Blepharoplasty/Eyelid Surgery

January 25, 2011

Osteoporosis of the Face

When you think of facial aging, wrinkles and sagging skin come to mind, but new research finds that skin isn't the only thing that ages.

Over time, so do the facial bones, which lose volume and recede, making you look even older.

And if crow's feet and jowly cheeks weren't enough, the bones of the eye socket gradually widen, the brow bone recedes, and the jawbone becomes less defined.

If you think of the facial bones as "scaffolding" for facial tissue and skin, the bone loss can contribute to that drooping, deflated look.

And sorry, ladies. While the most pronounced bone loss happened for men when they were 65 and older, the process starts earlier in women. Women's facial skeletons between 41 and 64 look much different than their facial bones did between the ages of 20 and 40.

The bone loss helps explain why getting a simple facelift (or skin tightening) won't ever make you look like your 20-year-old self.

In the 20th century, plastic surgeons assumed that facial aging was primarily due to skin aging and to gravity.  Hence, we focused on skin tightening and lifting.  But a lot of faces never looked like they did when they were younger.  Facelifts never completely achieved a natural, youthful look.

Over the past 10 years, we have increasingly recognized that facial fat loss is major issue.  Hence, substances that mimic the fullness of fat (such as Restylane, Juvederm, Radiesse, and Sculptra) have become wildly popular.  And results have correspondingly improved.  The results from comprehensive plastic surgery (surgery + filling + laser resurfacing) are starting to look pretty good.  But they still fall far short of true rejuvenation.

Now, we are understanding more of what's missing:  bone.

In the January issue of Plastic and Reconstructive Surgery, researchers from Rochester, New York, published their comparisons of facial CT scans of faces of differing ages.

With age, the scans showed that the bones that make up the eye sockets recede, enlarging the sockets.  This contributes to the appearance of excess or droopy skin around the eyes.

Similar losses of volume happen in the bones of the middle face, including the brow bone, nose, and upper jaw.  The loss of bone can also reduce the angle of the lower jaw, which is why those with a strong jawline in their youth may not be so well-defined in old age.

For those seeking facial rejuvenation, plastic surgeons should start considering how they can mimic the fullness of youthful facial bones.  Options might include more fillers, or even facial implants.

While it may never be possible to return a patient to looking 20 years old, adding volume to mimic lost fat and bones will improve results for most patients.

The study makes sense.  We know that bone densities in the back, hips, and legs decrease with age, why wouldn't osteoporosis also set in at the face?

Clearly, aging is multi-factorial.  "Quick lifts" and other gimmicks are certainly not going to treat all of the issues.  A comprehensive plan will be necessary to rejuvenate different issues at different decades.


January 01, 2011

Decreasing Enthusiasm for Lower Eyelid Blepharoplasties

A new understanding of lower eyelid aging is decreasing plastic surgeons' enthusiasm for lower eyelid surgery.

Based upon the latest research, we have a better understanding of what makes lower eyelids look old....

  • Skin wrinkles, including crow's feet
  • Pigment deposition
  • Bulging fat bags
  • Flat cheeks

Huh?  Flat cheeks?  Yes, you read right.  Flat cheeks.

As we age, we gain fat in some places (such as our tummies and buttocks), and we lose it in others (such as our breasts and cheeks).  In aging faces, the lower eyelids frequently demonstrate bulging fat bags.

  • Possibly, this could be the result of true fat accumulation (as occurs in the abdomen and buttocks).
  • But, more likely, the bags result from an age-related laxity of the tissues holding the fat in the orbit, where the fat is supposed to cushion the eyeballs.
  • Most important of all is that the bulging orbital fat looks more prominent next to the flatness of the upper cheeks.  The contrast between the bulging of the eyelid fat and the flatness of the adjacent cheek tissue renders the fat more visible and more unsatisfactory.

Regardless, lower eyelid blepharoplasties have, for decades, been the treatment of choice.  The surgery involves the removal of orbital fat through small incisions, along with the trimming of excess muscle and skin.

However, the results can look hollow.  Excessive fat removal makes the eyeball "sink" into the globes.  Moreover, persistently flat cheeks worsen the skeletal appearance of an aging face.

The solution is twofold....

  • very conservative lower eyelid blepharoplasties, with only judicious removal of...
    • lower eyelid orbital fat 
    • lower eyelid skin
    • lower eyelid orbicularis oculi muscle
  • filling the upper cheeks, with
    • an off-the-shelf filler, such as Restylane, Juvederm, Radiesse, or Sculptra
    • fat grafting
    • cheek implants

In other words, diminish the bulge but elevate the depression.  A hill doesn’t look so high when you fill the adjacent valley!

In my practice, I will usually treat the upper cheeks first with an off-the-shelf injectable, such as Restylane or Sculptra.  If the lower eyelid/upper cheek improvement is satisfactory, then the patient and I are done.  We have achieved rejuvenation without surgery!  Blepharoplasty surgery can be delayed for a few more years--or decades.

On the other hand, if the lower eyelids still look too baggy, then we proceed to the operating room for a conservative blepharoplasty.  After 2-3 months of healing, we reassess.  If the patient is happy, then that's it.  However, if the lower-eyelid/upper cheek area still looks too tired or too old, then I fine-tune the results of the blepharoplasties with more of the injectable--in the office, under local anesthesia, without cutting.

With this step-wise approach, not only are the results more anatomically accurate and thus more pleasing, but also the patient can take a more active role in her outcome.  By taking charge, she can make sure that she is not "over done."

My goal is always less surgery for a more subtle, more natural result.  Just say, "NO!" to the Beverly Hills look!!


October 30, 2009

Blepharoplasties in Men?

Yes, men benefit from blepharoplasties--plastic surgery of the upper and lower eyelids.  In this fellow's case, he was concerned that excess upper eyelid skin impeded his vision, especially in the upper, outer portions of his field of vision.


Formal visual fields testing at his ophthalmologist's office confirmed that his sight was significantly hampered.  His insurance company agreed to pay for his upper blepharoplasties.

But what about those "bags" beneath his lower eyelids?  Since his upper eyelids were being rejuvenated, the patient and I agreed that simultaneous lower blepharoplasties would produce facial harmony.  (But there's no convincing an insurance company to pay for even rational aesthetic surgery.  This gentleman had to pay for his lower eyelid surgery out of his own pocket.)

The end result is excellent.


He sees better, and he looks better.  He still has a masculine appearance, and is certainly not "over done."  A happy, confident patient is always my goal!


September 09, 2009

Under Eye Bags Caused by Muscle Hypertrophy

Hi, This has been a problem since I was a little girl.  Now I'm 40 and want to improve the appearance of my under-eye bags, whether it is with surgery or fillers.

I look tired all the time and my bags just keep getting bigger as I age. I went to another consultation for blepharoplasty (eyelid surgery).

The doctor told me there's nothing that can be done, because it's all muscle and not fat. Could I have hypertrophy?  What can I do?  I can't stand to look at myself or have others look at me.  If there is surgery for this, what is it called?


Shellee's undereyes 

Dear Shellee,

Find an experienced Botox injector.  Ask for 1 unit of Botox in the roll under each eyelid.  This might solve your problem without surgery.

(If your plastic surgeon is up on the latest treatments, 2.5 units of Dysport would also work.  Dysport is probably equivalent to Botox.)

Do be aware that this is a tricky use of Botox/Dysport.  There are a few potential (albeit unlikely) risks...

  • Lowering the lower eyelid margin (so that you see white beneath your green irises)
  • Loosening the tension on the fat beneath the eyes, such that bags really do become apparent (I agree with your current analysis.  You do not have fat bags, just excess muscle.)
  • Causing your eyes to become dry and scratchy

I highly doubt that you will have problems, but other plastic surgeons might be hesitant to give my suggestion a try.  This is definitely a Botox/Dysport use for experienced injectors only.

If the Botox/Dysport is unsuccessful, the injector could try more.  Or, a little filler in the upper cheeks (at the infraorbital rims--the bony rim beneath the eyes) can smooth the area out.  My favorite is Sculptra.

(By the way, the world's 2nd most beautiful woman--Angelina Jolie--also has muscular rolls beneath her lower eyelids.  Shellee, you're in good company.)


(Who's the world's most beautiful lady?  My wife, of course!!)


Mike Pickart


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