eyelid surgery older man

Eyelid surgery in a patient in their 90’s.

Eyelid surgery is more common as we get older. Our skin becomes more droopy and blocks our vision with age. Many patients wonder if they are too old to undergo surgery. Eyelid surgery is performed on patients of all ages, depending on how the problem is affecting their quality of life and if they are healthy enough to undergo the mild anesthesia used.

How old is too old for eyelid surgery?

We see patients of all ages for eyelid surgery. Many have eyelids blocking their vision or causing tearing.  Most patients come to our office because they are bothered enough by the problem that they know something must be done.  The main question they ask is “am I too old for this?” Chronological age is much less important than biological age, meaning how old do you feel, and how well is your body functioning. Many 90 year olds are in better biologic shape than some 60 year olds, based on how they’ve taken care of themselves and their respective genes.  Thankfully, most eyelid surgeries are done under mild sedation and local injection. The risk to the patient is very low and anesthesia is well tolerated.

Who shouldn’t have eyelid surgery?

Patients with certain chronic illnesses, such as advanced heart or kidney failure, active cancer under treatment, or those with a history of significant reaction to mild anesthesia should avoid elective eyelid surgery. Also, those on blood thinners that can’t be stopped should consider waiting until the medications can be held temporarily for surgery. Anytime we have a question about a patient’s fitness for anesthesia, we request a physical exam with the patient’s primary care physician, who can make additional recommendations.

Eyelid surgery consultations are helpful

An eyelid surgery evaluation can help us to evaluate your overall health and recommend the best possible treatment, which may or not include surgery. Sometimes, surgery can be performed in the office under local anesthesia only, further lowering your risk. Call our office at 801-264-4420 with any questions.

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.

 

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.

Humanitarian Surgery Trip: Yerevan, Armenia

Yerevan, Armenia, the site of our latest humanitarian surgery trip, is a city of about 1.5 million people located in one of the oldest regions of human civilization. The country sits on the north border of Iran, the east border of Turkey, the west border of Azerbaijan and the south border of Georgia. It has been continuously inhabited since early Old Testament times and was the first country to adopt Christianity as a state religion in 301 AD. The LDS Church’s humanitarian service, LDS Charities, organized the trip with Malayan’s Eye Hospital in Yerevan. Dr. Armine was our host. She is one of the few, if not the only trained oculoplastic surgeon in the country.

Eye surgeons in Armenia

Dr. Armine and Dr. Harris

Dr. Armine was fellowship trained in both the US and in India. However, being the only person among millions who does a particular job doesn’t give you an opportunity for collaboration or to compare your techniques and outcomes with someone else.  Our mission as dictated by LDS Charities is to teach what we know to others so they can become more self-sufficient and need our services less in the future. As such, we saw some of her more challenging patients and came up with treatment plans that she could carry out.  For the most challenging, we planned surgery so she could see how I was trained to do a procedure and incorporate those skills into her repertoire. It was great working with a surgeon that already had advanced skills and knowledge and just needed some extra help with complex decisions.  Her patients are in good hands.

Eyelid surgery in Armenia

Teaching eyelid surgery in Yerevan, Armenia

Armenia eye patients

Armenia eye patients

It just so happened that there was a holiday on Thursday and the hospitals and government buildings were all closed. We took advantage and drove out to a few sites.  About 35 kilometers from Yerevan is the town of Garni, where an ancient Roman temple was constructed around 125 AD. It sits right on the edge of cliffs leading down into a beautiful gorge cut out by flowing rivers.  Quite a site.

Garni Temple, Armenia

Garni Temple, Armenia

 

We then went up the road a ways to Geghard monastery, which was built between the 4th and 13th centuries, slowly carved out of a mountainside. A portion of the building is hollowed out rock with amazing domed rooms. A spring ran across the floor and light flowed in from oculi in the ceilings.

Geghard monastery, Armenia

Geghard monastery, Armenia

 

Our last day was spent visiting the town of Artashat, about 40 kilometers from Yerevan, where a beautiful clinic has been built. LDS Charities purchased some much needed equipment to treat advanced diabetic eye disease. I also spoke with the doctor in charge, Kristina Hovakimyan, about returning to teach her some basic oculoplastic techniques.  Hopefully, we’ll see her on a future project.  While there, we had an impromptu consult on a young boy with a tumor growing on his eye.  This was an immediate reminder of why they need instruction on how to deal with these issues. Of special note, nearly every ophthalmologist I met in Armenia was a woman, which is in stark contrast to the US, where until only recently women were entering ophthalmology in significant numbers.

Arteshat clinic

Artashat clinic, Armenia with Dr. Hovakimyan

Armenia is a beautiful place with wonderful people.  We hope to return again soon. The amazing doctors there are doing great work and their patients are lucky to have them. Our next humanitarian surgery trip – back to Haiti in September with my former partner Branson Call who inspired all this.  We’re looking forward to it!

 

 

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].