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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.

I’m on my way back from another week in Haiti.  I had many profound, disturbing, humbling and enlightening experiences. I thought I’d share a few here and try and put in words what you would experience if you made a similar trip.

Eye clinic

Eye clinic in Port-au-Prince.

First, I wanted to address the title of this post.  The “Third World” is actually an outdated and useless term, which came about after World War II to describe countries that neither belonged to NATO or the communist bloc.  This third group of countries were very often also poor and the two labels become synonymous. What the term does however, is lower these countries to a status unbefitting of the people living there.  There is no doubt that Haiti is poor, but to cast it and its people aside as being in a different world is unfair and detrimental to understanding their plight.  It takes around an hour to fly from Miami to Port-au-Prince, hardly a world away (remember when Haitians were crossing to Florida in rafts). In truth, they live in exactly the same world as the rest of us, that world just hasn’t given them as much to work with.  As a kid, I never wondered if my next meal was coming, or if I’d have access to clean water. The power was on 99.9% of the time, along with either the A/C or heat.  And if, God forbid, I or someone I knew got sick, I knew every possible treatment was available to them.  These all seemed to be my right as a human.  So when you see people who have little to no hope of achieving many of these basic rights, you can’t help but wonder what is going on in this world.

The good news is, I also saw hordes of people, mostly from the US and France, visiting on mission trips.  Most were with church groups building schools and churches, establishing water sources and doing ministering.  Everyone was jazzed about the difference they made and many talked about what they were planning for their next trip.  You can’t help but think with all this help coming, more than 3 years after the earthquake, it is only a matter time before momentum brings real change to Haiti. Just sending money to their government won’t help, just ask Somalia, Ethiopia, Sudan….

Just a couple of stories of patients I met.  I saw quite a few children with facial deformities due to tumors or hemangiomas, but also due to trauma.  Trauma was the theme of the visit.  This great young kid had been hit in the face by someone a few weeks earlier and had a persistently swollen right eye. I was worried about a foreign body.  During surgery, I encountered a hard mass against his eye and tenting the conjunctiva out where it appears red and swollen in the photo.  It turned out to be a chunk of bone that had been dislodged from inside his eye socket. No one had examined him thoroughly and this had been missed.

orbital fracture

Young man with medial orbital wall fracture

The same day, we saw two men in the ER who had been assaulted. One stabbed in the eye, the other shot through the cheek, with the eye being the exit wound.  Nearly every face we saw seemed to have some sort of scar.

facial trauma

Several cases of facial trauma

The young man with the stab wounds above had 4 1-0 sutures closing all his lacerations.  1-0 suture is usually used to close very thick tissues, such as the abdominal wall, not delicate structures like eyelids.  I removed them and replaced them with about forty 6-0 and 7-0 sutures.  The young woman above had numerous scars dating back to the earthquake, which split her eyelid in two and left it retracted.

post ops

Several post op patients

Her repair involved borrowing skin from her right upper eyelid to lengthen her left upper eyelid, as well as a full thickness resection of her scar and realignment of her eyelid margin.

The cases we did were all difficult, but the cases we couldn’t do were the hardest to deal with. We saw several patients with large growths emanating from various parts of their faces. They had saved money and paid for a CT scan (around $300, average monthly income is $60).  The scans showed invasive tumors filling their eye sockets and often extending into their brains.  Surgery was not an option.  When I’d recommend an oncology consult, the residents would shrug.  They knew that even with a consult, the treatment necessary would not be available in most cases. As one resident said when I asked her to explain to a patient what we were seeing, “tumors don’t go over well here, everyone knows they are going to die.”

orbital masses

Orbital masses

Anyone interested in helping us out, can either donate to CharityVision or contact our office. Every trip we identify a slew of instruments and supplies we need to offer better care.  Any help with attaining these supplies is greatly appreciated.  My retired partner, Dr. Call, and I have committed to having one of us visit every 3 months. The needs are seemingly endless.

I was invited to accompany Dr. Branson Call, my recently retired partner, to Port-au-Prince, Haiti in late spring of this year.  He has been traveling there on humanitarian missions for about 10 years making several visits per year.  In January of 2010, Dr. Call was in the operating room, getting ready to start surgery on a Haitian man when he says the floor started rolling and the lights went out.  All in the room hit the floor and for the next few minutes were tossed around, rolling into each other.  When they emerged from the building, the city was in chaos and scores of thousands had been killed.  A nearby nursing school had collapsed, killing some 30 nursing students.  Dr. Call spent the next few days treating trauma patients with the most meager of resources.  He eventually made his way out of Haiti on a bus to the Dominican Republic, where he reunited with his wife.  Over those few days he had no communication with his family back home, so their relief at his return was momentous.  I give you this background story so you can appreciate his dedication to Haiti and its people.

Dr. Call performing one of many operations in Haiti

Dr. Call performing one of many operations in Haiti

Our arrival was relatively uneventful.  We were delayed a day after tropical storm Isaac blew through the Caribbean and past south Florida.  The ride from the airport was eye-opening for someone who had little experience with the third world.  Throngs of people everywhere among houses reduced to rubble (or in the slow process of being reduced). Trash strewn streets framed arteries of people flowing in all directions or huddled in clotted masses around impromptu markets and street-side restaurants.  The energy was palpable, but felt like it was racing out in all directions, but accomplishing little.

waiting for water

Waiting for clean water in Port-au-Prince

We arrived at the hospital early Tuesday, a single story concrete building with visible cracks and rents in most of the walls.  A large crowd of people was assembled out front.  We pushed our way through the mass, past a metal gate and into a small courtyard ringed in short banana trees with a central awning and concrete half-wall seating.  A small meeting room and a few examination rooms also opened onto the courtyard with the small operating theater near the back of the plaza.  The facilities were Spartan, but adequate.

Young woman with anthrax scarring

Young woman with anthrax scarring

We quickly went to work seeing patients, many of whom had traveled some distance.  I was immediately struck by the amazing variety of pathology.  Most every case was far advanced, or what may be considered end-stage in the US.  Tumors that filled eye sockets, horrific scarring from previous anthrax infections, scarred eyelids with eyelashes curled in and abrading now opacified corneas, all seemed commonplace in this unfortunate group of patient.  A parade of children with small and large tumors was brought in. Some thankfully were benign dermoid tumors, scary in appearance but ultimately harmless.  Others were huge and disfiguring causing destruction of the eye or indicating a serious pervasive, likely life-threatening neoplasm.  When a young lady walked in with a simple drooping eyelid, I felt relieved that at least on case would be straight-forward.  I would later retract my enthusiasm.

Teenage girl with tumor

Teenage girl with large orbital tumor

Once we’d filled our day’s schedule, we headed to the operating room.  The Haitians are very curious when it comes to sterility and behavior in the OR.  They are almost fanatical about certain things, such as not wearing scrubs uncovered outside the OR, while they use the same gown throughout an entire day of surgery.  They often pass instruments back and forth between operating tables (we are operating simultaneously on two patients just a few feet apart) as long as they perceive the instruments haven’t been contaminated, but they are able to effectively reuse many items we would consider disposable, stretching the articles life far past it viable use.

The adventure in third-world surgery comes when the patient is prepped and ready.  As a surgeon, you quickly develop a plan in your mind based on the pattern of disease before you.  A ptosis surgery will require a skin incision, exposure of the levator aponeurosis via dissection through several delicate soft tissue layers and measured advancement of the eyelid muscle tendon to raise the height of the lid.  In an ideal situation you’ll have delicate instruments for the task. In Haiti we had a literal grab bag of old, dull and oversized instruments to choose from.  This turned straight-forward surgery into difficult surgery and difficult surgery into extremely difficult surgery.  After a few cases, you just accept the situation and muscle through, which is easy when you see the joy you bring to patients with no other hope.

Tumor excision

Tumor removal in young woman

After 3 days of case after case our time was done.  We packed up, boarded our plane and headed out.  On our drive to the airport we drove through the biggest tent city left from the 2010 earthquake.  USAID tarps held up with old boards random pieces of sheet metal went on for miles.  I was heading back to my house in the mountains with A/C, fresh water and warm beds.  We may have helped a few, but thousands more still need our help.  You can’t leave Haiti without already formulating a return plan in your mind.

Post-op patients

Post-op patients

 

Haitian residents

Haitian ophthalmology residents with Dr. Harris and Dr. Call

This past week I took a basal cell skin cancer off the eyelid of a man younger than I, and I’m in my mid-thirties.  Remember when skin cancer was something your grandma and grandpa dealt with?  Well those days are past and we are ushering in a generation of young people who will be dealing with skin excisions, biopsies, deforming surgeries and possibly early death due to their love of the sun, tan skin, and refusal to believe they are causing themselves harm.  On a recent trip to a sunny locale, I was applying sunscreen before going out on a  morning of boating.  A friend repeatedly scoffed at my use of sunscreen, insisting I needed more color and couldn’t understand what I was worried about.  Everyone in this person’s circle of friends was tan, young and feeling great, but what will the next few years hold for them.  Here are a few tanning myths that you need to get by right away to avoid being a shriveled up raisin of skin cancer in your golden years.

Myth #1: “I have to get a base tan so I won’t burn on my vacation. Many believe they need to achieve a “base tan” early in the spring, usually at a tanning booth, so they won’t get sunburned later.  Some even think this is protective against sunburns and thus skin damage.  Don’t buy into this farce. Any sun or tanning bed exposure that causes a tan is damaging your skin, end of story.  UV rays are still blasting away at your DNA and collagen no matter the color of your skin. Spray tans are no help either. Some believe that these will somehow protect you from a burn or damage.  Not true.

Myth #2: “I only need sunscreen if I’m going to the beach.”  Most people don’t think to put on sunscreen, unless they are expecting to be outside for an extended period of time.  A recent New England Journal of Medicine article showed a man who drove a delivery truck for 28 years. He developed dramatic changes to the left side of his face, which was bombarded by UVA rays, while the right side of his face was protected from the shade.  Check out the difference between the sides in the picture below.

Facial aging from sun exposure

Myth #3: “I’ve got dark skin so I don’t get sunburned.”  Many people born with naturally darker toned skin think they don’t need to protect their skin as they don’t burn as easily.  Whether or not you get a sunburn, the UVA and UVB rays are still bombarding you, causing mutations in your DNA and ruining your skin’s elasticity.  Olive skinned people don’t look any better in their old age than fair skinned people. Very dark skinned people are also at risk for sun damage.  Acral lentiginous melanoma accounts for 50% of melanomas in dark skinned individuals and is often missed as it develops on the palms and soles of the feet. Bob Marley died of this form of melanoma.

Myth #4: “It’s cloudy, so I’ll skip the sunscreen. ”  UV rays are still present on cloudy days. If you are going to be outside, apply sunscreen.

Myth #5:  “I wear sunscreen, so I’ll never have skin problems.”  I wish sunscreen was that good. The mistake most of us make is not reapplying it often enough and not realizing that it doesn’t block all UV radiation.  When possible, wearing hats, sunglasses and longer clothing will block out more UV radiation and further reduce your potential skin damage. Sunglasses are especially important to reduce early cataracts and surface damage to the eyes, including unsightly yellow spots on the eyes called pinguecula (see photo).

pinguecula

Pinguecula

 

 

 

 

 

 

 

 

 

 

 

 

 

Myth #6: “Tanning beds are a safer way to tan.”  And O.J. Simpson is innocent.  The tanning bed industry is constantly working to convince people that tanning beds are safe or even healthful.  Some claim their bulbs emit lower UVB and other say tanning is a great way to get your vitamin D. Both of these claims are misleading.  All tanning beds cause accelerated skin damage.  Multiple studies have shown that people who use tanning beds have a higher rate of melanoma.  And regarding vitamin D, you need about 2-10  minutes a day of sun exposure a day to produce plenty. If you drink milk regularly or take vitamin D supplements you don’t need any extra sun exposure.

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].