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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.

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.

 

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

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].