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Lower eyelid blepharoplasty is commonly performed along with an upper eyelid blepharoplasty (eyelid lift). Lower eyelid blepharoplasty helps to remove baggy lower eyelids and take away the shadows that make your eyes look tired.  Here are the most common questions, with answers, that we get from patients about the procedure.

Upper and lower eyelid blepharoplasty

Upper and lower eyelid blepharoplasty, before and after

Question: How is lower eyelid blepharoplasty performed?

Lower eyelid blepharoplasty is performed by making an incision through the inside of the lower eyelid (transconjunctival approach). Through this incision, the fat pads in the lower lids that form the bags are either removed or repositioned. This smoothes out the lower eyelids. Normally, skin is removed from the lower eyelid just below the eyelashes as well. This is closed with dissolvable stitches.

Question: What will I look like right after surgery?

Lower eyelid blepharoplasty normally causes some bruising and swelling of the lower eyelids, which can travel into the cheeks. The bruising lasts about 2 weeks. The swelling can take 2-6 weeks to completely resolve, depending on your age and the health of your skin.  I tell people they’ll look like they’ve been in a fight, but won’t have significant pain.

Upper and lower eyelid blepharoplasty

Upper and lower eyelid blepharoplasty, before and after

Question: What do I have to do after surgery so I heal properly?

The most important treatment for lower eyelid blepharoplasty is to use ice on the eyelids 20 minutes, on and off, for the first 48 hours after the procedure. This will reduce swelling and speed recovery. You’ll also use antibiotic ointment on the incisions 3-4 times daily for the first week.  Avoiding strenuous activity and not touching the incisions excessively is also important to allow healing.

Question: How long does healing take?

Lower eyelid blepharoplasty takes about 6 months to completely heal, but within 3-4 weeks, you’ll have a good idea of what your appearance will be like. You can conceal any of the mild redness with light makeup.

Upper and lower eyelid blepharoplasty

Upper and lower eyelid blepharoplasty, before and after

Question: How long does it last?

While your skin will keep changing after surgery, you can expect the lower lids to look great for many years. It is uncommon that we have to repeat lower eyelid blepharoplasty.

Question: How much does it cost?

Costs vary around the country and depending on if you have lower eyelid blepharoplasty along with other procedures.  As of March of 2016, when this article was written, we charge $2500 for the lower eyelids alone, when done in our office.  When done together with the upper eyelids, the cost is $4000. We also recommend having an anesthesia provider present, which costs around $300 extra.  When done in conjunction with other elective surgery in a surgery center, we charge $1500 for the lower eyelids, which doesn’t cover the extra facility and anesthesia charges.

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].

     

Our second day of lectures and surgery was much like the first, only the Vietnamese doctors were eager to get their hands into the work and apply what we were showing them. On day one, a certain doctor followed me closely, recording with his cell phone several of my procedures.  He stood so close with his phone that at times it blocked my view.  I could tell he was paying close attention because he would comment if I did something slightly differently than I had explained in our lectures.  I would explain that every case is a little different and there is a time for following the textbook and a time for customizing your surgery for the patient. He wanted to know what prompted my every decision and was clearly a very perceptive and intelligent man.  On this second day, when I returned to start a particular case after scrubbing, I found him in my chair at the head of the bed.  I asked him if he was ready to lead the case, which he said he was.  I let him at it and he did a marvelous job.  He clearly had some surgical experience as he handled the instruments with confidence.  He would clarify the surgical steps with me just to be sure, but it was amazing to me how fast these doctors picked up our techniques.  I have no doubt they’ll be able to continue performing many of the surgeries we taught them. 

Dr. Call giving instruction

 
Recovery
 

Dirty feet, happy patient

 Our last day in Dong Anh was spent doing a few extra surgeries in the morning.  We then left our hotel there and moved to downtown Hanoi.  On our way we met with a few other hospital administrators.  It seems once word gets out that you are willing to come to Vietnam and bring equipment with you, lots of hospitals want to convince you to come the them on your next trip.  The following day we travelled out to Ninh Binh, an outlying area with a large eye hospital.  We looked at their needs and assessed what we could do on a future trip.  They then took us to a few of their nearby tourist sites, which was very nice.  We saw a thousand year old Buddhist temple and a newly built, massive pagoda.  The country-side was beautiful the people were all very gracious.  We look forward to returning soon.

 

God of Ninh Binh

 

Big pagoda

Vietnam 2012

Several months ago, my partner Dr. Branson Call asked me if I’d like to accompany him to Hanoi for a medical mission he and LDS Charities had been planning for several months. I jumped at the chance. After a few delays, we finally made our way to Vietnam on March 4th.

Me giving the wife a last photo op
 
Dr. Call and the rest of the throng boarding our last flight from Taipei to Hanoi.

 

Day one:

We arrived in Hanoi around noon on Tuesday the 6th. We came via San Francisco and Taipei. We were met by a couple of LDS Charities service missionaries, Brother and Sister Michel from Sandy, Utah. They have been in Vietnam for almost 16 months and have spent over a year organizing our trip. When you combine the church and a communist country, the amount of red tape required to accomplish anything becomes daunting. Nonetheless, they managed to secure a new operating microscope, several trays of oculoplastic instruments and other incidental supplies. They were a very enthusiastic couple and were a great help.

 

The Michel’s rode with us by taxi to Dong Anh, a town outside of Hanoi. We met the doctors from the hospital at our hotel, where they had a very fancy lunch for us, including barbecue pork, salmon, various soups, rice and lots of great fruit. One fruit called buey (sp?) appeared like the inside of a grapefruit, but was much sweeter. The dragon fruit was also very good. From lunch we went to the hospital a few kilometers away. The building wasn’t in great shape and due to the high humidity, most of the buildings start looking run down quickly. We went inside and had a planning meeting for the rest of our trip, which we were told would consist of lectures in the morning to various doctors from the area, followed by lots of surgery in the afternoons.

 

That afternoon, we proceeded to a small clinic next door, which contained 1 slit lamp microscope, a table and chair, and a few other random pieces of equipment. We were quickly introduced to the Vietnamese way of doing things. This seemed to involve a huge mass of people all entering a room at once listening in as each got a 2-3 minute exam. We saw 40 or so patients that had come, 31 of which we felt could use surgery. We saw several children with congenital drooping eyelids, older ladies with eyelid scarring from trachoma, a young man with a disease which causes all the eye and eyelid muscles to stop moving, and a baby with a blocked tear duct. There were a few young people with facial scars due to accidents that hoped to have them revised. We got through all of them by around 5 o’clock.

 

 
 
 

By now Dr. Call and I were pretty beat, so they took us back to the hotel and we sacked out. I woke up at midnight feeling well rested and ready to work, but had to will myself 3 more hours of sleep. After that I was wide awake.

 

Day two:

 

We arrived back at the hospital on the 7th and were taken to a room where a ceremony was to be held to hand over the donated equipment. It was essentially a photo op for both LDS Charities and the local government. Several local journalists were there along with the president of the province. We were given some nice gifts and thanked for our time.

Afterward, I gave two lectures to the doctors on surgical techniques and eyelid reconstruction. It was challenging because the translator, a kid named Dat who was a non-member home from studying at BYU, didn’t know medical terms. I have no idea how accurate his translating was, but the audience seemed to be getting some concepts as they asked insightful questions.

 

Afterward, we had a quick lunch and then headed to the OR. (Just a word about Vietnamese people: they are small. Dr. Call and I are both well over 6 feet. They wanted us to wear these sandals everywhere in the hospital, but only had a size 8 or smaller. Needless to say we walked pretty funny trying to keep those things on. Thankfully we brought our own scrubs.)

 

They had just one OR running for the two of us. Again, it was similar to our clinic experience: lots of people milling around who may or may not need to be there, all standing one inch away from you wanting to see what you are doing. They had two beds, one next to the anesthesia machine, the other solo. A few patients were brought in and laid down and the pandemonium started. 20 voices all shouting at each other in Vietnamese, people crisscrossing everywhere, doctors smacking nurses backs when they didn’t listen, the same nurses laughing at each other for getting smacked. In the US you’d be appalled at how unorganized it all seemed, but here you just couldn’t help but smile and see it as and adventure.

 

We proceeded to start cranking out surgery after surgery. We had a few kids wake up during their cases, people showing up in the room with scrubs asking if they could be added on, people answering their cell phones and talking while leaning way to far into the surgical field. One guy decided he wanted video of the ptosis surgery I was doing, so he whips out his iPhone and holds it 6 inches from the girls face the entire case. It never dawned on him that this might bother me, so I didn’t let it. We got through fifteen cases that afternoon, which was amazing considering what we had to work with. However, you can really motor when you don’t have to dictate, chart orders, or even change your gown. We no sooner finished one surgery before they had the bed ready for the next patient. It ended up being quite efficient.