One of the most common surgeries I perform is eyelid surgery. Excess skin and fat of the upper and lower eyelids is a primary sign of facial aging given that the tissues in these areas are the thinnest in the body and hence one of the earliest to encounter loose elasticity. Along with the ravages of time, not only does the skin of the eyelids become lax and full of wrinkles, but it also affects the deeper tissues, the muscles and the fascia, becomes loose and can no longer hold back the fat that surrounds our eyeballs. The fat then herniates out, just like a groin hernia allows the intestines’ top to protrude, the fat to protrude out and gives us those “bags” under the eyes. This fat has particular properties. It seems to be particularly able to hold water and become swollen. Ever notice how your eyes are swollen after crying, allergies, colds, etc.?
The idea of blepharoplasty surgery is to remove or improve the excess stretched-out skin, part of the herniated fat, or both. The upper lid has two anatomical compartments of fat, and the lower lid has three compartments. This is important so that you can be sure the plastic surgeon has addressed all the areas. You don’t want to have a lump left over!
When I first learned how to do this surgery in my residency in Houston 20 years ago, the operation was very different from what I do now. At that time, the prevailing philosophy was to remove as much of the herniated fat and skin as possible. Of course, you have to leave enough skin in the upper lids for the patient to be able to close their eyes! This idea of surgery led to patients’ eyes sinking in, with a hollowed, cadaveric look setting in as the patients aged. Quite horrible. Removal of too much skin often led to a “hound-dog look,” with the lower eyelids pulling down, giving the face a sad expression.
The change came when plastic surgeons understood that as the face ages we naturally lose fat, and as such it is of paramount importance to keep what fat we have there. The new technique is to push the fat that has herniated back into the eye socket, giving a fuller look to the eyelids. If there is a little fat here or there, I snip it off—but just a little. For the lower lids, I rarely remove any skin unless the patient has a great excess. Instead, I place the incision on the inside of the lower eyelid in order to get to the fat. There is no external scar and there is a natural shrinkage of the skin that occurs, which helps to remove some of the skin wrinkles.
I perform all my blepharoplasty surgeries under local anesthesia in my office. You come in, have the surgery and walk out. If you have the upper lids operated on, you’ll need someone to drive you home; for the lower lids, you can drive yourself home. Recovery takes about two days, and the sutures are taken out or dissolve in a week. It still takes another six weeks for the swelling to decrease until the final result is obtained and you look bright-eyed and b…