facial plastic surgery - eyelid lift

Upper eyelid blepharoplasty

Facial plastic surgery: Does it make you look younger or more attractive?

A recent study in the Journal of the American Medical Association: Facial Plastic Surgery looked at how much younger people appeared after certain facial plastic surgery procedures.  It involved one rater looking at before pictures and guessing the patient’s age and rating their attractiveness. A different rater did the same with the after photos and the results were compared. On average, the patients looked 3.1 years younger and were slightly more attractive. The problem with the study was that the same person didn’t see the before and after photos together, which is typically where the most difference is noted and what would happen in real life with a patient’s acquaintances.  But it does highlight a question: Does plastic surgery make you look younger or more attractive, and is this actually the goal?

Expectations around facial plastic surgery

When discussing patients’ expectations before eyelid & brow surgery, I try and stress that I’m not trying to shave off years, just trying to improve their peripheral vision with the added benefit that they won’t look as tired or angry.  We all know that there is “good old” and “bad old” when it comes to how people age.  Some patients, although into their 70’s or 80’s, still stand up straight, show good muscle tone and weight, and carry themselves like much younger people. While many patients in their 40’s to 60’s are just the opposite: overweight, sedentary, with poor skin and poor diet.  Plastic surgery isn’t likely to make this second group significantly more attractive or youthful, given all the other factors making them look prematurely older.  A red flag that someone is going to be unhappy after surgery, no matter how good the outcome, is their expectation that changing this one small aspect of their appearance will solve their problem of not feeling young or attractive.  It just doesn’t work like that.

What I hope my patients can understand is that we are all aging chronologically at the same rate, which no one escapes. No one can expect to look younger than the calendar suggests if they aren’t taking the best care of their bodies. We can slow the feeling of inevitable degeneration by first living a healthful life and only addressing those aspects we can’t otherwise change, such as baggy eyelids or a sagging brow, with facial plastic surgery or other procedure.  Patient’s with these realistic expectations are nearly always satisfied with their outcomes and will radiate both youth and attractiveness to the people they know and love.

 

Dark Circles Under Eyes: 5 deep tear trough treatments

We’ve talked before about dark circles under eyes. One of the most common causes is a deep tear trough.  The tear trough is that depression extending from the inner corner of your eye diagonally toward your cheek.  This depression occurs where the facial fat has thinned out and dropped down into the cheeks. The bone of the eye socket is now right below the skin and the two are fairly well attached to each other.  As the skin above and below age and change, this area becomes even more apparent. It can become dark and develop a noticeable shadow, which makes one appear tired and more aged.  There are many options to treat this, and the methods are changing as we better understand facial aging.

dark circles under eyes - Facial filler Juverderm

Juvederm treatment under eyes and around mouth.

1. Make-up:

Many women (and even some men) utilize concealer in this area to lighten the skin and diminish the shadow.  When the problem is subtle, make-up is a great, non-invasive and inexpensive treatment.  As the problem worsens, however, make-up cannot fully hide the changes and may begin to accentuate it.

2. Skin lightening creams:

In certain people and ethnic groups, the skin in this area darkens. This can be due to actual pigment changes in the skin or from very shallow blood vessels just below the thin skin. When it is pigment related, skin lightening creams, such as hydroquinone, can be effective.  When starting this type of treatment, it is helpful to consult a skin specialist or aesthetician highly experienced in its use. Start with a weaker concentration (no higher than 4%) and use it for a short time until you are sure you aren’t especially sensitive.  Slowly increase the use and concentration until the desired effect is achieved. Rarely will these types of creams completely fix the problem, but they can make a noticeable improvement.

dark circles under eyes - Hydroquinone skin cream

Hydroquinone skin cream

3. Phototherapy:

Intense pulsed light, and even some laser treatments, are used to lighten skin pigmentation and tighten skin in the under eye area. Often this is proceeded by use of a topical lightening cream and possibly a short course of Retin-A to maximize effect.  Again, this should be done by someone with a lot of experience in administering the whole treatment.  Different skin types react differently, so be sure your practitioner explains how they are tailoring your treatment to you personally.

4. Facial Filler:

Hyaluronic acid fillers such as Juvederm, Belotero, and Restylane are well suited to treating the tear trough area when the problem is loss of facial fat volume.  Filling this area back up with a substance that is similar to the building blocks of normal collagen can give a new youthful appearance to the mid-face. It is relatively inexpensive, costing around $500 for a treatment. In many cases it lasts 12-18 months.  Filler is injected with a small needle into the space directly above the bone and then massage around until it appears smooth.  In a few weeks, it softens up be hardly be felt.  It is a safe procedure with some occasional bruising taking place. When injected deep, the chances of it getting into a blood vessel and causing problems in uncommon, although this is the greatest risk. See Dr. Harris explain more about facial filler in a short video here.

dark circles under eyes - Belotero facial filler

Belotero facial filler

5. Lower eyelid fat repositioning and blepharoplasty:

When fat in the lower eye socket begins to come forward, it creates a bag in the lower eyelid. A crease forms at the bottom of the bag over the bone of the eye socket. Lower eyelid surgery (blepharoplasty) is performed to move fat from this bag into the upper cheek and tear trough, which fills in the depression and returns the fat to a normal location, where it was before it descended into the cheek.  In some people, a portion of the fat is also removed. In others we also remove a small amount of skin below the eyelashes. All of these techniques serve to smooth out the transition from the eyelid to the cheek, which is a hallmark of a youthful, rested appearance. See our gallery for eyelid before and after photos.

If under eye shadow or bags are a problem for you, give us a call for a free consultation at (801)264-4420, or email Dr. Harris directly at [email protected].

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.

Eyebrow trends change with time, but droopy brows are never in style. When the brow starts to descend, it can cause a hooded look pushing down the eyelids and leaving you looking tired. While you can’t avoid getting older and losing skin elasticity, there are several ways to approach beautification of the brows.

Eyebrow proportions

Eyebrow proportions from britneybeauty.com

1. First, figure out the best eyebrow shape and color for you, and actively maintain it. Choose a shape you like, but keep it natural. An overly-thin brow makes you look older while very thick or dark brows can dominate your face and take attention from your eyes. Understanding the proportions of a beautiful brow is important. The head of the brow should start in line with the inner corner of the eye and ideally with the outer corner of the nostril (see #1 on Angelina Jolie above).  The peak of the arch should line up with a line drawn from the outer corner of the iris to the corner of the nostril (see #2 above). The end of the brow should fall on a line from the outer corner of the eye to the corner of the nose (see #3 above).

2. Consider reshaping drooping brows with Botox injections. When injected above the brow, it will help to lift the brow into a more youthful-looking position by immobilizing the muscles.

3. Fillers, such as Juvéderm and Radiesse, can be injected and instantly lift the end of a brow that’s begun to sink over time.

4. If you need a dramatic lift, browlift surgery is a permanent fix that can be done endoscopically, which makes it a minimally invasive procedure. During a browlift, the muscles are repositioned to lift the brow into a more natural position. Plus, any sagging excess eyelid skin can be removed as well.

For a few tips on shaping and tweezing the brows properly, click here and here for some excellent articles on Elle.com and here for a video demonstration.  Taking a little time to properly learn to shape your brows can give a whole new look to your eyes.

Ear Gauge Repair

Ear Gauge Repair

We’ve all done things to our look that down the road we regret.  A bad haircut or perm, rocking the blue eye shadow a little too hard, countless fashion choices that expired days after they were hot.  But for some choices, a change is more difficult than just changing your wardrobe or letting your hair grow out.  Ear gauges have been trendy for several years now, with some taking it to extremes creating massively stretched out lobes. Many people choose this trend when they are young, in high school or college, only to realize that it is hard to be taken seriously when it’s time to enter the workforce.  Some company dress codes even  preclude employees from wearing large jewelry in their ears, forcing the gauged ears to flop empty throughout the workday.  Many people are now choosing to have plastic surgery to reverse the appearance and return their ears to a more normal appearance.  A recent spot on the TV show “The Drs.” showed a patient undergoing the procedure.

As the video showed, reversing the problem is straight-forward and can be done in the office.  Scarring is minimal and generally improves over the first year.  The ears can be re-pierced after a few months if that is desired.  We perform a similar procedure on earlobes that have been stretched out by heavy earrings and lobes torn through accidentally.  If you have gauges and want to discuss having them reversed, give our office a call at (801)-264-4420. See Dr. Harris discuss ear gauge reversal by clicking here.

 

Often when people come to our office complaining that their eyelids are sagging, they actually have a drooping forehead and brows.  This downward sliding skin causes the upper eyelid to look especially redundant and fold over the eye.  Many times, especially in men, the brow hairs are down at the level of the eyelashes and the brows block out their entire upper visual field. Simply raising the forehead without even touching the eyelids corrects most of the problem and dramatically improves their visual angle. Recently, a couple of patients told me they just couldn’t believe how much of their world they were missing out on seeing because of their heavy brows.  So in this article, we’ll talk briefly about what causes this problem and what are the main ways of treating it, including their pros and cons.

What causes brow and forehead descent?

  • The main cause is aging.  With age the skin of the forehead becomes less elastic and gravity causes it to descend. It is fairly firmly attached at the top of the head, but more mobile over the forehead where the frontalis muscle allows the skin to move up and down with facial expression.  In time this skin gets stretched and has no place to go but down.
  • Weight loss can also cause drooping of the brows.  Heavier individuals develop a layer of fat under the forehead and brow skin, which when lost can lead to forehead droop.
  • Certain illness can cause loss of tissue elasticity and drooping brows.  Others cause damage to the nerves that innervate the forehead and brow muscles, such as Bell’s palsy or facial nerve injury. The brow and forehead droop

What are the main ways it is treated?  With my patients I like to divide the treatments into good, better and best.

  • Good: Direct brow lift will raise the brows very well.  It involves an incision above the brow hairs full thickness and removal of a strip of skin.  The brow is then raised with heavy sutures stitched from the deep skin below the hairs into the muscle and covering of the bone up higher.  Its biggest drawback is the scarring it can produce.  A man with very bushy eyebrows may be able to hide the long linear scars, but in most they are very apparent, even after months of healing.  The shape of the brow often tends to be more rounded, which looks fine in a woman, but unusual in men.
  • Better: Newer techniques are being used to raise the brows, either through small incisions above the brow hairs, or through the upper eyelid incision used in blepharoplasty.  These techniques, call browpexy, essentially just raise the brow height with sutures without removing skin or shifting underlying tissue planes.  They produce relatively smaller scars, but generally aren’t as powerful and tend to regress quickly.  I do think they are better than direct brow lift, however, due to their less noticeable scarring.
  • Best: Moving the entire forehead, or a large portion of it, will give the longest lasting, best looking brow lift.  This can be done in several different ways, some which involve raising the hairline and others that are remove a portion of skin, leaving the hairline intact.
    Brow lift and upper eyelid blepharoplasty

    Patient who wanted a conservative brow lift and eyelid lift due to skin blocking his vision

    How do the methods of forehead elevation differ and which is best?

    • The median forehead lift involves making an incision across the entire forehead through a deep crease (if you’ve got one), removing a strip of skin, and suturing up the forehead and brows in similar fashion to the direct brow lift.  The scar can be noticeable, but in the right person is a good choice.
    • Endoscopic brow lift is my method of choice for forehead elevation. It involves making 3-5 incisions behind the hairline through which instruments are introduced to elevate the skin off of the forehead down to the brow area.  A camera is used to directly visualize the dissection around the brows to avoid damaging the nerves and blood vessels in this area, and to partially remove the muscles of the brow which cause the furrow above your nose (think of it as permanent Botox).  A portion of skin can be removed above and behind the ear to create lift in an outward/upward direction as well.  The forehead tissues are then fixated in a higher position using either a suture and screw or a resorbable fixation device called an endotine.  I was recently introduced to absorbable screws (Lactosorb) combined with sutures and find this to be  a very stable method of fixation that can’t be easily undone by a patient not properly caring for the tissue flap after surgery.
    • A pretrichial (meaning in front of the hairline) lift involves an irregular incision along the hairline with a portion of the forehead skin removed.  This gives a great forehead lift without raising the hairline.  It can cause noticeable scarring and works best for someone who has thicker hair and wears it forward.
    • The supposed “gold standard” forehead lift is the coronal lift.  This involves an incision from ear to ear over the top of the head, with dissection down over the forehead and brows and  removal of a portion of the scalp and hair.  Many plastic surgeons swear by this procedure, and in actuality it is the most long lasting along with the pretrichial lift, but it requires a large amount of skin removal, a large scar which is often noticeable even in thick haired people, it causes numbness of the scalp behind the incision, and it can dramatically raise the hairline.

    Forehead and brow lifting can make a dramatic improvement to a tired appearing face.  Of all the procedures I perform, this procedure leaves patients the most satisfied as it so dramatically improves their visual field and appearance.  If you have further questions or think you might be a candidate, give our office a call or email me directly at [email protected].

     

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.

Making the decision to have a cosmetic procedure is a big one, and one you shouldn’t take lightly. When weighing their options, many people get too focused on one particular aspect, such as cost or reputation of the surgeon, while overlooking other important details. The following can serve as a checklist to consider before making the decision to commit to a procedure and surgeon.

Patient and scalpel

  1. First and foremost, find a surgeon you are confident will do the right thing for you.  Selecting a good doctor is a process in itself that I covered a few weeks ago on this blog.  To summarize the highlights, you need to seek out a person with quality experience, board certification and fellowship training, which ensures their colleagues have seen their work and have given the stamp of approval.  It is easy to pay for a weekend course in a procedure and set up shop doing it, but there is little to no oversight in the learning process and the surgeon’s skills are an unknown. You will also hopefully like this doctor and feel they treat you with respect. If they are marginal in their manners before you have surgery, their manners are unlikely to improve once they have been paid.
  2. Ask the surgeon to explain all your options, including those that don’t require surgery.  There is rarely only one way to do things and often the best treatment is no treatment at all.  Be wary of someone who has a cookie-cutter approach to all patients, steering them into the procedure he/she is most comfortable with or is most lucrative. My patients are always surprised when I end up telling them I wouldn’t have surgery in their case.  They seem at first shocked, then appreciative that I would direct them away from something that I’m in the business of doing. For a careful surgeon, however, it is a no-brainer.  Surgery is complex and creates myriad problems that must be overcome before a good outcome can result.  Doing a procedure when it isn’t indicated or in the patient’s best interest is just a recipe for regret for all parties concerned.
  3. Don’t choose based on cost.  Choose based on outcomes.  A surgeon who is significantly cheaper than everyone else has often lowered his/her prices to attract clients that word-of-mouth referrals aren’t generating. In tough economic times you will find lower prices, but don’t let this mesmerize you into overlooking other potential negatives of the doctor or facility.
  4. Know the risks.  Every surgery, no matter how simple or how great it turned out for your best friend, has risks of complications.  For example, I perform ptosis eyelid surgery, which is notoriously unpredictable.  Correcting ptosis, or a drooping eyelid, involves isolating delicate muscles and adjusting them to move the eyelid to an exact level, symmetric with the other side. During surgery we make careful measurements and even have the patient open and close their eyes to ensure symmetry.  However, it is not uncommon to have everything look perfect in the post-op area, then a week later after swelling and scarring have taken their toll, have the eyelid be slightly off.  A difference of only 1 millimeter is often unacceptable to patients and may need a revision.  Most good surgeons will spell this out to the patient before surgery, but almost no patient seems to remember this when it actually happens to them. When you go in knowing there can be complications and directly ask about them, you are less likely to be surprised when things don’t go exactly as planned.
  5. Understand anesthesia and its limitations.  Many cosmetic procedures are performed under sedation, not general anesthesia. This means the patient is awake, but given medicine for relaxation and pain by IV infusion.  Depending on the procedure, this anesthesia can leave the patient completely aware of what is going on during surgery. Most people will see that avoiding general anesthesia is a plus as you recover much quicker immediately post-op, can leave the surgery center after as little as 30 minutes, have no sore throat from a breathing tube, and are less likely to have nausea from anesthetic gas.  For others, the thought of being aware of surgery is too much and will result in anxiety.  Talk to your surgeon about exactly what your level of awareness will be and if you are comfortable.
  6. Inquire about the site for your operation. Will it be in a hospital, an outpatient surgical center, in the doctor’s minor procedure room, or in a reclined exam chair.  Different procedures require different support and certain more involved surgeries need to be done where help exists if something goes wrong.  If a surgeon insists on doing a procedure in their office, ask if you could have it done in a surgery center if you chose. If the answer is no, there may be an issue with the doctor not having credentials to perform surgery in an accredited surgical center. This is commonly a problem with physicians operating outside of their formal training. If a family practice physician decides to start doing liposuction by getting trained at a weekend course, they will likely not be able to convince a reputable hospital of surgery center that they are proficient enough to perform the procedure. They will have to perform the lipo in a medi-spa or outpatient office where they alone would be liable in the event of a complication. A doctor maintaining privileges at one or many hospitals is a sign that he/she has been cleared by both peers and insurance adjusters to perform quality surgery.
  7. Avoid surgeons who claim to be the only one doing a procedure. This is a tough one.  We all want the latest and greatest technique, but if only one person is doing something, it may not yet be tested for general consumption, or it may be just different to entice early adopters. You want proven surgical techniques that are accepted by the majority of surgeons because of their good outcomes. Look at the history of facelift techniques and you’ll see lots of procedures that have come and gone, trying to simplify the procedure and lessen complications, but many of them gave poor outcomes and were abandoned.  Find someone doing a tried and true technique with long-term patient follow-up results.
  8. Ask about recovery time. This varies widely from patient to patient and procedure to procedure. The majority of facial cosmetic procedures will leave you looking like you’ve been in a fight for a week or two, sometimes more. As with complications, patient rarely seem to remember the conversations we have before surgery about how bad they will swell and bruise, and they tend to be shocked the next day by their appearance. Knowing that you will look pretty rough for a few weeks, and that it will get better, will help your patience to wait out the outcome you are expecting.
  9. Ask about long-term outcomes. Gravity and aging are constantly working against our desire to look young and vigorous. A great surgical result today doesn’t tell you anything about what you’ll look like in 1, 5 or 10 years.  Ask your surgeon how long they expect the results to last, and then remember, they don’t have a crystal ball and everyone ages at different rates. As cosmetic surgery is expensive, consider having a procedure done once the improvement will be more noticeable and less likely to need repeating. This will also prevent that buyer’s remorse commonly seen when people find the surgery didn’t make the life altering change they were expecting.
  10. Manage your expectations. We all want to look like we did in our youth, but there are limits to the effectiveness of surgery. As I’ve said before, the hardest part of my job is helping people understand before surgery what they can expect after surgery. Remember the older you are, the more wrinkles present, the more advanced your problem, the more difficult it will be to restore the past look. The patients I find are most pleased after surgery are those who say things like “I don’t want to look 18 again, I just don’t want to look tired all the time.”  These are reasonable expectations from cosmetic surgery.  Patients that focus on every crease and fold as if those are the key to why they don’t look like a teenager anymore are in for a potentially disappointing and expensive experience chasing youth.