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COSMETIC SURGERY

What is a blepharoplasty?
A blepharoplasty is generally considered a cosmetic surgical procedure aimed at improving the appearance of the eyes. An upper blepharoplasty removes the fold of skin above the eyelid as well as fat pads which may be causing a puffy appearance. In addition to correction of upper eyelid hooding, an upper blepharoplasty restores or creates an "eye shadow" space in women and a sharper, more alert appearance in men.

A lower blepharoplasty removes loose skin and fat pads which cause dark circles or puffiness underneath the eyelids causing a tired appearance. The goals of blepharoplasty are to improve the appearance of the eyes while maintaining the natural shape of the eyelids.

What are the different types of upper blepharoplasty?
There are a number of different types of upper blepharoplasty with several different distinctions.

1. Upper Blepharoplasty - this is the most commonly performed procedure with the incision hidden in the natural crease of the upper lid. Varying amounts of skin and muscle are removed to achieve the desired result. Conservative removal is generally performed in males and females who do not desire a high lid crease. Fat is removed if there is excess puffiness.

2. Upper Lid Crease Procedure - this technique is designed to create a crease in the upper lid between the eyeshadow space and the eyebrow. This is performed in patients with minimal upper lid folds, Oriental patients desiring a double fold, and in patients who have an uneven crease following previous surgery.

3. Upper Blepharoplasty with Browpexy - this technique combines the upper blepharoplasty with elevation of the tail of the eyebrow through the upper blepharoplasty incision. This is for patients with an unstable brow that could be pulled down with an upper blepharoplasty and for a slight browlift.
4. Upper Blepharoplasty with Browlift - this technique combines and upper blepharoplasty with an endoscopic browlift to improve the appearance of the eyelids, forehead, and eyebrows. The browlift is performed through tiny incision hidden above the hairline. In addition to lifting the brow, the frown lines above the nose are improved with this technique.
5. Upper Blepharoplasty with Ptosis Correction - this technique combines an upper blepharoplasty with tightening of the loose levator muscle, tarsolevator advancement, to correct a droopy upper eyelid.

What are the different types of lower blepharoplasty?
There are a number of variations in technique for lower blepharoplasty with several different distinctions.

1. Transconjunctival Blepharoplasty - this technique hides the scar inside the lower eyelid and is designed primarily to remove the fat from the three fat pads underneath the lower eyelid. The main advantages are that the scars are hidden and the risk of changing the shape of the eyelids is reduced but not entirely eliminated. The main disadvantages are that excess skin and muscle underneath the eyelids cannot be tightened.

2. Transconjunctival Blepharoplasty with Laser - this technique combines the transconjunctival removal of fat with laser resurfacing with CO2, Erbium, or other lasers to tighten the skin under the eyes. The advantage is additional improvement of the lines underneath the eyelids and the crow's feet. The main disadvantages may be prolonged redness, change in the color of the color, or scarring from the laser as well as a change in the shape of the eyelids.

3. Transconjunctival Blepharoplasty with Chemical Peel - this technique combines transconjunctival blepharoplasty with use of a chemical peel around the eyes, most commonly TCA (trichloroacetic acid). The risks are similar to laser resurfacing.

4. Lower Blepharoplasty - this technique hides the scar just under the eyelashes and in a smile line near the corner of the eye. The lower blepharoplasty is designed to remove fat from underneath the eyelids and tighten loose skin and muscle. The main advantage is a more longer lasting result allowing sculpting of the fat which reduces the risk of developing a hollow appearance long after surgery. The main disadvantage is that the shape of the eyelid can be changed ranging from a more round to serious complications such as scleral show and ectropion.

5. Lower Blepharoplasty with Skin Flap - this technique is similar to a standard blepharoplasty with use of a flap of excess skin which is tightened while preserving the muscle.

7. Lower Blepharoplasty with Lateral Canthopexy- similar to standard blepharoplasty with tightening of the corner of the eyelid to avoid changing the shape of the eye.

8. Lower Blepharoplasty with Lateral Canthoplasty - similar to standard blepharoplasty with division of the lateral canthus for correction of looseness of the lower eyelid. This is used to prevent or correct lid malposition, a pulled-down lower lid.

9. Lower Blepharoplasty with fat repostioning- similar to standard blepharoplasty with repositioning of the fat pads to fill in areas of hollowness under the eyes.

10. Lower Blepharoplasty with Midface Lift (Cheeklift) - this technique is performed through the lower blepharoplasty incision to improve the appearance of the eyelids and the cheeks by lifting the fat pad above the cheekbone.

How Do I Know Which Procedure Is Best For Me?
Prior to surgery, the preoperative consultation is performed which will include evaluation of your eyelid features and discussion of your desired changes. The contour and shape of the eyelids are examined. Dr. Codner will often request that a patient bring in old photographs to help determine how the eyes have changed with aging or from previous surgery. An important part of the evaluation is analysis of eye prominence, canthal tilt, and lid laxity. The preoperative evaluation will determine which procedure options are best for you.

Eye prominence
The relationship of the position of the eyeball relative to the bone underneath the eyelids determines the degree of eye prominence. Patients with prominent eyes have the front of the eyeball positioned in front of the bony rim. Patients can have large or prominent eyes as part of a family trait or from hyperthyroidism, Graves' Disease. Patients with prominent eyes will often have scleral show, or the white part of the eye showing between the lower eyelid and the bottom of the iris.

Patients with deep set eyes have the eyeball positioned behind the bony rim. Although deep set eyes are also a common family trait, they can also occur with aging or after trauma such as a black-eye. Different techniques are required for patients with prominent and deep set eyes.

Canthal Tilt
The relationship between the inner corner of the eyelid, the medial canthus, and the outer corner of the eyelid, the lateral canthus, determines the shape or tilt of the eyelids. A positive canthal tilt is when the outer corner of the eye is above the inner corner. This upward slant gives the eye a more almond shape. A negative canthal tilt is when the outer corner is below the inner corner. This downward slant gives the eye a more round shape. Different techniques are required for patients with positive and negative canthal tilts.

Lid Laxity
The eye shape is also influenced by the amount of looseness or laxity of the lower eyelid. The test commonly performed to evaluate laxity is the lid snap-back test. This test is performed by stretching the lower lid away from the eye and measuring the time it takes to snap back into position without blinking. Lid laxity will generally require correction in order to avoid any change in the eye shape after blepharoplasty.

TREATMENT OPTIONS
Following the completion of your evaluation, Dr. Codner will discuss the options which are most safe and effective for your case. Additional ancillary procedures such as Botox, Chemical Peels, and Laser Resurfacing may be considered to enhance the overall result after surgery.

Botox
Botox is a medical grade form of botulism toxin which is used to reduce the appearance of wrinkles around the eyes. It has been used safely in medicine for over 15 years with an excellent safety record. The injections can be performed during an office visit. Botox is used to reduce the frown lines in the forehead and the crow's feet lines around the eyes with results lasting 3 to 4 months.

Chemical Peels
Chemical peels are performed during surgery to tighten some of the fine lines around the eyes which cannot be tightened with blepharoplasty. In addition to fine lines, chemical peels can effectively improve sun damage on the face.

Laser Resurfacing
Lasers have been used to improve the appearance of the skin for nearly 10 years. The laser treatment has been used to safely tighten loose skin and improve sun damage and is for cases that require a more aggressive approach than a chemical peel can provide.