My Thoughts on Blepharoplasty
There are so many ways to enhance and rejuvenate the eyelids that the prospective patient can be quite confused at the end of an endless Internet search. I want to present my thoughts about the aging process around the eyes and why I have chosen the method that I have to restore the eyelid area in the way that I do and why. In short, many surgeons look at aging around the eyes, what surgeons call the periorbital region, as a question of removing excess, what I term positive-space problems. That is to say, you have too much skin, you have a sagging brow, you have wrinkles, and you have an eyebag. Instead, I believe there are equally existing “negative space” problems meaning there is an absence of tissue contributing to the aged appearance, namely fat around the eyes. I know that it is common to think well if I just lift my brow high enough or remove enough skin that my problem will be fixed, but in order for patients to truly believe that my philosophy is in alignment with the way natural aging occurs I always encourage them to look back at their photos in their own youth. I often tease my patients that I know how they looked in their youth better than they did without ever having seen their face before. The upper eyelid in particular is hard to understand the aging process. The analogy I use to help educate my patients is to consider that it is like a balloon that deflates. When a balloon deflates, it just needs to be re-inflated. The way that I re-inflate the balloon is using fat grafting. Yes, at times I will do an upper blepharoplasty to remove some of the crepey and hanging skin but the core of my method for the majority of my patients is adding fat. As far as the lower eyelid is concerned, my real fear is the external incision, not due to the risk of scarring but because it destabilizes the integrity of the lower eyelid forcing the surgeon to re-strengthen the lower eyelid and thereby possibly causing problems. I have done the transconjunctival approach (no-incision) for 20 years and have never had an issue of inability to close the eyes, change in eyelid shape, or other long-term eyelid dysfunction that I have seen way too often from patients walking through my door. Another analogy that I use is to the describe the lower eyelid like an island where the water recedes away from it. The island is the eyebag of fat and the water is the fat that goes away from the eyelid to leave an exposed island, that is, fat bag. I believe that to get the safest and most consistent result is to reduce the island partly (the fat bag) and to elevate the shoreline back up, which is the fat transfer. I hope these simplified analogies help you understand better how and why I do what I do.