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 

In contrast, Dr. Steinsapir developed Microdroplet ^TM botulinum toxin as an alternative method for addressing brow ptosis and forehead lines without freezing facial expression or creating the risk of a droopy eyelid. Microdroplet ^TM botulinum toxin concentrates treatment in the muscles that account for eyebrow depression. These muscles live right along the eyebrow. The key to the treatment is using very small doses of botulinum toxin just below the level of the skin where the muscles of facial expression insert. This effective traps the botulinum toxin so the treatment can’t diffuse into the upper eyelid. Because only the muscles that pull the eyebrows down are relaxed, the frontalis muscle of the forehead does not have to work as hard to lift the eyebrows. This means fewer forehead lines without paralyzing the frontalis muscle. That frozen look is associated with heavy forehead treatment. Microdroplet botulinum toxin creates a forehead lift without freezing the forehead. This means you have natural forehead movement.

Microdroplet ^TM botulinum toxin treatment is so unique that the United States Trademark and Patent Office recognized Dr. Steinsapir as the inventor of this method and issued a rare medical method patent for this treatment.

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.

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.

The double fold suture methods for Asian eyelid surgery, are ostensibly closed methods. Small incisions are made in the eyelid for the purpose of hiding the sutures used to form a crease. In contrast, anchor blepharoplasty is an open eyelid method. In order to perform an anchor blepharoplasty, the surgeon must make an upper eyelid crease incision. Through this incision, the orbital septum is identified and opened. A very clear operational understanding of eyelid anatomy to perform the surgical dissection needed to perform the surgery. Unfortunately, many eyelid surgeons lack this basic but specialized anatomic knowledge. In my experience operating with senior plastic surgeons, less than 5% of these surgeons possess the knowledge, skill, and experience to correctly perform this dissection.

Anchor blepharoplasty anchors the upper eyelid platform skin and the underlying orbicularis oculi muscle to the levator aponeurosis, the tendon like expansion of the levator palbeprae superioris muscle as it inserts into the upper eyelid tarsus. Attachments from this tendon to the skin are responsible for holding the upper eyelid platform skin firmly. As these attachments give way, the eyelid platform skin above the eyelashes becomes lax. Unfortunately this is precisely the area of the eyelid that must be taut to hold eyelid make up. Also when this skin lacks appropriate support, the upper eyelid lashes are not well supported and the upper eyelid lashes droop. This is known as lash ptosis. Lash ptosis is one of those subtle things that contribute to the eyelids looking tired.

For an Asian eyelid, a double fold is created when there are attachments under the skin between the upper eyelid crease and the levator muscle. For many Asians, these attachments are under developed. This accounts for the absence of a double fold. In some cases these under developed attachments may produce an incomplete partial fold. The suture methods force the crease to form along the path that the sutures are treaded. So long as the sutures remain intact, the crease is present. When the sutures break the scar tissue created by the passage of the sutures is seldom strong enough to maintain the crease and fold. This accounts for why the threading procedures do not hold up long term.

In contrast, the open double fold surgery produces eyelid structure that is permanent. The most critical aspect of successful double fold surgery is placing the crease at the correct position of the eyelid. The precisely height of the upper eyelid crease seems to be a bit of a mystery for most surgeons. Many surgeons being very diligent students have followed what is described in the textbooks. That would be great but for one fact. The appropriate height of this crease is not correctly reported in most plastic surgery textbooks. In Converse’s Textbook of Plastic Surgery, the height of a Western eyelid is noted to be 10 mm. Other texts note that for Asian eyelids the crease height should be 8 mm. These numbers are wrong on two counts. A surgeon making a crease at 10 mm will not find that the crease will heal to the desired position. As the upper eyelid wound heals, it migrates superiorly 1 to 1.5 mm. This means that a crease placed at 10 mm will heal at 11.5 mm above the eyelashes. An Asian crease cut at 8 mm will heal at 9.5 mm. At this height, the fold will never properly drape the upper eyelid. Most Asian women will feel that their eyelid is Westernized. Not the desired effect! I typically make my Asian upper eyelid crease incision at 5.5 to 6.5 mm. This means that the upper eyelid retains its quintessential Asian character.

With the eyelid open and the levator tendon carefully exposed, the presence of upper eyelid ptosis can be addressed with sutures that reinforce the upper eyelid tendon or, when necessary an actual anterior levator resection ptosis procedure can be performed. This permits as much or as little correction of upper eyelid ptosis as needed. Also this exposure is needed to anchor the upper eyelid skin and orbicularis to the levator tendon at the height of the new eyelid crease. No closed method permits this type of correction.

Not sure about your potential Asian eyelid surgeon? Have a frank conversation about their assessment of your eyelids. What height will they be placing the upper eyelid creases? How much skin do they intend to resect. Will the surgery only involve removal of skin, or skin, muscle, and fat, and why? Do they intend to open the orbital septum? (They should) If not, what is their plan to form a long-term upper eyelid crease and what height are they planning to place the crease? If the answers to these questions are lacking, you should consider interviewing more eyelid surgeons. These are very basic issues.

Dr. Steinsapir
Los Angeles

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 or surgeon 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.

Dark under-eye circles can be caused by a number of conditions, including thin lower eyelid skin and not having enough fat between the skin and underlying muscle (the orbicularis oculi).  The deepest part of the dark circle is where this lower eyelid muscle attaches to the bones of the face. The only permanent solution for this problem is to add volume to the under eye area.  The best approach is to use hyaluronic acid fillers such as Restylane, which can be adjusted to create the perfect taut under-eye area.

Fat grafting is another method that is often used to treat this problem.  Unfortunately, fat grafting requires a surgery.  The surgery may be accompanied by a number of unpleasant side effects, including profound bruising, persistent swelling, and the development of bumps and lumps that sometimes require additional surgery to address.

Ending a long day by putting slices of cucumbers under your eyes may help you relax, but it won’t make a dent in your dark circles. If you’re truly interested in permanently lightening or erasing dark circles, consult a cosmetic surgeon who specializes in 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.

The only time you need to get clearance from an ophthalmologist is when your plastic surgeon is not appropriately trained to take care of the eyes and is therefore unqualified to properly assess the health of your eyes. Board-certified general plastic surgeons lack the necessary training, skills, and experience to accurately assess eye health. Of course they are not the only surgical specialty that offers cosmetic eyelid surgery without these important skills.  Facial plastic surgeons, dermatologists and cosmetic surgeons of various stripes and background all offer cosmetic eyelid surgery without the detailed knowledge needed to provide care for the eyes. For this reason, if they are performing your eyelid surgery, they should send you to your general ophthalmologist for clearance.

Unfortunately, the general ophthalmologist may not fully understand the procedure, so they might not know what signs to look for in regards to whether you’re a good candidate for the surgery. As a result, the ophthalmologist may unintentionally clear you for a surgery that could compromise your eye health and comfort. It makes sense that a surgeon who is both board certified in ophthalmology and fellowship trained in to perform eyelid surgery will be the best choice.

Without in-depth training in oculoplastic surgery, eyelid surgery performed by general plastic surgeons, facial plastic surgeons and other cosmetic surgeons may not be ideal for your individual needs. Surgeons who lack training in oculoplastic surgery and board certification in ophthalmology don’t have the skills, training, and knowledge to manage post-surgical eyelid issues that may arise. Often this lack of training also means that they lack the finesse that sets the stage for successful results when foreseeable issues are considered and factored into the design of a surgery. Even the choice of which eye drops to use after eyelid surgery to comfort the eyes or a thoughtful discussion before surgery regarding what to expect can make all the difference.

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.

Fat transfer has become very popular. Doctors are even calling them “stem cell facelifts.” Technically, adults stem cells are in the grafted fat, so there is a tiny grain of truth to this. Mostly though, it is a lie. These stem cells have nothing to do with the results accomplished with a facial fat transfer.

Dr. Steinsapir finds that fat grafting to the lower eyelid is an inferior treatment. First it requires a surgical procedure to obtain the fat. Harvesting the fat requires a small surgery with definite, though rare, harvest site healing issues.

Placement of facial fat also requires a surgical procedure. It is common for the face to bruise with placement of the fat. The bruising commonly takes about 10 days to resolve. The take of the fat is not predictable. Experienced fat grafters including Dr. Steinsapir believe that about 60-70% of the grafted fat survives. Over filling the face with fat can make the face too full. Where that fat is placed in the cheeks, chin and temple areas the grafted fat tends to hide in existing facial fat. Dr. Steinsapir likes fat grafting when the face needs a good deal of volume.

However, fundamentally, the lower eyelid is not an ideal location for fat grafting. The reason for this is poor tissue coverage. The dark circle or tear trough is defined where the lower eyelid orbicularis oculi muscle inserts into the bone of the maxilla. This means no fat under the insertion of this muscle, the thinnest spot of the dark circle. Putting the fat above or in the muscle is a sure way of making bumps. You don’t want bumps, especially not bumps caused by grafted fat. Unlike certain fillers that are prone to bumps, those fat bumps are not going away. 20 years from now those fat lumps will still be there. In fact if you happen to gain weight since your fat grafting, guess what? Your lumps will gain volume too.

How common are lumps after fat grafting? Gee, fat grafters as a group don’t report this information. Many of these patients find their way to Dr. Steinsapir’s office for help. Some of them were made worse because a well meaning surgeon injected the bump with corticosteroids to melt them away. They show up with a lump where the grafted fat is and a hole where the steroids have damaged the natural lower eyelid fat. 5-florouracil is sometimes used to modify the unwanted lumps from fat grafting. This is an anti-cancer medication that can sometimes modify scar tissue. However, when this does not work, actual eyelid surgery is needed to remove these nodules of grafted fat. It is Dr. Steinsapir’s opinion that as many as 30%, possibly more of patients who have had fat grafting to the lower eyelids have unwanted lumps.

Now compare this to filling the dark circle with Restylane. Restylane is an office service and does not require surgery. No second wound is needed to obtain the material. The product is available with local anesthetic. Using a topical numbing cream applied to the skin also helps to make the procedure very comfortable. Deep anesthesia is not needed. Restylane can be shaped to the face once injected. You can reapply makeup two hours after treatment so down time is minimal. It is possible to bruise from this type of treatment but typically the bruise is not as profound as that associated with fat grafting. If there are any lumps, bumps, or unwanted highlights on the skin, these can easily be modified with an enzyme called hyaluronidase.

Restylane often lasts a year or more. This treatment is easily performed by an experienced midface injector like Dr. Steinsapir. It can be adjusted at any time in the office setting with a very safe injectable enzyme. This certainly beats needing to have surgery on the face or needing the face injected with an anticancer drug.

Fat grafting does it last? Yes, certainly. However, after fat grafting it is very common for swelling to persist for several months. It is all too common for individuals to become dissatisfied with the degree of facial improvement once the swelling has resolved many months later. Individuals who have been fat grafted, often feel that the volume from the fat grafting has disappeared. While this is seldom actually true, the deflation that occurs as the fat grafting heals causes natural disappointment with the procedure. This leads many to wonder if fat grafting was worthwhile. Combine this with lumps in the lower eyelid when fat is placed in the thin tear trough area and you have a formula for unhappiness. Given this reality, Dr. Steinsapir feels that under eye Restylane is almost always the preferred option over fat grafting the lower eyelid.

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 ranks at the top with a handful of medical centers in the United States. Dr. Steinsapir performed his surgery on an outpatient basis at the Surgery Center at the UCLA Medical Center. Dr. Steinsapir addresses a broad array of cosmetic oculofacial concerns including cosmetic eyelid surgery, Asian eyelid surgery, endoscopic forehead lift, BOTOX and dark circle treatment. Contact us today to schedule a personal consultation with Dr. Steinsapir.

Dear Editor:

I read Robert Johnson’s article “A Nip and a Tuck” about cosmetic surgery for the 65-plus crowd that appeared in the October 31, 2011 WSJ.  The article only mentions a single specialty that offers cosmetic surgery: general plastic surgeons certified by the American Board of Plastic Surgery.  Either general plastic surgeons are very good at public relations (they are), or the author was unmotivated to provide readers with a balanced perspective.  General plastic surgeons are not the only board certified surgeons who offer safe, high quality cosmetic surgery.

For years general plastic surgeons failed to train their residents for cosmetic surgery. General plastic surgery residency instead focused on broad training in reconstructive general plastic surgery.  Despite claims to the contrary, treating a burn is not the same as performing liposuction, a facelift, or an eyelid surgery.  This lack of leadership has resulted in a less than ideal standard of care for these elective cosmetic surgeries.

Over the past 40 years, otolaryngologists, ophthalmologists and dermatologists have built excellent fellowship training programs in facial plastic surgery, oculofacial plastic surgery, and dermatologic surgery that provide in-depth training in cosmetic surgery to allow these surgeons to offer cosmetic surgery to the American public that is arguably safer and of better quality than that offered by general plastic surgeons.   The American Board of Cosmetic Surgery, a non-ACGME board, accredits high quality cosmetic surgery fellowships that are open to a number of surgical specialties including general surgeons, gynecologists, oral maxillofacial surgeons, as well as general plastic surgeons. These highly trained specialists provide a quality alternative to board certified general plastic surgeons who lack formal training in cosmetic surgery.  It is now well accepted that fellowship trained dermatologists practicing liposuction are much less likely to be sued for liposuction malpractice than general plastic surgeons to cite just one example.

It is not controversial to state that general plastic surgery residencies do not provide adequate training in cosmetic surgery.   Fortunately the field of general plastic surgery has recognized this and now offers a growing number of fellowships in aesthetic surgery for board eligible general plastic surgeons.  However, compared to fellowship trained specialists in facial plastic surgery, oculoplastic surgery, dermatologic surgery, and cosmetic surgery; general plastic surgeons still have a ways to go before the public trust in this specialty is truly deserved. Unfortunately readers of Mr. Johnson’s article were left unenlightened about these issues.

Sincerely,

Kenneth D. Steinsapir, M.D., Los Angeles, Ca.

Associate Clinical Professor

Division of Orbital and Ophthalmic Plastic Surgery

Jules Stein Eye Institute

David Geffen School of Medicine at UCLA

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.

Fixing Minor Problems

BOTOX treatments are popular because they are noninvasive and effective in relaxing tense muscles and smoothing wrinkles.  BOTOX is a naturally-occurring purified protein that relaxes muscles but is eventually broken down and expelled from your body completely.  The effects usually last 4 to 6 months.

With botulinum toxin A products (BOTOX, Dysport, Xeomin), adverse issues are usually the result of an unbalanced treatment.  Forehead treatment can be associated with upper eyelid or eyebrow ptosis.  Unbalance forehead treatment can result in issues of asymmetry.  It is possible to improve your treatment results using the appropriate counter treatment along the eyebrow using Dr. Steinsapir’s Microdroplet method.

Eyelid Ptosis

If your BOTOX treatment has caused eyelid ptosis, Dr. Steinsapir recommends finding an oculoplastic surgeon to help you with this particular issue.  Oculoplastic surgeons are trained to assess and treat upper eyelid ptosis. A prescription for Iopidine (aproclonidine ophthalmic solution) can be helpful in this circumstance; this medication is a glaucoma drop that can elevate the eyelid a couple of millimeters. The drops can also be used to assess the severity of the ptosis and predict the likely time frame for the resolution.  Dr. Steinsapir recommends trying the drops twice a day for a week.  If successful in opening the eye, the ptosis will likely resolve in 4-6 weeks and the drops will help improve the eyelid ptosis until resolution takes place.

The likelihood of upper eyelid ptosis is extremely small in the hands of an experienced injector.  Less experienced injectors are more likely to perform a treatment that causes ptosis.  It’s important to carefully research a doctor or nurse’s credentials and their track record for successful injections.  The individual performing your treatment has a profound effect on the risk of side effects.  Upper eyelid ptosis has been reported in as many as 5% of cases. The incidence of upper eyelid ptosis in the hands of experienced injectors is much less.   Dr. Steinsapir has seen only three mild cases of ptosis in his last 3,500 treatments.

Other Options

What if your doctor tells you that there are no treatment options?  Rescheduling an event like a wedding can be impossible.  Consider having a heart to heart with your photographer.  Can they photograph you to minimize the appearance of a droppy eyelid or photoshop your images after the fact?  If so, consider going forward with your plans and let the photographers cure your eyelid position digitally.

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 his expert care.

To learn more about Dr. Steinsapir’s specialized BOTOX 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.