Archive for the ‘Oculoplastic and Eyelid Surgery’ Category
Facial cosmetic surgery is a very personal and monumental decision. Universally, all patients want the best outcomes. In today’s corporatized America, with heavily influential marketing spin, pharmaceutical companies, medical device companies, and even practitioners promote a less is more mentality to push products and services that often over promise and under deliver on the results. In no way can skin creams, injectables, or lasers deliver the types of results once can achieve with surgery. In a similar manner, minimally invasive sounding surgeries are in no way a substitute for time tested peer reviewed procedures that provide quality long lasting results.
Unfortunately not every person will achieve acceptable results with Botox or injectable fillers such as Juvederm, Restylane, and Radiesse. These products have their place in facial aesthetic practices, in properly selected patients, but in general should be viewed as temporary treatments with less impressive results when compared to surgery. Their primary advantage is that they have minimal social while providing a benefit. Botox is being used more and more as a preventative cosmetic medicine that delays wrinkle formation. Fillers camouflage initial signs of aging, but ultimately putting too much filler in a face, the liquid facelift, can alter ones appearance creating an artificial overinflated appearance. Using filler to augment facial structures can be useful to patients wanting to get a general idea of the appearance prior to permanent surgical procedures such as lip and cheek enhancements procedures. Creams reverse the signs of photo aging and contribute to collagen formation and production but are limited in their effectiveness. Lasers are an excellent option to delay the signs of aging and treat sun induced skin photoaging, but in no way can they tighten skin like facial cosmetic surgeries such as a facelift.
Surgical procedures are the best option for impressive endurable results. Rhinoplasty can dramatically affect ones facial appearance in a way that almost no other cosmetic surgery can. The nose can cause undue and unnecessary attention drawing attention away from other attractive facial features. Aging face surgery has many layers of effectiveness based on the surgical techniques used and how they are applied. In general, minimally invasive techniques can produce an artificial appearance and or short-term results. When considering aging face surgery most sophisticated patients are looking for surgeries that will last as long as possible with the most dramatic natural appearing results. There are no shortcuts to achieving optimal results and when applied, shortcut techniques frequently under deliver on the surgical results end.
Becoming an informed patient who understands the benefits of finding the right intervention or surgery for the right patient will ultimately save one time and money over the long haul. Getting things done right the first time is of paramount importance to achieving optimal outcomes with a high degree of patient satisfaction, while avoiding problems and bad outcomes.
Posted by: Benjamin C. Stong MD
Today, the vast majority of surgeons perform lower eyelid blepharoplasty or eyelid lift techniques using a transconjunctival approach with fat removal and a skin pinch to rejuvenate the lower eyelid. Additionally laser treatments or chemical peels may be used to improve skin texture and smooth wrinkles. The evolution of this treatment resulted from concerns of postoperative ectropion or lower eyelid malposition associated with more traditional techniques and lack of familiarity with the measures required to prevent these complications. The transconjunctival approach makes an incision on the inside of the eyelid and while it is a safer approach in less experienced hands, it has also resulted in an incomplete lower eyelid and midface rejuvenation.
The characteristics of the aging process of the lower eyelid and midface include decent of the midface soft tissues and fat pad, elongation of the lower eyelid, pseudoherniation of fat from around the eye resulting in puffiness, formation of the tear trough deformity, and redundancy of the skin and muscle of the lower eyelid. The transconjunctival lower eyelid blepharoplasty with fat removal and skin pinch fails to address several of these issues. Removal of fat from around the eye can lead to a hollowed appearance of the lower eyelid and an abrupt transition from the lower eyelid to the midface that appears unnatural and artificial. Additionally, a skin pinch removal from the lower eyelid fails to remove the excess muscle underneath the skin and shorten the eyelid. When considered in whole there are several problems with this technique and it fails to address several of the issues that occur with age in the lower eyelid and midface.
The skin muscle flap blepharoplasty with fat transposition is the most contemporary technique available in lower eyelid blepharoplasty, and it corrects several of the issues that the transconjunctival blepharoplasty with fat removal and skin pinch fails to address. First, and most importantly, the fat from around the eye is conserved and repositioned in the tear trough (the groove that forms between the eyelid and the nose and midface) obliterating it and resulting in a smoother more natural transition between the lower eyelid and midface. The skin muscle flap blepharoplasty also removes muscle as well as skin for a more natural correction of the redundant soft tissue of the lower eyelid. When the eyelid is properly re-suspended during the procedure the risk of permanent post procedure ectropion is virtually eliminated.
Shortening the lower eyelid is best accomplished by performing a midface lift at the same time as the lower eyelid blepharoplasty. The medical literature supports that by adding a midface lift to a lower eyelid blepharoplasty more skin and muscle can be removed resulting in a shorter more youthful lower eyelid. Most midface lift techniques do not effectively release and re-suspend the soft tissues of the midface. When considering a midface lift it is important to find a surgeon who performs a transtemporal extended subperiosteal midface lift to ensure an excellent outcome. When performing a skin muscle flap blepharoplasty with fat transposition along with a midface lift the aging characteristics of the lower eyelid and midface are more completely addressed resulting in a natural, more complete periorbital and midface rejuvenation.
It is also important to consider adding a skin resurfacing procedure to improve wrinkles and skin texture and quality of the lower eyelid and finish the rejuvenation. This can be accomplished through either chemical peels or ablative laser procedures. Contemporary laser procedures allow for excellent skin resurfacing and rejuvenation with shorter healing periods when compared to chemical peels and more traditional laser procedures. The state of the art laser skin resurfacing techniques combine an epidermal laser peel with a fractionated deep dermal laser resurfacing to treat both superficial and deep wrinkles and brown spots. The Pearl Fusion procedure combines the Pearl and Pearl Fractional procedures to offer the most advanced laser technology while providing the safest outcomes.
Finding a plastic surgeon who understands how the different surgical techniques correct the aging characteristics of the lower eyelid and makes informed recommendations based on the patient’s particular issues is important to achieve superior outcomes and avoid complications. Midface lifts can correct the drop of the cheek soft tissues, efface the nasolabial folds, and shorten the lower eyelid. While a deep plane facelift can also lift the cheek soft tissues and smooth the nasolabial folds, the midface lift offers a greater effect and more permanent change to the midface soft tissues and nasolabial folds. Performing a skin muscle flap blepharoplasty with fat transpositions along with a midface lift offers the most complete periorbital and midface rejuvenation available today.
Benjmamin C. Stong MD
Atlanta, GA
The fourth and fifth decades of life are a time when people often begin to become more aware of age and committed to facial plastic surgery procedures. Accumulated sun damage and prior skin care rejuvenation regimens affect when patients begin to consider blepharoplasty, brow lifts, and facelifts during these decades. Often, patients will also add staged or simultaneous skin resurfacing rejuvenation procedures to maximize and augment surgical results. There is often a misconception that surgery and procedures need to be delayed as long as possible to avoid additional surgeries in the future. The truth is there is no good or bad time to under go surgical and skin rejuvenation procedures; it is only appropriate when a patient becomes bothered enough by the issue to consider surgery and is an intensely personal decision. The most important consideration to avoid bad outcomes and unnecessary surgeries is to find a practitioner who uses techniques that will provide superior, long lasting results.
Eyelid lift surgery or blepharoplasty offers a long lasting procedure and when performed correctly is often not necessary to have repeated in the future. Similarly, Brow Lifts usually only need to be performed once if the surgery addresses the laxity issues in the forehead, upper eyelid, and brow complex and adequately releases and re-suspends these tissues. Minor touch up procedures may be included in future treatments to maintain and maximize results from blepharoplasty and brow lifts. Revision surgery becomes important when considering revising suboptimal results from poor, inadequate techniques and is more difficult due to scar tissue from the previous surgery and is more expensive. Having a procedure performed correctly the first time is of paramount importance.
Facelifts are procedures that can be performed multiple times over a patient’s lifetime. To avoid unnecessary and costly revision surgeries, finding a surgeon who effectively releases and re-suspends the SMAS layer, the primary support layer, of the face is important. Many surgeons believe they get equally effective results with less aggressive work on the SMAS layer, but there is no short cut to providing superior long lasting results. When performed properly, a facelift can provide patient satisfaction for ten years, or more. A facelift addresses an aging jaw and neck line, resetting the clock, but it does not stop the clock from restarting. Some patients who want to be aggressive about hiding their age may choose to undergo two or three facelifts during their life. Another popular misconception is that undergoing multiple facelifts will result in a pulled or windswept look. The truth is that when the skin and deeper SMAS layer are pulled in the correct direction, a facelift can be performed as many times as desired to maintain a more youthful jaw and neck line. An additional misconception is that a comprehensive and thorough jaw, cheek, and neck lift can’t be performed through an abbreviated mini facelift incision. This notion is also false; a thorough facelift can be performed through the short scar, abbreviated, mini, s-lift facelift incisions safely with superior outcomes. Consultation with a knowledgeable facial plastic surgeon will allow for a comprehensive facial rejuvenation plan over the years when a patient is interested and healthy enough for surgical procedures.
Skin resurfacing rejuvenation procedures are important to consider when augmenting and maximizing surgical results. In addition to noninvasive lasers such as IPL LimeLight and YAG Laser genesis procedures, ablative resurfacing procedures become necessary to maintain youthful looking skin. Finding a practitioner who offers the state of the art laser rejuvenation procedures is necessary for excellent outcomes with the shortest healing times. Currently, combining confluent and fractionated laser modalities offers the best treatment for both superficial and deep discolorations and wrinkles as well as stimulating collagen formation. It also avoids complications and prolonged healing times from more traditional chemical peels and lasers. Laser resurfacing rejuvenation procedures can be performed as often as necessary to restore and maintain youthful, vibrant looking skin.
Botox, facial fillers, medical skin care products and other preventative and maintenance therapies should be continued in the forties and fifties to maximize the longevity of surgeries and skin rejuvenation procedures. Consultation with a knowledgeable facial plastic surgeon, who applies a global perspective when discussing patient goals and their future considerations, will put the patient at ease and establish trust that the practitioner is making thoughtful recommendations based on his expertise and training.
Posted by: Benjamin C. Stong MD
Oculoplastic surgery is a sub discipline of Facial Plastic and Reconstructive Surgery and is performed by Facial Plastic Surgeons as well as Ophthalmologists who sub specialize in eyelid surgery. There are two components to oculoplastic surgery: cosmetic and reconstructive surgery. Blepharoplasty, ptosis repair, and ectropion repair can be performed for both cosmetic and functional, reconstructive reasons. If they are performed for eye dysfunctions such as obstructed vision, excessive tearing, or eye protection, they are considered reconstructive procedures and if they are performed specifically for aesthetic reasons they are considered cosmetic. Repair of the eyelids from cancer removal or trauma is always considered reconstructive surgery.
Blepharoplasty of the upper eyelid always includes removal of excess skin and muscle and usually removal of excess protruding fat from around the eye. The most optimal incision uses an extended incision compared to a more traditional blepharoplasty incision and is carried over the outer orbital rim to correct excessive lateral hooding because the outer eyelid and brow complex age more rapidly than the central eyelid and brow. When the brow is in low position a brow lift procedure is necessary prior to correction of the eyelid to avoid problems. Lower eyelid blepharoplasty is less straight forward with several techniques employed by many surgeons. The most state of the art technique involves a small imperceptible incision just under the lower eyelash line with conservation of the bulging fat to move it into the tear trough in order to create a smooth, youthful, seamless transition between the lower eyelid and cheek with removal of excess muscle and skin. Removal of lower eyelid fat can create a hollowed effect with an abrupt, unnatural transition between the lower eyelid and cheek.
Ptosis repair involves two primary techniques. The first uses an incision in the upper eyelid to tighten the Levator muscle/tendon complex by removing a portion of the tendon, advancing the tendon and reattaching it closer to the eyelid margin, or plicating the redundant tissue. The second method is performed on the inside to the eyelid and involves removing a portion of Mueller’s muscle elevate the eyelid. Sometimes skin may need to be removed during the ptosis repair depending on the amount the eyelid margin needs to be raised and excess skin that is present. Less frequently, a brow lift may need to be added to the procedure if the brow is in a low position.
Ectropion repair is performed for excessive laxity in the lower eyelid and is performed in two ways: a canthopexy and canthoplasty. A canthopexy is simply repositioning or tightening the eyelid tendon and a canthoplasty involves making a skin incision and removing excess skin and shortening the horizontal distance of the eye. The need for a canthoplasty over a canthopexy is based on the distance the eyelid moves from the eyeball or globe and is commonly performed for excess laxity associated with facial paralysis and age related involutional ectropion otherwise canthopexy procedures are desirable for less severe laxity issues because they don’t shorten the horizontal length of the eye resulting in a more unnatural appearance.
Eyelid reconstruction from Mohs skin cancer surgery or trauma involves evaluating the amount of remaining functional eyelid remaining for full thickness defects. If less than a third of the eyelid is missing then a primary wedge resection repair is indicated because there is enough built in redundancy to the eyelid and relaxation following surgery to achieve an excellent outcome. If there is approximately fifty percent to two thirds of the eyelid missing a tenzel rotation advancement flap is used with a release of the eyelid tendon to gain enough tissue and movement on the remaining eyelid to advance the two edges together and achieve a cosmetically excellent outcome. For near total eyelid defects, pedicled Hughes flaps can be used to replace the entire lower eyelid with transposition flaps to repair subtotal defects of the upper eyelid.
Oculoplastic cosmetic and reconstructive surgery is performed by all Facial Plastic Surgeons as well as Ophthalmologists with specific training. It requires a detailed knowledge of eyelid anatomy and function as well as plastic surgery reconstructive principles to achieve excellent outcomes. Understanding the type of training and knowledge base of your surgeon is critical to avoiding bad outcomes and achieving desirable results.
Post provided by Benjamin C. Stong, MD
The upper eyelids and brow should be considered together for rejuvenation of the upper third of the face. The upper eyelid is one of the first areas of the face to show signs of aging, with excess skin. If left long enough, the redundant skin can obstruct a patient’s peripheral vision. Patients often complain of heaviness of the upper eyelid with outside observers commenting that the patient looks tired. Along with redundant skin, the upper eyelid can have bulging of the fat pads that surround the eye. The excess fat should be removed during upper eyelid blepharoplasty (eyelid lift).
The brow descends with age due to laxity in the supporting structures. The lateral, or outer portion of the brow, descends at an accelerated rate when compared to the central portion of the brow because of differences in attachment to the underlying soft tissue and bone. This results in a more rapid accumulation of redundant skin on the outer portion of the upper eyelid, which is termed “lateral hooding.” When determining the correct brow lift procedure, the surgeon should determine if the effects of aging on the brow include primarily the lateral brow or the more central portions of the brow. If there is a significant discrepancy in aging of the central and lateral brow, with the lateral brow primarily affected, a lateral temporal brow lift may be indicated. With this procedure an incision is placed in the hair overlying the temple and the brow is elevated in an upward and outward direction to restore its natural arch and youthfulness.
Often times patients do not seek consultation until the effects of aging are more advanced with the central brow having dropped significantly, as well. In this instance a total brow rejuvenation procedure should be performed, with several options currently being used. The most state-of-the-art brow lift procedure is the endoscopic brow lift whereby the brow is lifted using tiny incisions in the scalp and telescopes to release the brow and reposition it in an elevated position. There is controversy as to the effectiveness of this procedure. Over time, it has become apparent that in experienced hands it is an equally effective, less invasive procedure.
The trichophytic brow lift, an open technique, camouflages the incision by placing it in the hairline mirroring the entire length and carrying the incision down into the hair tuft over the temples. This is an effective technique that is still commonly used today by many surgeons. The primary consideration is whether the patient is willing to tolerate a much longer incision and more invasive procedure. Other types of brow lifts still used today, although less commonly, include: the coronal, direct, and midbrow lift with specific indications for each technique. The direct and midbrow lift place incisions in the forehead skin and are typically indicated for facial paralysis and older, male brow lifts respectively. The coronal brow lift approach places a large incision in the central scalp from ear to ear and is almost never indicated for rejuvenation procedures, but rather as an approach to facial trauma and head and neck procedures. The coronal brow lift incision may be indicated to reverse a previously over pulled brow procedure that has resulted in a “surprised look.”
When considering the upper eyelid and brow as a unit, one must restore brow position prior to removing upper eyelid skin to prevent “lagopthalmos,” or eyelid retraction, and dry eye. If the brow is at an appropriate height with a youthful arch, the upper eyelids may be addressed without a simultaneous brow lift. When a low brow position and redundant eyelid skin occur together, a brow lift should accompany an upper eyelid blepharoplasty with the brow lift performed first to prevent negative outcomes.
When patients present with primary concerns about their upper eyelids, the brow must be assessed at the same time in order to get optimal results. When a low brow is not corrected at the same time as the upper eyelid blepharoplasty, a future brow lift procedure can have a much higher complication rate and may preclude the procedure all together. Finding a surgeon who is familiar with the many brow lift techniques and assesses the brow and eyelids together as a complex, is important to avoid complications and deliver optimal results.
Post provided by: Blepharoplasty | Eyelid Lift Atlanta GA | Benjamin C. Stong MD