Blepharoplasty is plastic surgery of the eyelids.
As we age, a complex series of changes takes place in the tissue around the eye. Skin becomes thinner and less elastic, fat may protrude or atrophy, and even the bone can resorb, lending less support to the soft tissues. Many of these changes can be improved or corrected surgically.
In Colorado Springs, blepharoplasty (or eyelid surgery) is intended to tighten the tissues of the upper and/or lower eyelids. It is useful for improving the appearance of aging around the eyes. In the upper lids, the procedure removes excess skin in virtually all cases. Depending on the individual anatomy, fat and muscle may also be addressed. The lower lids may be full and/or there may be skin laxity, both of which would be corrected surgically.
Blepharoplasties and related eyelid surgeries are among the most commonly performed surgical procedures and may involve removing, reshaping, restoring, and repositioning of the eyelid skin and underlying tissue. Blepharoplasty is generally considered the top facial cosmetic procedure because the eyes, though not anatomically central on the face, are the central point of focus and attention for those looking at you. Our eyes manifest our underlying emotional state and disposition, and they are critical in determining the first impressions others make about us. As the New Testament scripture has described, the eyes are the windows to the soul (Matthew 6:22) and the first feature people notice when viewing our faces.
Given Dr. Burroughs’ prior training as an eye microsurgeon, he is truly a cosmetic eyelid specialist. Ophthalmic specialists are frequently known for their compulsive personalities, and a running phrase in ophthalmology is “millimeters matter.”
Eyelid surgery is the most critical and detailed type of facial plastic surgery.
Dr. Burroughs has taught blepharoplasty surgical technique to other surgeons and is published in surgical textbooks and journals on proper evaluation, technique, and care of blepharoplasty patients. Prior to his extensive subspecialty training in eyelid, orbital, and facial plastic surgery, he was an eye surgeon and therefore has extensive concern, appreciation, skill, and experience with surgical treatments of eye disorders. Upper eyelid blepharoplasty surgery is performed through a cosmetic lid crease incision, allowing the surgeon to reshape the contours of the upper eyelid. Removal of redundant skin allows makeup to be used more effectively and brings out the natural beauty of the human eye.
Many patients have furrows or worry lines between the eyebrows that can be surgically improved simultaneously with an upper blepharoplasty. When evaluating a patient’s aesthetic needs, many factors are critical in achieving the best results that are customized for that individual’s goals and situation. These include the following: male upper eyelids are generally fuller, heavier, with greater skin redundancy than female eyelids. Male eyelids have a lower eyelid crease and must not be over-sculpted to avoid creating a feminine look. Female eyelids can undergo heavier fat sculpting and thinning. They also should have higher, more arched eyebrows and a higher eyelid crease. As for age, the benefits of undergoing an upper and/or lower eyelid blepharoplasty will continue for many years. People continue to age, and so do their faces and eyelids. In general, though, one may think of an upper eyelid blepharoplasty “lasting” up to 10 years, depending upon the brow position and stability, whereas a lower eyelid blepharoplasty can last even greater, depending upon the stability of the mid-face.
Overly aggressive surgical lifting is not desirable as the results can look unnatural, feel uncomfortable, and even compromise the health of the eyes. Therefore, Dr. Burroughs strongly encourages patients to aim for a natural, more rested look. Cosmetic eyelid surgery can yield phenomenal restorative results, but must be balanced in context with other facial aging changes, such as brow ptosis (descent), midfacial ptosis, facial fat wasting, and severity of surrounding facial wrinkles. As our eyelids age, they commonly stretch and sag but also become thinner and lose their more youthful, fuller look. Along with these changes, the normal eyelid and eye socket fat can prolapse forward and downward giving a pronounced ” baggy” look. Race is very important in surgical decision making as many patients maintain their family lineage characteristics of eyelid contour, thickness, and upper eyelid crease position. Asian patients, in particular, require special attention to their variations in crease position and upper eyelid fullness. Most Asians do not want to be “westernized” or “Americanized,” but to simply rejuvenate unwanted age-related changes. Rarely, when considerable change is desired, Dr. Burroughs generally tries to achieve what the individual patient wishes regarding their own specific racial ideals of beauty and handsomeness. A “one size (solution) fits all” approach does not yield optimal results.
Dr. Burroughs is often referred patients of diverse racial backgrounds from other plastic and eyelid surgeons because of his expertise and expansive experience. Skin wrinkling is not always due to excess skin bunching up upon itself. Oftentimes, age related thinning, allergies, sun damage, and dermatologic conditions are the cause. Many plastic surgeons erroneously over-tighten by removing too much skin to address the wrinkles, which can lead to devastating poor eyelid closure and eyelid malpositions that can cause eye pain and vision problems. Some skin conditions such as excess oil glands and thickening of the eyelid skin can lead to poor wound healing, swelling, and scarring.
Whenever possible, it is essential to optimize the eyelid and periocular skin health before proceeding with surgery. To achieve optimal, customized surgical results, it is critical to assess for asymmetry of the eyes and face. These asymmetries can include: relative eye size (e.g., how “open” the eyes appear); eyelid contours and positions; eyebrow position; eye projection/retraction from the orbital socket; cheek and frontal bone projection or flatness; and uneven skin quality and aging differences. Unrecognized preoperative asymmetries with eyelid and facial surgery may lead to unsatisfactory results and unmet expectations. Careful discussion on what can and cannot be achieved with soft-tissue (e.g., blepharoplasty) surgery helps maximize the postoperative satisfaction.
A protruding bony eyebrow ridge or forehead can cause the eyes to appear small, set back, and shadowed. This can be improved by debulking excessive upper eyelid fat, raising the eyelid crease, and raising the eyelid margin height, making the eye more open so it appears larger and more forward. Alternatively, a flat bony ridge above the eyes may need the opposite approaches. If the eyes are extremely set back, they can be brought forward through implants placed under and behind the eye, and rarely, by adjustments to the orbital rim and eyelid attachment points. Similarly the eye position to the cheek prominences is paramount when surgically addressing the lower eyelid for cosmetic or reconstructive surgery.
On side profile, the cheek, under most circumstances, should extend slightly anterior to the eyes. If the cheeks do not protrude forward sufficiently, then guarded surgery must be done on the lower eyelids to avoid causing them to drop (slide down the face), which can lead to chronic dry eye and vision problems. If the eye to cheek position is not ideal, then surgical options include: fat implants or transfer, cheek implants, and suspension of the mid-face (cheek) fat pads and soft tissues superiorly. Ideally, the lower eyelid is a convex continuum with the cheek and lower face and not the age-related sagging and indentations that are commonly seen in older patients. Lower eyelid assessment includes inspection of the multiple bags, folds, and wrinkles. The lower eyelid itself has 3 fat compartments that can protrude forward and sag with age.
Additionally, like other soft-tissue facial structures, the cheeks can descend with age. Along the bony rim, the eyelid muscles attach firmly, causing an age-related indentation that is accentuated by the superior fat bags protruding and inferiorly by the mid-face fat pads and tissue descending. These multiple causes must be identified and, if desired, optionally addressed specifically during lower eyelid blepharoplasty. Otherwise, incomplete addressing of these multiple issues will lead to incomplete improvement. Fortunately, Dr. Burroughs utilizes many techniques that can be performed through small and adjoining incisions, thereby gaining maximal improvement with minimal external skin incisions.
In women, the ideal eyebrow position is approximately a centimeter above the orbital rim, whereas in men, it generally rests at the orbital rim. Brow and forehead lifting can restore the eyebrow back to these positions, but caution must be exercised to avoid over elevating the eyebrows, which can lead to a more feminine look in male patients and a startled or frozen look in females. Dr. Burroughs performs, when indicated, a number of brow and forehead lift techniques. Sometimes a patient may have extreme asymmetry between the two eyebrows necessitating different techniques to improve the brow symmetry.
Oftentimes, when the eyebrows are low, there is excess upper eyelid skin. If both issues are not addressed simultaneously, suboptimal results may arise. Some surgeons erroneously try to do an upper eyelid lift, when actually a brow lift was needed. Later, when the brows are lifted, there may be insufficient skin to allow the eyes to close properly leading to dry eye problems. The lacrimal tear gland is located at the outside edge of the upper eyelid. The main lacrimal gland is important particularly for reflex tearing if something irritates the eye. As we age, the support attachments of the main lacrimal gland loosen, and the gland drops and extends forward into the eyelid. Novice surgeons have mistakenly removed it, thinking it was eyelid fat, which can create postoperative dry eye problems. Dr. Burroughs frequently repositions the gland back to its proper position during upper eyelid surgery to avoid a lateral bulge in the upper eyelid. Furthermore, infectious, inflammatory, and even serious cancers can affect the lacrimal gland, so these concerns need to be addressed prior to undergoing cosmetic or reconstructive eyelid surgery or procedures. Raising the upper eyelid height (ptosis repair) is accomplished by carefully identifying the major tendon or muscle responsible for eyelid elevation and tightening it. Dr. Burroughs has performed thousands of these surgeries and even published surgical techniques to address these issues. Lowering the upper eyelid is also possible by weakening the tendon of the muscle, which can help the eyes close better. Upper eyelid height and contour adjustments may be performed on one or both eyes to improve eyelid position asymmetries, function, and cosmesis.
Additionally, the perception of moving an eye forward or backward can be achieved by raising or lower the eyelid heights. However, the removal of skin will not safely adjust the eyelid height (where the eyelid margin rests on the pupil) as ptosis repair is needed to address this issue. Dr. Burroughs also routinely corrects lower eyelid malpositions, but these require advanced techniques and understanding of the anatomy. The shape and appearance of our eyes are largely based upon the inner and outer corners where the eyelid meet together. These corners are called the “canthi” and the height position of these are relative to one another and the surrounding facial tissue and structures. The canthi positions of one to the other, as well as to the eye and surrounding tissues, is very important, not only for the shape of the eyes but also the function of the eyelids. Patients with loose or down-turning eyelids can have dry, irritated eyes and sometimes watery eyes due to the eyelid laxity impairing the tear drainage pump. Therefore, canthi repositioning is a critical component of either upper or lower blepharoplasty surgery as the appearance (e.g., roundness, “cat eye,” “almond eye,” etc.) and function are determined by where they are positioned. Our eyes require a healthy tear film.
The Colorado climate is very dry, and many patients have “dry eyes” due to any number of tear film deficient (qualitative or quantitative) states. These patients with a poor tear film either require special planning, tear film optimization preoperatively, or more conservative surgery. Furthermore, patients that have undergone laser refractive surgery (e.g., Lasik, PRK) can have a worsened response to dry eyes. Although, some reconstructive eyelid procedures can address and improve these issues. If a patient has preoperative dry eyes, then they need to remain vigilant with the use of ocular lubricants (tear supplements, ointments) in the postoperative period. Patients who have had prior eye surgery (e.g., glaucoma) also sometime require customized surgeries to protect their ocular health and vision. Dr. Burroughs is asked by referring physicians (even other plastic surgeons) and knowledgeable patients the specifics of how he does eyelid surgery. Each patient is unique and requires a customized approach for optimal success. Sometimes, eyelid fat needs to be sculpted out, transposed (moved to an adjoining area), relocated (moved to a new area), or a combination of each of these.
Similarly, sometimes skin incisions need to be shorter, longer, or more extensive, depending upon a patient’s unique anatomy and issues of concern. Sometimes, Dr. Burroughs routinely preserves the muscle, for patients with weak eyelids, under the incision and removes it at other times to debulk and optimize wound closure and contour with the surrounding skin. Each patient is unique, which Dr. Burroughs finds both intellectually and artistically challenging when it comes to what set of approaches is in the patient’s best interests for the most successful and safest result.
Other Diseases and Situations That Can Impact Healing and the Eyes
Many conditions may alter the timing and amount of cosmetic eyelid surgery that is safe. Some of these disorders need to be recognized as they affect the surgical plan and healing process. Examples include diabetes, ongoing smoking, thyroid eye disease, muscle wasting conditions, neurologic conditions, rheumatoid arthritis, lupus, and other autoimmune disorders. Eyelid malpositions (e.g., entropion, ectropion, retraction) are also important in the surgical planning and sometimes a staged approach is crucial to a safe outcome. Tear duct blockages, for instance, can impact surgical infection risk and should be identified and addressed before proceeding with ocular or eyelid surgery. Floppy eyelid syndrome is a form of eyelid laxity that is closely associated with sleep apnea and eye problems including tearing, redness, and eyelid ptosis. Interestingly, many of these conditions are easily recognized by a cursory look at the eyes while others require a magnified eye exam with a slit-lamp biomicroscope. Dr. Burroughs’ prior training and ongoing board certification in Ophthalmology especially suits him for assuring the safest, most successful surgery possible given the impact these other co-existing diseases and issues can cause.
Each of these factors makes undertaking cosmetic eyelid surgery a serious and sometimes complicated decision. However, it is generally considered one of the most satisfying plastic surgical procedures. It is generally quick, painless, and an affordable means toward improving the facial appearance. Dr. Burroughs often reminds patients if they can only do one facial procedure, then start with the eyelids since they are the center of attention on our face when we meet and talk to others. Fortunately, most patients may safely undergo cosmetic eyelid surgery, but each patient is unique, necessitating individualized assessment and planning. During a consultation, Dr. Burroughs may or may not directly speak about each of the above factors during the evaluation, but each of them is considered in your surgical planning.
Frequently asked questions about cosmetic blepharoplasty and cosmetic eyelid surgery:
1. Does insurance ever cover eyelid surgery?
Insurance will often pay, less your specific copays and deductibles, for eyelid surgery that is performed to improve vision. For instance, if your upper eyelids are drooping and this is blocking your vision, your insurance company may pay for upper eyelid surgery. If the upper eyelids are blocking vision, insurance companies require a visual field test be obtained to demonstrate that the eyelids block the peripheral vision and that the vision is improved by elevating the eyelids. If your lower eyelids are droopy and this is causing eye irritation or watering of the eyes, your insurance company may pay for correction of this problem. Insurance companies typically require that the medical need be documented with photographs, which are reviewed by the insurance company during the preauthorization process. Some problems like bags in the lower eyelids do not affect vision and are never paid for by insurance companies. Other problems like excess skin in the upper eyelids that effect vision when severe enough are paid for by insurance companies when photographs and visual fields document a medical need for the surgery. Dr. Burroughs’ office can act as your advocate to help get your insurance company to pay for medically necessary procedures. Many of the procedures he performs are done only to improve appearances, and these cosmetic procedures are not paid for by your insurance company. During you consultation, Dr. Burroughs will determine what procedures will offer the most functional (medical) and cosmetic benefit and discuss the range of options.
2. Where is the incision made when performing upper eyelid blepharoplasty surgery?
In nearly all cases of upper eyelid blepharoplasty surgery, there is excess skin in the upper eyelids, so removal of extra skin is only possible with an incision. Fortunately, the skin of the upper eyelid is some of the thinnest skin in the body and typically heals with little to nearly invisible scarring. Further, the incision site can be hidden in the fold of the upper eyelid allowing the incision to be hidden while healing. The incisions usually have to extend to the lateral crows feet area to avoid unwanted excess skin at the outside corners of the eyes.
3. How is the upper blepharoplasty incision made?
Dr. Burroughs has used lasers, scalpel blades, bovie (electric needles), and radio frequency needles. His preference is to make the incision with a scalpel blade or with an electric (bovie) needle set at a low setting to optimize the wound shape and architecture while minimizing collateral heat damage that other modalities can cause. Once the initial skin incisions are made, then depending on the circumstance and patient needs, the other modalities can be used. One problem with lasers is they can easily become uncalibrated, causing the incision to be inaccurately placed, and they also can cause heat damage that leads to slower wound healing and, rarely, more scarring.
4. What kind of sutures does Dr. Burroughs use for blepharoplasty surgery?
Dr. Burroughs finds eyelid wounds heal cosmetically better and faster with non-dissolving sutures that are removed between 7-14 days after surgery. Dissolvable sutures “dissolve” by causing local inflammation and can sometimes leave the incisions looking more red and “bumpy” in the initial phases of healing. Dr. Burroughs also finds that performing a “running” suture to be easier for removal than a series of interrupted sutures that have to be individually removed.
5. Is fat or muscle removed during upper blepharoplasty surgery?
Aesthetically, the tendency is to leave as much fullness in the upper eyelids as possible. Removal of too much fat from the upper eyelids can give one a hollow appearance that is not desirable. Often the fat pad in the upper eyelid adjacent to the nose is bulging forward and is reduced in size at the time of upper eyelid blepharoplasty surgery. This is done conservatively to get rid of the bulge without causing a hollow appearance. Some patients benefit with removal of the superficial skin while leaving the underlying muscle, which can be helpful in older patients or those with pre-existent muscle weakness before surgery that can worsen eyelid closure after surgery. Others, most in fact, benefit with some eyelid muscle removal, which can help reduce the crows feet appearance and provide a subtle and pleasing brow lift.
6. Can the eyebrows be lifted or the lines between the eyebrows “11’s” removed with upper blepharoplasty surgery?
Yes. There are several options to include Botox, filler, and surgery to improve these areas. Dr. Burroughs has published an article in the Archives of Facial Plastic Surgery journal, detailing an optimal technique to address these concerns at the same time as upper blepharoplasty surgery.
7. Can ptosis (drooping of the eyelid margin) of the upper eyelid or sagging of the lower eyelids be addressed at the same time that cosmetic eyelid surgery is performed?
Yes. It is very common for patients to have surgery done to improve function at the same time that cosmetic surgery is done. The portion(s) of the surgery that is done to improve eyelid function and eye comfort may be covered by your insurance company.
8. If I’m having upper eyelid surgery, what else can be safely done at the same time?
Many other procedures can be done just before, during, or after your upper eyelid surgery. This can include Botox, chemical peels, and fillers. Additionally through an upper eyelid incision, Dr. Burroughs can gently raise the eyebrows, reduce the wrinkle lines between the eyebrow, improve frontal area headaches, raise the lower eyelids, and improve the crows feet areas.
9. Are there any special considerations if I am planning or have had eye surgery (laser or cataract)?
Yes. It is optimal when medically appropriate (you can see well enough to function) to have eyelid surgery first. Very rarely, eyelid surgery can change one’s vision and cause the need for glasses or an adjustment to one’s glasses prescription. Usually by 6-8 weeks, the eyes are stable and no further refractive (eyeglass) changes occur. It is quite rare for major shifts to occur, but because both laser and cataract surgery depend upon very accurate and stable preoperative measurements, it is best if one is thinking of doing eye surgery and eyelid surgery to do the eyelid surgery first. If you have already had laser (e.g., Lasik) or cataract surgery performed, then generally no substantial visual changes will occur, but is a slight risk. Patients that have had prior laser surgery are at a higher risk for dry eyes, which can be exacerbated following eyelid surgery and needs to be carefully monitored during healing.
10. Where is the incision made to lift a drooping cheek?
This varies from patient to patient, but it may be made either in the upper eyelid, the lower eyelid, or at the temporal hair line. You should discuss this with Dr. Burroughs during your consultation.
11. Do I need an upper eyelid lift or an eyebrow/forehead lift or both?
This varies from patient to patient and their desired goals. Generally, if the eyebrows are resting at or below the orbital rim, then some form of brow or forehead lifting will be required for the best result. Dr. Burroughs can discuss this during your consultation.
12. What is double eyelid surgery?
Asian patients have different anatomy than occidental patients. Some Asian patients are born with a fold in the upper eyelid and others are not. When the fold is present, it is called a double eyelid. The fold in the upper eyelid of Asian patients is much nearer to the eyelashes than it is in the occidental eyelid. It is often said that Asian patients wish to have their eyelids “westernized.” In our experience, Asian patients seeking double lid surgery want their eyelids to look like those Asian patients that are born with a fold in the eyelid and do not wish to have their eyelids look like occidental or “western” eyelids. This form of cosmetic eyelid surgery is performed by Dr. Burroughs. If you are considering this type of surgery, it is helpful to bring a photograph of a model with the appearance you hope to achieve, so that this can be discussed and decided if it may be safely and reasonably achieved. Dr. Burroughs’ stepmother is Korean, and while he was still in the Air Force, he performed many Asian blepharoplasties on Filipino and Korean patients. He has also surgically treated patients from Japanese, Chinese, Taiwanese, Cambodian, and Vietnamese descent.
13. Is it possible that I may have trouble closing my eyes after upper eyelid surgery?
Yes, but this is usually a temporary issue that improves greatly upon suture removal in most cases. The upper eyelids are central to form and to visual function. Removal of too much skin from the upper eyelids does not look natural and causes problems with lid closure. Dr. Burroughs is an expert in both ophthalmology and plastic surgery which is why he is acutely aware of the need for the lids to both look and function normally after cosmetic eyelid surgery. The most serious complications of facial cosmetic surgery occur with eyelid surgery. Some patients with medical issues such as weak facial muscles require an even greater concern for properly performed eyelid surgery to enable the best and safest result. In the early stages of healing, sometimes the eyelids will not completely close, but after the sutures are removed, generally the skin loosens up and muscle strength returns allowing full closure of the eyelids. During this time, utilization of artificial tears, gels, and ointments can improve eye comfort and vision.
14. What is eyelid surgery recovery like?
Recovery varies by the exact procedure(s) performed and the individual patient. Generally, eyelid surgery is minimally painful but results in bruising and swelling. Patients should plan on being home on the day of surgery and for two additional days. During these first few days, cool compresses are applied to the eyelids to reduce bruising and swelling. After the third day, most patients can drive a car and get about fairly easily. Postop patients should avoid heavy lifting and strenuous exercise for 10-14 days after their procedure. Most patients will wear sunglasses for 2-3 weeks to hide bruising and swelling. Dr. Burroughs will provide you with detailed written instructions prior to your procedure.
15. Are there potential complications from eyelid surgery?
Yes. All medical and surgical procedures carry some risk. You should discuss the risk of complications with your doctor prior to surgery so you can make an informed decision on how to proceed. Many patients select Dr. Burroughs for their surgery because of his ophthalmic background, and they believe the risk of complications with cosmetic eyelid surgery may be lessened when performed by a surgeon with special plastic surgery training of the eyelids and who is vastly experienced in performing these procedures. A careful ophthalmic history and exam is critical before any eyelid surgery. Each year, Dr. Burroughs has been the first to diagnose eye problems prior to surgery that could cause suboptimal results following surgery or even vision loss whether surgery is performed or not. Dr. Burroughs will appropriately refer you to the correct eye specialist if he detects a problem that needs to be addressed prior to eyelid surgery.