanent eyebrow makeup to move.  Occasionally, a woman has plucked her thin eyebrow hairs and penciled in a brow at a higher location.  Before considering having this eyebrow location marked permanently with a tattoo, Dr. Steinsapir recommends a cosmetic consultation.  In some cases, an endoscopic forehead lift may correct the location of your eyebrows and improve your appearance and make your eyebrows appear more natural.  For this reason, before you have your eyebrows tattooed in a higher location, consider having a surgical consultation for an endoscopic forehead lift.

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.