When Do I Do an Upper-Eyelid Blepharoplasty and How?

But should we always just add fillers or fat to the upper frame of the eyelid and never remove any tissues?  The answer is no.  If the eyelid skin is above the eyelash margin, I rarely if ever remove skin.  Filling fat or fillers into the upper eyelid and soft-tissue of the brow is sufficient to make the eyelid look more youthful, even if this is not immediately intuitive.  If the eyelid skin edge is crêpey in appearance or hangs low, a combination of some skin removal with fat transfer is ideal for the best results.  However, if I had a choice based on a patient’s budget I would still rely on fat grafting as the principal method to make the upper eyelid better.  Because I remove so little skin and never fat or muscle from the upper eyelid, the eyelid crease height should change very little from its current and youthful position (which preserves identity and enhances youth) but also the individual can still close her eyes.  Unfortunately, I see too many individuals who have been subjected to traditional eyelid surgery that prevents their eyelids from closing, which can be dangerous especially when one is sleeping.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum

Like the upper eyelid, I find myself performing many more fat transfers to correct the aging process than traditional eyelid surgery.  Further, if I perform a traditional lower-eyelid procedure I will almost always use some fat transferred to improve the result.  In fact, I look at traditional eyelid surgery as a complement to fat transfer, rather than the other way around.

There are two principal ways to manage the lower eyelid traditionally, either a skin-muscle procedure in which there is an external incision or through what is known as a transconjunctival approach that has no skin incision.  I prefer the latter approach not to limit the risk of scarring, which is pretty minimal, but to avoid changing the shape and contour of the lower eyelid.  When surgeons use a skin-muscle flap, they must tack the suture to the lining of the bone.  When that occurs, there can be slight inaccuracy or change during the healing process such that the canthus (where the upper eyelid meets the lower eyelid) can be altered so the person does not look the same or worse yet does not look natural.  For this reason, I almost never make an incision in the lower eyelid skin if I can avoid it.

I use the analogy of the typical eyebags as “rocks” that appear only when the tide (fat level) is low and so the way to manage the eyebag is to refill the tide (fat) to a higher level to cover it up.  This works in about 90% of individuals.  At times however the eyebag is so prominent that you simply cannot cover it up with fat.  In these cases, which are less than 10% of the time, I have to remove some fat at the same time that I add it below the existing fat.  This combination of reducing the rocks and increasing the tide can help effect the most favorable desired change for a smoother result in the lower eyelids.

I have been asked though what about the wrinkles?  That is a matter for neurotoxin (Botox) and laser skin resurfacing to help manage the aging of the skin.  I believe cutting away wrinkles surgically simply does not work and can contribute to the problem mentioned above of changing the eyelid shape, which is a terrible thing.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

One of the most confusing things that I have encountered is how to manage the aging Asian eyelid.  The reason for this is twofold.  First, if an Asian is born without an upper-eyelid crease where do you make the incision so that you don’t have a visible scar?  Second, when you remove skin from the upper eyelid of an Asian, you raise the position of the crease, which may look okay in a non-Asian (I would disagree) but it can look absolutely fake in an Asian because Asians typically are not born with high eyelid creases.

I have divided the management into three clinical scenarios:  Asians who are born with a natural crease, Asians who are born without a crease (or a very partial crease), and Asians who have had a surgically created crease made for them in the past. In the first clinical scenario, Asians who are born with a crease may be viewed just like a white person, i.e., one could simply remove skin.  And that is true.  However, the problem is, as mentioned, when skin is removed, the eyelid crease can ascend to the point that it looks unnatural.  In my opinion if I just put fat into the eyelid and brow in an Asian, I am able to make that individual appear much more youthful but at the same time maintain his or her eyelid crease height at a normal or natural position.  In an Asian that has a very low hanging skin that folds over the eyelash margin, I will remove skin from that person but almost always in conjunction with adding fat to the upper eyelid at the same time to maintain the crease position so that it does not artificially go too high.

In an Asian born without an eyelid crease, the biggest mistake is to try to remove skin, for two reasons.  First, since there is no natural position where the skin creases over, there is no place to make the cut.  When you arbitrarily define a line for incision, you can see the scar and if you try to take fat out, you can create a partial crease adhesion so that the person develops a partial crease.  That is a bad thing because it can change the person’s appearance and at the same time still the individual does not have a definable crease.  If you try to make the incision very long along the eyelash margin, the problem is unpredictable scarring, as the incision should never be placed there in the first place.  Interestingly, because one has a narrower eyelid opening that one has when one does not have a crease even removing skin from the upper eyelid does not help to make the eyelid position really look more open, which disappoints patients.  There are two ways then to manage this situation of an Asian without a crease.  First, one can make a crease, which can truly make the eyelid appear more youthful.  The problem with this approach is that it does change the way an eyelid appears from when that person was youthful (if that is ok with the patient).  Furthermore, there can be a long recovery period when creating an upper-eyelid crease, and the patient must know that.  The second way to rejuvenate an Asian eyelid without a crease is simply to add fat or fillers, which can plump up the eyelid to make it more youthful in appearance without any incisions.

The final scenario is an Asian who had a crease made in the past.  If the crease were made only a few years ago, then typically the creases made during the period from the 2000s forward were quite natural.  In the 1980s however the creases made were quite artificial in nature since a lot of skin and fat were removed and the creases were made artificially too high.  Interestingly, over time many of these eyelids start to descend and the crease can actually look low again.  The problem of removing eyelid skin at this point is that one can then unmask the previously bad result and at times even make the result look more unnatural in appearance.  The reason for this is that in fact when one is removing the upper-eyelid skin one is actually just removing brow skin, which is thicker and unnatural.  If the surgeon has a question as to whether it was an old-style Asian blepharoplasty or a new one, all one need to do is to lift up the eyelid skin to evaluate the height of the crease to determine if it was made unnaturally in the past or not.  This algorithm will hopefully help Asian patients seeking eyelid rejuvenation and also help surgeons seeking to help Asian patients with eyelid rejuvenation.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

Pillow Faces Can Look Weird and Bad

Recently, I had a lady who at the age of 57 started modeling for the first time in her life thanks in large part to the syringes I have put into her face to make her look better.  Her new boyfriend remarked that she looked better than she had when he saw her 7 years ago and was so attracted that they were now going out together.  However, he admonished her never to get any fillers like the modeling agency owner because that person looked artificial.  Little did he know that she probably had 10 times more fillers than her modeling agency owner friend.  How can so many syringes look absolutely natural and not overfilled whereas a few syringes look dreadful?

The answer lies in the artistic distribution of the product.  Unfortunately, I see too often the two areas where product is placed are the central, anterior cheek and the lips.  These areas are very unforgiving and they look very unnatural especially in a face that is volume depleted elsewhere.  It is so important that temperance be executed when filling these two facial zones.  The trick of filling a face naturally and beautifully is to fill other areas of the face so that the face actually looks good.  Balance and restraint is the key.  However, to make a face that is over 50 years of age to truly look amazing requires enough syringes placed all over the face rather than too much in just one area.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.

Correcting Fat Loss in IPL Damage: My Thoughts

Unfortunately, I have heard a lot on the Internet about facial fat loss following a laser treatment like intense pulsed light therapy, or IPL.  Fortunately, I have never seen a patient of mine with this outcome.  I think partly because this phenomenon is rare and partly because I use much lower-energy lasers than what are out there on the market so as to limit this risk.

There is great question of whether this phenomenon actually is real.  I personally believe that it is since there are enough people claiming that they have suffered this problem, and there are lasers on the market targeted to reduce excess fat.  The problem that I have on my forum relates to questions pertaining to the nature and evolution of this fat loss and how to manage it properly.  In general, I cannot answer these questions very well because I simply do not have enough experience to discuss the subject with authority.

If I am planning to perform a fat transfer the problem is I do not know when exactly the injury has stopped.  It could be a few months, a year or greater, as some individuals claim ongoing fat loss.  In my opinion (and this is only conjecture), if there is damage, it should be self-limited if there is injury to the blood supply to the fat and should not be ongoing.  My best guess is that I would wait at least a year before contemplating performing a fat transfer on that individual.  Also, of course, I would like that person to clarify that he or she thinks that in fact the fat loss has stopped before considering a fat transfer.

The biggest problem that I have encountered with individuals who have had an IPL injury to their fat is not physical but psychological.  Too often a patient becomes so obsessed with their fat loss that no treatment will ever make him or her satisfied.  They are living in the past and constantly evaluating in the mirror whether there is more fat loss or whether the surgery did enough to correct it.  This is a very dangerous thing because the individual can be psychologically unstable and cannot appreciate the improvement in the face.  In addition, some individuals experience further fat loss only due to stress from the initial incident causing them to age in appearance from stress rather than by physical insult.  Or after 1 to 2 years it is normal to lose a little more fat due to aging that could then be blamed on the IPL treatment.  For all of these reasons, treating patients who have reportedly lost fat after an IPL treatment can be difficult and problematic.

Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call (972) 312-8188. To Learn more about Dr Lams’ plastic surgery procedures or to ask Dr Lam a question please visit his plastic surgery forum.