Introduction

Welcome to Plain Talk About Plastic Surgery, a podcast that brings you down-to-earth, honest, and practical information about relevant plastic surgery operations and procedures.

I’m your host, Dr. Elizabeth Kerner, and these are my opinions about procedures that I provide based on my 32 years of experience.

Today, I would like to discuss blepharoplasty. Blepharoplasty just means a plastic procedure or a procedure that changes the eyelids. So you have your upper eyelid and you have your lower eyelid.

As in all things plastic surgery, this should be a very, very easy thing to discuss. But once you start talking about the upper eyelid, you have to talk about the brow. And once you talk about the lower eyelid, you have to talk about the eyeball and the bony rim around the eye.

So we’re going to start with the upper lid today. I’ll do another podcast on brow lift or forehead lift because I think there’s enough to discuss that we can just devote a relatively short segment of time to that.

Where the position of the brow, your eyebrow hair, impacts what is done on the upper lid: we’ll discuss that today.

What is Blepharoplasty, and Understanding the Incredible Anatomy of Your Eyelids

In simple terms, a blepharoplasty is removal of excess skin on the upper or the lower lid, as well as redistribution of the fatty pockets. For such a little piece of our face and relatively little piece of our body, there’s an awful lot of anatomy packed into those eyelids.

If you start from the outside on the upper lid there’s skin and then oftentimes there’s a little tiny bit of fat, especially on the inner part of the eye right under the skin. Then you have your orbicularis muscle which is an oval, circular muscle that goes around the eyelids – upper and lower, one big muscle – and it helps you to close your eyelids.

Beneath that is a little thin membrane called the septum. And beneath the septum are little fatty pads. On the upper eyelids, there are two well developed fatty pads and on the lower there are three.

Below that would be the bone, and then below the fat and the bone are the muscles that make your eyeballs move. And then if you keep going way, way deep, you get into the blood vessels that go to the back of the eyeball. I’m just going to say “eyeball” rather than “globe” because that’s just sort of what comes out of my mouth most of the time.

So on the upper lid, what happens with time and our good old friend gravity is the lid skin begins to stretch. Now, if you’re somebody who pulls on your eyelids or rubs them all the time you can actually accelerate that process. Then there’s lots of people that just have a lot of extra upper eyelid skin and it seems to be a familial trait or one that’s from the family, and that is without question true.

The Inescapable Pull of Gravity and How it Affects Our Eyelids

However, where gravity comes into play is what happens with your eyebrows. As we age, gravity will begin to pull the eyebrows down. Because, you see, there’s only one muscle that keeps your eyebrows up. That’s the frontalis muscle, and that’s a horizontal muscle that goes from the rim above your eyes – that little bony rim where your eyeballs protrude out of – up into the top of the scalp.

Because there’s only one muscle that pulls your eyebrows up, it has to be pretty strong. So if you look at yourself and you have a lot of horizontal wrinkle lines in your forehead, it just means that your frontalis muscle is working really hard to keep your eyebrows up.

Gravity of course is going to pull this down because the weight of the brow which is just skin and hair and fatty tissue, and then the orbicularis underneath of it, is affected by gravity. The frontalis muscle and of course the bone of your skull probably isn’t, although there’s a lot of controversy in plastic surgery whether bones do elongate with aging and gravity. We certainly know that they can remodel but I don’t think they actually get longer myself.

So what happens to make the brow come down a little bit, and I am going a little bit into my brow podcast but we’ll go over that again in more depth, is because the muscle around your eye that closes your eyelids is going to pull down on your brows. And then those three little muscles in the center part, your corrugators and your glabellar muscle – the “Elevens”, what we use Botox in – also are brow depressors.

So you’ve got one muscle, the frontalis to pull your forehead up, and you’ve got four muscles to pull it down, plus good old gravity.

So for most people who get out into their 40s, 50s, and 60s, you begin to see redundant skin on the upper eyelids. This is called dermatocalasis or loss of elasticity of the skin. Sometimes it’s blepharochalasis although that really means that the whole eyelid has gotten loose.

Upper Eyelids: Anatomy, Conditions of, and Upper Eyelid Surgery

And a very interesting tidbit: when I was researching to try and figure out when the first cosmetic eyelid surgeries were done, which were probably in the early 1960s, I could never quite put my finger on it. Our good old friend, Dr. Dupuytren, who I discussed in Dupuytren’s Contracture, back in the early 1830s was one of the first to describe extra, redundant skin of the eyelids.

Now, he didn’t try to operate on it but he described it. I guess that surgeons and medical scientists in those days just didn’t have very much that they could do. They couldn’t really operate. They didn’t have medicines, they didn’t have hospitals. So it seems like they just sat around and thought about the human condition and what happens to our body, and then came up with names for all these little parts of things that are not going right and are part of natural aging, but maybe are accelerated.

I’m doing this podcast during the COVID pandemic, and I wonder if with a whole lot of surgeons not being able to work that there’ll be some great thinkers who will come up with wonderful ideas about things that 100 years from now people will go “well, that’s so obvious! I can’t believe that generation didn’t know it.” Unfortunately, I don’t think I’m one of those great thinkers, but it’s interesting to think that might happen.

Why Eyelids Droop

So back to upper eyelids. What happens is the eyelids can begin to stretch, it makes a roll, it pushes down on your eyelid and you feel like you can’t see as well. And then there’s the cosmetic aspect of you just look tired, and your eyes sort of hang down.

Now there’s also another condition of the upper lids. Remember, I told you upper lid anatomy is not that easy. There’s a little tiny muscle that goes from a tubercle on your rim, down to the cartilage of your upper eyelid. That muscle’s called the levator and its sole function is to open your eyelid. So you’ve got the big orbicularis that closes it and this little bitty muscle that opens it.

In a lot of people with aging – probably not gravity but aging, genetic tendency, wearing hard contacts, rubbing your eyes a lot – that muscle will begin to stretch and the eyelid itself will pull and lengthen. And you can usually tell that when you look at somebody if the crease of their upper eyelid is very deep, so the have a very hollowed upper eyelid, it looks like they have not foldy skin but just a lot of upper lid.

The Importance of Diagnosing Ptosis Before Surgery

This is oftentimes called “bedroom eyes” or “sleepy eyes.” And when you look at the person, you can tell that their eyes are sort of half-mast. So instead of the eyelashes being above your iris, they’re kind of beginning to impinge down towards the pupil. And this is called ptosis, spelled P-T-O-S-I-S.

So why am I boring you with all this anatomy? Because it’s quite important. If you have ptosis and it’s not fixed, taking the  skin off of the upper lids is not going to make your eyes look all that much better. If you have a very low forehead or what we call brow ptosis – again, drop of the forehead – if that’s not corrected, you won’t get as good of a result as you might want.

The actual operation on the upper lids is really quite simple. We make a small incision in your natural crease line, unless you have very deep hollowed eyes and then we may bring it out a little closer to the eyelid margin. We remove a strip of extra skin. I like to go through the muscle in just one small part towards the inner part of the eyelid. We tease out the fat that’s there, that’s that little white bulge you can see under your skin. And now we have excellent small electrocautery devices that allow us to do that very easily. Bleeding is about a drop, if it’s even that much.

Potential Complications of Upper Eyelid Surgery

Then the skin is closed up along the natural crease line or what’s called the supertarsal crease. “Tarsis” being your eyelid. As with all plastic surgery operations, complications would be bleeding or infection, or the scar would get thick, red and raised.

Most of those don’t tend to happen. Certainly infection is not very common, although occasionally someone will get a sty. If you have lots of little white bumps underneath of your skin, what are called millia, you might develop those little white bumps in your scar.

Occasionally, the scar does have to be touched up but most of the time in three to four months, it’s a nice little white line.

The biggest complication of the upper lid operation would be taking too much skin off of the upper lid so that you couldn’t close your eye. That’s a big huge one. It could be treated, you could go back in and put a little skin graft but that would be… not catastrophic but boy, talk about a complete failure.

If you haven’t been able to tell that a patient has ptosis or that the eyelids are low, the operation won’t look so good afterwards because the eyelids will still look too low in relationship to the pupil.

Bleeding happens extremely rarely and is going to be more prevalent in someone who has either undiagnosed or poorly treated hypertension.

Does Upper Eyelid Lift Surgery Hurt? What About Swelling?

I like to do upper blepharoplasty with my patients asleep. I don’t like to put a lot of numbing medicine in because then it puffs up the skin and I can’t tell exactly how much skin I’m taking out. A lot of people will do it under sedation and do numb up the eyelid. For me, it’s a very, very light anesthetic, and it generally takes about 25 minutes a side to do the upper lids.

This is an outpatient operation with extraordinarily little pain afterwards. Most people will take Tylenol or Advil. We do have you use ice packs to your eyes afterwards to help with the swelling and bruising, and I do restrict your activities because I think doing a lot of exercising that first week while you have stitches in is only going to make you more swollen and bruised.

You are certainly welcome to go back to work whenever you wish and stitches come out at a week. Time from surgery to when “this is how you’re going to look” is about three months for most people.

Lower Eyelid Surgery

That’s the upper blepharoplasty. The lower blepharoplasty is essentially the same operation except we’ll make a small incision right underneath of the eyelash line, lift off the skin from the muscle that’s right attached to the eyelids. So when you squint and pull your eyes in really tight, we want to leave that little three to four millimeter strip of muscle right underneath of your eyelashes alone, and then go through the muscle down to the bone, then take out extra fat.

On the lower lids, there’s three well developed fat pads: the inside, the middle, and then outside the temporal.

If you don’t get the temporal, which a lot of times gets missed, things never look quite right. You always have that little fatty, bulgey fat pad.

Some surgeons will take the fat and redistribute it along the bony rim so that it doesn’t look like you have a crease there. I like to release muscles and try and do that because when you put the fat there, it just continues to grow and pretty soon you have new bags.

Also, another common technique is to make an incision inside of the eyelid along the conjunctiva – that’s the pink part – and you can take the fat out that way. Then very little skin, if any, is removed. A person who would be a good candidate for that is someone who just really has fat bulgies but is not so much going to have a whole lot of skin removal.

The big issue with the lower lid is how strong your lower lid is. If you have a weak lower lid, so I can pull on it and it takes multiple seconds to kind of snap back to the eyeball, or when I look at you I see a good triangle of white to the side of the iris because the eyelid is drooping down, then something’s going to have to be done about the lower eyelid position.

It’s going to need to be tightened back up to the bone, and an oculoplastic surgeon would do that operation. That’s not something I was ever trained in. The problem with doing that is it narrows the aperture. So the width of your lower lid is going to be shorter because it’s too long. If you think about taking a wedge out and tightening it up, it’ll pull the lid up but it makes your eyeball look a little bit smaller.

Almost everybody as they get older will have some degree of looseness or laxity of that lower lid. And I think the hardest job for a plastic surgeon who does lower blepharoplasty is determining whether that patient really does need to be referred to have the lower lid tightened up, or can we get away with doing this and not creating any more problems. Because if you take too much skin out, that’s going to pull the lower lid down. Again, that’s called an ectropion and it does not look good. It requires a second operation to fix it and it’s kind of a pain.

What Makes Lower Eyelid Lift Surgery More Complicated Than Upper Eyelid Lift Surgery

Lower lids I think are much more complicated. They’re more fraught with potential problems. Most of it is related to lower lid position, how much fat you take out, what the crease is like, what we call the “tear trough”, or that little indention along the bone, what your skin looks like; if you have lots of wrinkles, they’re not going to go away. The only way to get rid of all the wrinkles in the actual skin is either to take skin out, and on the lower lid, we may take three or four millimeters.

We generally don’t take enough out to make a huge difference to the crepiness. So then you have to go to peels or lasers. But then when you start using those, they’re going to tighten the skin and that could lead to ectropion itself. So there’s a lot of discussion in terms of how can we make the lower lid look as good as it possibly can.

Anatomy being what it is if you have a prominent eyeball, so you have what’s called a bulgy eyeball, kind of bug-eyed, your lower lid is going to be a little lower. If you think about men, they tend to have – not all men but some men – a little bit of a beer belly. And they wear their belts below it. You hardly ever see a man with his belt right at his belly button.

So that’s what the eyeball does to the lower lid. It bulges out and it causes that lower eyelid, just like the belt, to be low. And patients that have a very prominent eyeball, which we conversely call a “negative vector eye,” those patients almost always have to have something done to elevate the lid and put it back in a more normal position.

Lower lid is still about the same. One incision is made, stitches are in for seven days. You still have a week of restrictions for sports activities. Usually there’s a little more swelling and bruising of the lower lid because there’s almost always a bit more fat to take out.

Risks and Complications Associated with Lower Eyelid Surgery

Risks and complications are predominantly related to position of the eyelid in relationship to the eyeball. Scars tend to do extremely well.

The other big risk would be the potential for bleeding. If you did have bleeding in the lower lid, it actually could be rather catastrophic because if the bleeding was not recognized, it could kind of wander its way back down towards the retina and cause blindness.

I’ve never seen that but the pictures are pretty dramatic. The eyeball gets really big and swollen and I would think anybody in their right mind would be able to tell something was wrong.

I am very strict when I’m doing lower lids. If someone has hypertension, it has to be treated and we almost always give our patients additional antihypertensive medicines before they wake up just to mitigate this potential for a complication. I’ve never seen it and certainly don’t ever want to.

Of the whole stable of plastic surgery procedures, I would say upper lids have to be about the simplest for the patient. The simplest recovery and really the least risks and complications. Lower eyelids certainly don’t hurt but require a bit more technical skill.

Conclusion

If you have big bags and you just look like you’ve been out all night or you’re tired or sick, doing upper and lower blepharoplasty is just such a quick thing to do that can have an amazing impact on how you look. That of course will impact your self image and your self confidence.

So this has been a quick little romp through upper and lower blepharoplasty, and we’ll discuss the forehead in our next podcast.

Thank you very much for listening to Plain Talk About Plastic Surgery, a podcast by Dr. Elizabeth Kerner. Feel free to visit my website www.drkerner.com. That’s D-R-K-E-N-E-R.com for more information. For other episodes and upcoming episodes, you can go to my website www.drkerner.com/podcasts or you can subscribe to our newsletter to know when a new episode is available, or you can find my podcasts almost anywhere you get your regular podcasts, and this is also on YouTube.

Thank you very much for listening.

Have a great day and don’t forget to use your sunblock.