The Fat Has It – Especially For Our Eyes!

Written by Frank P. Fechner, MD

Before and After Photo of Young Man after Advanced Lower Blepharoplasty

“The eyes are the mirror of the soul!”
This saying reflects the importance we put on the eyes when looking at people. And it is not only the eyes themselves; rather their appearance is substantially influenced by the surrounding facial regions including the under eye area. This underlines why cosmetic eyelid is so important and popular: it supports the attractiveness of the eyes without “changing” who we are.

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Upper Eyelid Lift at Age 20

Written by Frank P. Fechner, MD

A 20-year old patient asked us: Am I too young for blepharoplasty?

With any cosmetic procedure, the patient goals, motivation and anatomy have to be considered first. The age is really secondary. In rejuvenation procedures such as facelifts, age is an important consideration. For the eyelids, enhancing the definition and appearance of the eyes can be a valid goal for a 20 year old. Age related changes are obviously not the concern.

A consultation with an experienced facial cosmetic surgeon will help in discussing concerns, goals and possible treatment options. Risks associated with an eyelid lift need to be discussed, too.

Upper blepharoplasty is commonly performed in many people of Asian heritage in order to achieve a more defined upper lid crease (a.k.a. double eyelid).  Most Asian  patients are between 18 and 30 years of age.

Advantages of an Laser Eyelid Lift?

Written by Frank P. Fechner, MD

Patients sometimes ask about the benefits of an laser eye lift which they may have heard about.

Because the term “laser eyelid surgery” is not well defined for plastic surgeons, the discussion has to start by asking what it actually is. There are a couple of possibilities:

1. Laser resurfacing around the eyes.  The out layers of the skin are removed through heat generated by the laser machine. The depth of resurfacing will determine how much change can be anticipated. Usually, fine lines and wrinkles are the main target. This procedure has been fallen out of favor for many experienced facial plastic surgeons.  For Dr. Fechner, re-sculpting the lower lid region by reducing puffiness and filling in the dark-circle depressions below the lids take a priority. For the upper lids, resculpting and removal of skin excess result in very nice improvements.

2. The laser is used to make an incision for blepharoplasty.  Although it is possible to make incisions with many different instruments, none have been proven to heal better than the one made with a high quality scalpell.


Can Fat Grafting or Sculptra Be Used to Treat Prominent Skin Veins Below the Eyes?

Written by Frank P. Fechner, MD

Prominent Veins may develop around the eyes – how can they be treated.

These veins are located superficially, just underneath the skin. Fat grafting is very effective for under the eye hollowness (a.k.a. tear troughs).  We reserve Sculptra for other facial regions such as cheeks and jawline.

But for veins, both fat grafting or filler injections would likely fail to provide satisfactory results. One of the secrets to successful volume treatments is placement deep underneath the skin, especially in the lower eyelid region.

Vascular lasers (such as a YAG) can be tried. If this does not work, one may be left with 3 further options: attempt of micro-coagulation, make-up or surgical repair through a small incision.

Blepharoplasty – How Painful is Eyelid Surgery Using Local Anesthesia?

Written by Frank P. Fechner, MD

We feel that blepharoplasty is well suited to be performed under local anesthesia with pre-operative relaxing medications. Although everybody is very protective of one’s eyes, our patients are usually surprised how relatively easy the procedure is for them. The sedatives are administered by mouth and take usually about 30 minutes to be effective. Once the patient finds themselves in a relaxed state, markings are performed for accurate planning of the procedure. Next, using a tiny needle, local anesthetic solution is deposited underneath the lid skin. After the first injection, additional “pokes” are performed through the already numb skin. Therefore, the patient feels only a slight stinging as the solution “freezes” the lids. Once complete, the blepharoplasty procedure itself can be performed without discomfort. The lids will stay anesthetized for approximately 1 hour.

We conducted a study evaluating the discomfort associated with local anesthesia injection in 56 patients. When using a scale from 1 to 10 (1 representing no pain; 10 excruciating pain), the average discomfort level was 4 (mild to moderate pain).

I have skin wrinkles after lower eyelid lift. What can be done?

Written by Frank P. Fechner, MD

I assume that this is after transconjunctival (“inside the eyelid”) blepharoplasty with additional wrinkling developing after the fat was removed. Most patients have some skin excess before the eyelid lift which can worsen after the puffy lid is deflated through fat removal.
In this case, there are a few options available:

  1. chemical peel
  2. laser resurfacing
  3. skin excision

The Pros and Cons

Each of these treatments have their pros and cons. Skin removal with a so-called “skin pinch” procedure may be most effective. It must be performed carefully and conservatively in order to prevent complications.

Chemosis after Eyelid Surgery

Written by Frank P. Fechner, MD

Chemosis represents a condition where the conjunctiva swells excessively. The eyes show a gelatinous and almost translucent layer which appears like it could be easily wiped away. It is usually painless, not dangerous and always resolves. Although this can be associated with many medical conditions, it is most commonly seen after facial trauma and surgery . Chemosis can occur with after any plastic surgery around the eyes, it develops most frequently after lower eyelid lifts.  It is very rare if only the upper eyelids have been treated. If further eyelid procedures have been performed such as canthopexy, canthoplasty or facelifts, chemosis may be more common.

In general, chemosis after blepharoplasty is very rare. In the less than a handfull of patients we have encountered chemosis, it resolved after 4 to 6 weeks spontaneously. Ophtholmologists will simetimes treat with steroids or other medications (i.e., diuretics); good scientific evidence for the efficacy of these medications for chemosis is lacking. We have found conservative lubricating eye care to be sufficient. The literature and colleagues of mine report patients in whom chemosis lasted 9 to 12 months after blepharoplasty…

In general, chemosis will stress both, the patient’s and surgeon’s patience alike but it will resolve eventually.

What is the Best Treatment Approach to Tear Troughs?

Written by Frank P. Fechner, MD

The tear trough deformity (a.k.a. naso-jugal fold) represents the depression underneath the under-eye puffiness. They are absent in most young people and slowly develop in the 30s or 40s. People refer to tear troughs as “dark circles” under the eyes and they are responsible for a tired and worn out look.

Fortunately, modern cosmetic medicine offers options for correcting tear troughs. 

First, we usually consider non-surgical options like injectable fillers. We prefer Restylane for this particular region for its predictability and longevity. Commonly, Restylane lasts 1 year or longer in the under eye regions.

Second, fat transfer (a.k.a. fat grafting or fat injection) is a minimal invasive option for ultra-longlasting effects. Fat is usually harvested from the abdomen or hip region through micro-liposuction. Because only about 10cc of fat is removed, no significant effect develops in the donor region. The fat is then prepared, concentrated and injected into the region of volume loss. We use the micro-droplet technique and the fat is placed deep underneeth the muscle layer. Some bruising and puffiness is always present after the fat treatment; we recommend our patients to plan on a good week of recovery. There is usually no pain.

If aging of the lower lids also warrents tightening of skin and reduction of the lower lid puffiness, advanced lower blepharoplasty may achieve the best improvment. We perform these procedures in the office under local anesthesia with a sedative. Recovery is usually determined by puffiness and bruising afterwards; 10 days is usually sufficient.