In our office, we see people everyday who are dissatisfied with the appearance of their lower eyelids and are seeking lower eyelid blepharoplasty. Whether it be due to bags that have formed or deep tear trough lines, the lower eyelids can make give us a tired or even ill appearance. We’ve written before about lower eyelid bags and shadows and it is important to figure out if your problem can be easily remedied, or if surgery is in order. When, with the help of an oculoplastic surgeon, you determine that you will need some surgical intervention, it helps to know your options and the best techniques to achieve a good result.

 

lower eyelid bags

Lower eyelid bags

What lower eyelid blepharoplasty (eyelid lift) complications can occur?

Over the past 30-40 years, lower eyelid blepharoplasty has changed tremendously. As surgeons have gained a better understanding of facial anatomy, facial aging and how the tissues respond to surgery, their techniques have evolved. The standard practice for lower eyelid blepharoplasty used to be creating an incision below the eyelashes, dissecting through the muscles and soft tissue layers, exposing and removing fat, then removing excess skin and closing up.  This technique worked for some, but very often caused scarring in the lower eyelids, which pulled them down and/or out away from the eye.  Patients would end up with dry, irritated eyes, eyelid redness, and possible inability to close the eyes.  Others may not have scarring, but the removal of fat alone would cause a hollow appearance, especially in thinner patients.

How is lower eyelid blepharoplasty performed today?

Techniques evolved and most surgeons have updated how they perform the surgery.  We now commonly make our incisions through the inside of the eyelid to access the excess fat.  This avoids dissecting through tissues that commonly cause detrimental scarring.  The three fat pockets of the lower lid can be partially removed, or the fat can be moved into areas, such as the tear troughs, where it is missing causing a sunken appearance. Once the fat is repositioned or removed, a small amount of extra skin can be removed through an incision below the eyelashes, without any dissection that can cause scarring.  We also will often tighten the lower eyelid from the outside corner to ensure it stays in a youthful position and doesn’t pull down or away.

What is the recovery for lower eyelid blepharoplasty?

Eyelid surgery almost always causes bruising and swelling, though this may vary in intensity.  Bruising resolves in 1-2 weeks and swelling can take 1-4 weeks, but longer in some individuals.  Pain is minimal, but some have itching as they heal.

What will I look like after lower eyelid blepharoplasty?

Check out our before and after photos by clicking here.  Here are a few examples:

upper and lower blepharoplasty

Upper and lower eyelid blepharoplasty

Upper and lower eyelid blepharoplasty

Upper and lower eyelid blepharoplasty

If you have questions, email Dr. Harris at [email protected], or call our office at (801)264-4420. To read what other surgeons have written on the subject, start by clicking here.

It has often been debated what if any effect our diet has on our skin.  Does chocolate lead to acne?  We’ve all heard these sorts of questions.  Well several studies have recently shown that a diet rich in certain nutrients can give your skin a healthier glow.  Other foods, when avoided, may prevent break outs or poor skin appearance. Here’s a short list (put together by the authors of Eat This, Not That) of skin friendly nutrients and the best foods in which to find them.

Vitamin E: Almonds are packed with vitamin E, which is a powerful anti-oxidant which scavenges free radicals which can cause skin breakdown.  In one study where participants consumed 14mg of vitamin E (about 20 almonds), they had less evidence of UV skin damage after sun exposure.

Omega 3 fatty acids: The omega 3’s are essential fatty acids, meaning you don’t make them on your own and have to get them through the diet.  They are linked to lower triglycerides and have several beneficial effects for the heart.  Flax seeds are packed with omega 3’s. In one skin study, participants that consumed a half teaspoon of flax seed for 6 weeks had more plump and hydrated skin with less redness and irritation.  Salmon is also a great source of omega 3’s.

Almonds for better skin

Lycopene: This free-radical found most commonly in tomatoes can also give extra protection from UV radiation.  Cooking tomatoes will concentrate this nutrient.  Lycopene is also found in watermelon.

Vitamin C: This is a key ingredient in collagen and is found in lots of foods, including citrus fruits and carrots.  Sweet potatoes are an excellent source.  One study showed that consuming 4mg daily over time can reduce the formation of wrinkles by as much as 11%.

Folic acid: Leafy green vegetables are a great source of this nutrient, which is integral to DNA repair.  Studies have shown that those who eat a diet rich in green vegetables including folic acid have half as many skin tumors as those who have diets sparse on these vegetables.

Omega 6 fatty acids: Described as the ultimate moisturizer, omega 6 fatty acids have been shown to reduce scaly, itchy skin and may be of great benefit to people with eczema.  Safflower oil is an excellent source.

Vitamin A: This fat soluble vitamin helps reduce the overproduction of surface skin cells, reducing skin oils and clogged pores.  Carrots are a great source.

Catechin: This anti-oxidant is prominent in hot green tea. It has been shown to have anti-inflammatory and anti-cancer properties.  It has been shown to reduce the effects of sun damage in people drinking 2-6 cups daily.

green tea for good skin

Flavanols: Dark chocolate is rich in this anti-oxidant shown to reduce the roughness of skin and prevent skin cancer.

A good rule of thumb is to eat a diet high in vegetables, incorporating as many colors as possible.  Avoiding foods with a high glycemic index has also recently been associated with clearer skin.  In addition, dairy has been recently linked to acne and anecdotal evidence has spurred a number of new studies.  Bottom-line, a healthy diet will be evident in a brighter, healthier countenance.

 

 

Think about the first image that crosses your mind when you hear the word Botox or facial filler. It is likely one of a plastic, frozen faced woman with evidence of one too many facial plastic surgery procedures, unnatural facial proportions, oversized lips and unnaturally tight skin.  These are the extremes that websites and the media have convinced us are common place.  For this reason, many of my patients are hesitant or scared about using these products as they don’t want that unnatural look.  But they are still in my office asking about what can be done.  So where is the happy medium?  Reverse aging changes in a way that doesn’t appear artificial.  Herein lies the art of facial plastic surgery.  Artfully using these medications can yield great improvements in facial appearance.  Misuse or overuse can do the opposite at great cost to you.

The key to Botox/Dysport is putting the right amount in the right place.  That seems intuitive, but results can vary greatly by the technique used and experience of the injector.  Botox is popular because it works and most people who are happy with their Botox treatment get a nice flattening of the lines between the brows, on the forehead and in the crow’s feet.  When improperly placed, brows drop or have a “Spock” appearance, lower eyelids can sag, and the face may look too inanimate to be real.  To get a natural effect, first start with an experienced injector, one that will study your facial expression and target the problem muscles, rather than just injecting in a standard pattern.  Then, expect to be invited back after the first week to ensure the proper result was attained.  Sometimes, I feel I’ve given my patients enough to relax the forehead evenly, but after a week I need to add a few more units to the outer forehead muscles.  This allows me to better map out the face and subsequent injections will be on target.  Where a few get into trouble is wanting to eliminate every facial wrinkle with Botox and convincing someone to inject them.  Your face needs expression, which is an underappreciated part of facial beauty.  An appropriate dose of Botox will allow for this movement and still soften the telltale signs of aging.  If your doctor takes his/her time and follows up, your results should end up exceeding your expectations.

In like fashion, the key to good filler is the right filler, in the right amount, in the right place.  Again, that seems intuitive, but many people get into trouble when they want either the wrong type of filler or too much filler placed.  An experienced injector will have a preference for certain brands and types of fillers in different areas of the face.  This is usually based on their experience and results. It is in your best interest to let the injector direct you on what filler they want to use.  If you have a strong preference, seek out a person who specifically advertises using that brand.  With regard to the amount of filler placed, many people think more is better.  This is where the unnatural appearance is most likely to enter the picture.  Overinflated lips, cheeks and tear troughs are dead giveaways that work has been done.  My advice is start slow and add as necessary. Fillers all come by the vial.  An injector can inject part or all of the vial and save the rest for a few days until the initial swelling has resolved.  This allows a metered approach and can give you a maximum improvement without overdoing it.  The flip side to this comes when patients expect a maximum improvement at a minimal cost.  Often two to three (or more) vials are necessary to get a significant improvement, especially in the smile lines and cheeks.  With one vial retailing for around $500-600, many people aren’t willing to spend that much on a non-permanent procedure.  This is where you need to have a frank discussion with your injector about what result you can expect and whether you’d be better off saving for a surgical procedure or maximizing other less invasive treatments.  Having appropriate expectations is key to your satisfaction.

 

Facial aging takes a toll on our lower face as skin thins, fat atrophies and descends, and wrinkles form. Three common problems people come in for are deep nasolabial folds (the crease from your nose to the edge of your mouth), vertical lip lines (sometimes called smoker’s lines, but not exclusive to smokers), and small or fading lips. All of these changes are tell-tale signs of aging, but there are products available that do a great job of reducing their appearance. Let’s look at each one.

Nasolabial folds:

nasolabial folds

Nasolabial folds (arrow)

These folds are present in everyone who ever smiled, but as your facial skin becomes less elastic and facial fat shrinks away, the cheeks descend and form permanent nasolabial folds. These can be accentuated by significant weight loss, sleeping on your side, and skin damage due to tanning. Preventing them is ideal, but aside from using sunscreen, which won’t guarantee they’ll stay away, you can’t do much to avoid them. There are three main ways they are treated. 1) facial fillers such as Juvederm, Restylane and Radiesse are used to fill in the lines, restoring some of the lost volume. These can be injected both directly beneath the crease, but also into the cheeks above creating some minor lifting. In both instances, dramatic reduction of the lines can result. With most of these products, some improvement from baseline can be seen for about a year (more or less varying by individual). There are some risks, such as rare severe reactions to the fillers as well as over-placement of product. Restylane and Juvederm can be dissolved in place with a second injection, but Radiesse has to be expressed or surgically removed. All will fade with time if left in place.

Radiesse to the nasolabial folds

Nasolabial folds and mental crease (chin line) treated with Radiesse.

Vertical lip lines:

vertical lip lines

Vertical lip lines

Loss of fat around the mouth along with facial movements can lead to formation of vertical lip lines. Many people find these objectionable because they are associated with smoking and they make the person appear tired or unhappy.  Other than using sunscreen and not using your lips, you can’t do much to avoid them.  Four different treatments are commonly utilized.  Botox can be injected in small amount in several places along the lips to relax the muscles causing the lines.  This can, however, cause your mouth to move differently and look irregular when you smile.  Fillers, most commonly the hyaluronic acid varieties such as Juvederm and Restylane, can be injected in various patterns to soften the lines’ appearance.  Some people also inject collagen, but this tends to last for a much shorter time. Laser skin resurfacing has also been shown to improve the appearance of these lines.  Finally, dermabrasion, which is essentially sanding down the skin to remove the wrinkle, can be done.  I prefer the injectable fillers as they are not permanent, can be reversed if too heavy handed, are very unlikely to cause inadvertent scarring, and won’t generally affect your mouth movements.

 

Fading (flat) lips:

Progressive addition of Juvederm to the lips

Thin lips with progressive addition of Juvederm for volume

Lip fullness can be something you lose with time, or something you just never had. The ideal proportion of the female lips are about 40/60, or if you look straight at the total height of the upper and lower lips closed, the upper lip should be 40% and the lower lip 60% of the height. Most commonly, the upper lip is more flat or rolls in and under as we age, making it appear thin. To regain that ideal shape, you must replace volume. Similar to above, dermal fillers work very well for this. They are injected along the vermillion border (junction of normal skin and pink lip skin) near the central portion of the lip, as well as within the body of the pink tissue of the lip. The outer edges near the corners of the mouth are avoided to prevent that fish mouth appearance. Maintaining the proper proportions and being conservative with volume changes will make the lips appear full and youthful, not inflated.

Call our office at (801)264-4420 for a consultation to discuss dermal fillers and your options.
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I came across this video segment from ABC news about men and facial plastic surgery.  Botox use and eyelid surgeries among men are becoming increasingly popular.  I’ve seen and operated on quite a few men the past few months, many of whom were told by their wives that it was time to address their drooping eyelids. Check out the video below.

Myth #10: Vitamin E reduces scarring – Vitamin E is an antioxidant, which are agents that neutralize the oxidant effect of free radicals (molecules that damage collagen and cause skin dryness, fine lines and wrinkles). Free radicals are not the cause of scarring and any effect you may see from a vitamin E cream on scarring is either something else in the cream, an effect of the massage you did while you put the cream on, or would have happened anyway. Many creams claim to reduce scarring, such as Mederma, but few have any hard evidence that they work.

Myth #9: Skin pores open and close – When looking in the mirror you may notice lots of black pores, especially on the tip of your nose. Scores of cosmetics and treatments have been devised to reduce the appearance of these pores, many claiming they close the pores. Others claim that steam or hot water opens the pores. The pores are always open, which is necessary to allow us to sweat. The skin oil, or sebum, also comes out of the pores. The pores appear closed or full when the oils get backed up, clogging the opening. Warm water or steam helps melt these oils, cleaning out the pores. The pores, however, have no muscles and do not open or close.

Myth #8: Acne is caused by fatty foods and chocolate – Acne is caused mainly by hormonal changes, which can be affected by stress, genetics and other unknown factors. Diet may affect this to some degree, but their isn’t clear evidence how. A few studies done in the late 1960’s seemed to disprove the relationship between chocolate and acne. Pimples are formed when clogged pores become inflamed and collect both oil and pus. What exactly causes this inflammation to occur is not known.

Myth #7: Anything organic is better for the skin than synthetic products – Natural products rarely exist in a form that is perfectly balanced for you skin’s use. Either they are too potent and can cause irritation or too weak and don’t have much affect at all. Luckily, there are lots of chemists who can balance the beneficial properties of these materials to give you the best effect possible. Organic products only have to contain a small amount of naturally occurring chemicals (as little as 2%) to wear the organic label. (The price will likely be more than 2% greater than the non-organic variety).

Myth #6: Getting a base tan prevents burns later – Tanning in any form, whether at the beach or in a tanning bed is causing permanent damage to your skin. A base tan does nothing to prevent this damage. Face it, if you insist on tanning now, you will pay with extra wrinkles later (but not much later) as well as dramatically increase your chances of skin cancer.

Myth #5: Sunburns are only bad when you are young – Many people believe that any sun damage that will lead to skin cancer or wrinkling occurred when they were a teenager, and is out of their control now. They then proceed to continue tanning thinking skin protection is no longer important. UV damage can lead to skin cancer in only a few years time. I’ve seen several patients with facial skin cancers in their thirties. Sunscreen is always a good idea no matter your age.

Myth #4: Skin creams with collagen can replace collagen – Collagen is a large molecule and isn’t going to pass through your skin and somehow incorporate itself exactly where it was lost. Your body has to synthesize new collagen on its own from basic proteins. Certain vitamins, such as A and C, can help this along.

Myth #3: Vitamin A (retinol) will thin out the skin – Vitamin A enhances the skin’s barrier function, aids in collagen production, regulates oil production, reduces skin dryness, and increases skin oxygenation. Topical steroids will thin the skin when used for prolonged periods.

Myth #2: Dry skin creates wrinkles – Moisturizers may temporarily reduce the appearance of very fine lines by plumping up the skin, but no moisturizer will permanently reduce wrinkles, no matter the cost.

Myth #1: Shaving body or facial hair makes it grow back thicker – The part of the hair you can see above the skin is essentially dead and has no way of signalling back to the body to change its growth pattern when cut. Shaven hair will feel more rough as the cut ends are blunt, but the volume of hair has not and will not change.

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We now have 2 good products on the market for smoothing out dynamic wrinkles: Botox and Dysport. Both are forms of botulinum toxin, a potent chemical that blocks signals at the junction between nerves and muscles. Botox (onabotulinum A), has been around for about 30 years and was initially developed to treat disorders of muscle spasm, such as frequent uncontrolled blinking (blepharospasm). Doctors noted that their patients who received Botox around the eyes had decreased wrinkles, an unexpected benefit of the treatment. An enterprising pharmaceutical company, Allergan, sought a cosmetic indication from the FDA. Botox Cosmetic was introduced to the market, approved for treatment of glabellar wrinkles (those vertical lines between your eyebrows). As is often the case, doctors experimented with injecting Botox in many areas of the face and today it is administered all around the eyes, face and lips.

In 2009, a second product came on the market called Dysport (abobotulinum A), which is very similar chemically to Botox. Many doctors have now gained experience with both medications, but which one is better? Patients who have tried both often prefer one over the other stating that one has a faster onset or lasts longer. A double blind randomized trial (the gold standard for research) was conducted in which patients were injected at the crow’s feet on one side of their face with Botox and the other side with Dysport. They were photographed at the time of injection and at 30 days after. They were also asked to rate which side they liked better. Among the 90 patients studied, they rated Dysport better 2/3 of the time and the researchers also rated Dysport as better for smoothing crow’s feet than Botox. The difference was mainly noted when patients were smiling very vigorously. At rest no difference was noted. In other studies, the risks and side effect profiles were equivalent.

In my experience, Botox and Dysport both work well.  Patients who have used both comment that Dysport seems to have a quicker onset (1-3 days vs. 3-7 days), but that hasn’t been universal.  Dysport can be slightly cheaper as the company that distributes it in the US often offers rebates to the patients. If you have been using Botox and it is working well for you, I’d continue with it.  Occasionally people develop a tolerance to one drug and then you could switch over to the other and likely still get good results again. If you have never tried either, the choice is yours. They both work well and are safe.

If you are interested in trying Botox or Dysport, call our office for a consultation at 801-264-4420.