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My Eyelids were Pulled Down after Eyelid Surgery.
What Should I Do?
Eyelids being pulled down after blepharoplasty is surprisingly more common than most people
realized.
This condition of the eyelids being pulled down is referred to as rounding, scleral show
or lower eyelid retraction.
This condition can be caused by factors related to support of the eyelids as well as tissue
loss from the surgery.
Proper examination by a specialist can help you understand which of these factors apply
to your situation.
In my experience, many patients undergo revision procedures which are minimally effective and
ultimately cause unnecessary scarring.
The key to your situation is understanding the anatomy and restoring the critical anatomic
relationships to correct the eyelid position.
It’s also important to maintain proper eye lubrication.
When the eyelid is retracted, part of the eye, in particular the inferior aspect of
the cornea becomes more exposed and can become scratched or infected.
In addition, you may develop exposure because your eyes don’t close completely when you
sleep so application of ophthalmic lubricating gel at night may be necessary.

Which Doctor is Best for Eyelid Surgery?
This question can be answered simply but unfortunately we live at a time of terribly unprofessional
behavior by a group of general plastic surgeons who are openly misinforming the public by
using the term “board certification” inaccurately.
The way to determine the best doctor for you to perform your eyelid surgery is by learning
about the doctor’s background training and areas of practice focus.
It is no secret that background training in eyelid surgery is far more extensive and complex
in Oculofacial Plastic Surgery when compared to the background training of general plastic
surgeons.
However, background training is still a starting point and individual factors such as artistic
abilities and technical skills are not standardized in any field.
In addition, training begins the process but actual daily practice ultimately determines
level of mastery.
As a Cosmetic Oculofacial Plastic Surgeon for over 20 years, people who come to see
us rapidly understand by speaking to our staff and myself how much eyelid surgery we perform
and the style in which I do these procedures.
When choosing your surgeon, review their background training, their practice focus and their results
so you can feel confident about your decision.

What are the Potential Complications of Blepharoplasty?
As a Cosmetic Oculofacial Plastic Surgeon, I deal with complications of eyelid surgery
for patients coming from around the world. Eyelid surgery ranks every year among the
top 5 popular cosmetic surgery procedures performed. Unfortunately, a significant percentage
of people undergoing eyelid surgery will have undesirable cosmetic outcomes such as drooping
of the upper eyelid or skin shortage resulting in eye exposure. Lower eyelid changes in my
experience is even more common such as lower eyelid rounding or scleral show. More serious
complications also occur such as lower eyelid retraction or eyelids pulled down or ectropion
which means the lower eyelid is everted and the inside is exposed. The question which
naturally follows is “how do you lower your risk for complications”? I would say that
as in other fields of medicine where specialized disciplines have evolved as the knowledge
and techniques became too much for a generalist to master, it is everyone’s interest who’s
considering cosmetic surgery to understand that plastic surgery is too broad a field
for one surgeon to be exceptional in every area. This trend began several decades ago
as the specialties of Cosmetic Surgery and Oculofacial Plastic Surgery became well defined
areas for surgeons to specialize in. Unfortunately, this evolution has been perceived as a threat
by a large group of general plastic surgeons who campaign with the term of “board certified
plastic surgeon” as way to deceive the public into perceiving them as superior to doctors
who are Cosmetic Surgeons or Specialty based cosmetic surgeons. In addition to background
training, practice focus results in experience at a deeper level. For example some plastic
surgeons do a lot of reconstructive breast surgery so although they had a more general
background in training, they chose a practice focus which ultimately gave them a higher
level of specialization which can be argued provides their patient with a higher level
of care. In my opinion, complications which are associated with the level surgeon’s
background and experience can best be avoided by having the procedure performed by a surgeon
with specialized training in eyelid surgery and practice focused on cosmetic eyelid surgery.
Other surgical complications can also be minimized by the surgeon spending a lot of time with
you to learn about your medical history and the details of your desired results. In addition,
in my experience, complications related to general anesthesia are avoided by performing
all my procedures under local anesthesia and LITE™ intravenous sedation. I also find
that performing the procedure efficiently with minimal trauma and working with my own
dedicated team of assistants who know my system results in a better patient experience and
quicker recovery.

How Do I Prepare Before Eyelid Surgery?
Preparation for eyelid surgery involves 2 separate factors.
1 is general health including medication and supplements you’re taking.
We need to know about health conditions such as high blood pressure, heart disease, diabetes
as well as drugs which are blood thinners such as aspirin and ibuprofen or supplements
such as Vitamin E, ginkoba and echinacea.
The second factor is the presence of eye conditions such as dry eyes and blepharitis.
Eyelid surgery can have a significant impact on the health and function of the eyes.
If you have dry eyes, its important to have a regimen which maximizes the lubrication
of your eyes prior to surgery.
In addition, discuss with your surgeon the potential need for specialized methods of
performing eyelid surgery to maintain the position of the lower eyelid so the tear film
is properly distributed over the eyes.
The more information you provide your surgeon about your medical history including any eye
conditions, the more prepared your surgeon will be for your procedure.

Are the Results of Blepharoplasty Permanent?
The results of eyelid surgery can have long term benefits.
As a practicing Cosmetic Oculofacial Plastic Surgeon for over 20 years, I have seen my
patients over this time period and have been impressed by how good their eyes appear.
The long-term benefits of eyelid surgery also depends on your age at the time of your procedure.
In our practice, we discuss the natural changes of facial aging and how these changes affect
the appearance of the eyes.
Depending on the age you are at the time of your procedure and your general health, the
results of your eyelid surgery can last as long as 5 to 10 years, It’s important to
understand that your eyes don’t revert back to the way they looked before surgery but
additional procedures may be beneficial to help optimize the appearance of your eyes
as time goes on.

How is Transconjunctival Blepharoplasty Different from Other Types of Lower Eyelid Surgery?
A transconjunctival blepharoplasty is a method of improving the appearance of puffy under
eye bags without any external incisions.
This is in contrast to a more commonly taught procedure to general plastic surgeons called
a “transcutaneous blepharoplasty”.
Stability of the lower eyelid is critical to appearance and function and the transconjunctival
approach has the advantage of the surgeon being able to avoid disrupting the delicate
muscles and ligaments necessary for lower eyelid support.
Typically in my practice, I perform transconjunctival procedures for people of all ages and often
combine it with skin enhancement for dark under eye circles and fine lines such as fractional
CO2 laser and platelet rich plasma or PRP treatment.

How are blepharoplasty surgical scars minimized?
Minimizing scars after blepharoplasty requires precise planning, minimally traumatic surgery
and high quality postoperative care.
When planning a blepharoplasty, I begin by minimizing the need for external incisions.
For example, I perform lower eyelid blepharoplasty from the inside of the eyelid to address puffy
under eye bags thereby avoiding external scars altogether.
For excess upper eyelid skin, the upper eyelid incisions need to be placed artistically so
even with the eyes closed, they should be minimally visible.
Choosing an optimal suturing technique and the application of advanced wound healing
technology such as the use of platelet rich plasma or PRP are methods I use which have
been beneficial for my patients.
Following postoperative care instructions is very important for minimizing scars after
blepharoplasty.
As with any surgery, proper planning, execution and aftercare will minimize undesirable scarring.

What are the Risks of blepharoplasty?
Eyelid surgery, like any other surgery involves risks such as bleeding and infection.
Unlike other surgeries, eyelid surgery has a direct impact on the function and health
of the eyes and can affect your vision.
A properly detailed history and physical examination of the eyes can help reduce the risk of undesirable
results and complications.
Conditions such as ptosis or lacrimal gland prolapse are often missed prior to cosmetic
blepharoplasty leaving people dissatisfied with their results.
Examples of surgical complications include drooping of the upper eyelids after surgery,
skin shortage preventing proper eyelid closure, undesirable scarring.
Lower eyelid complications examples include lower eyelid retraction or eyes pulled down
or rounded as well as ectropion or eyelids turned outward.
Unfortunately undesirable results can be associated with eye problems including dry eyes and corneal
ulceration.
It’s important that you know that terms like “board certified” is actually being
used deceptively by surgeons with less expertise in order to create a perception of superiority
in plastic surgery for the eyes when compared to doctors with more specialty based training
and more focused area of practice.
In my experience, as with any medical specialty, the risks of complications can be significantly
reduced by choosing a surgeon who has extensive knowledge and expertise with eyelid surgery
and can provide you with evidence to support this position.
Eyelid surgery can have a significant benefit to your appearance so don’t let the risks
dissuade you from having a procedure.

How are Upper and Lower Eyelid Surgery Performed?
Blepharoplasty or eyelid surgery can be performed under local anesthesia, local anesthesia with
intravenous sedation as well as general anesthesia. In our practice we perform blepharoplasty
routinely under local anesthesia with LITE™ IV sedation.
Upper eyelid blepharoplasty typically involves design of an eyelid crease and removal of
excess skin. In addition fat and soft tissue can be sculpted as needed. Some people have
a condition called “lacrimal gland prolapse” or downward displacement of the gland responsible
for making tears to keep your eyes lubricated. In situations of lacrimal gland prolapse,
a special technique is needed to re-suspend or restore the position of the lacrimal gland.
Lower eyelid blepharoplasty is performed to address sagging skin, puffiness and excess
skin. Lower eyelid blepharoplasty can be performed from the outside also known as a transcutaneous
approach and from the inside known as a transconjunctival approach. It’s very important to understand
that the position and appearance of the lower eyelid can be negatively impacted by lower
eyelid surgery.
I’ve helped many people who’ve experienced complications such as lower eyelid retraction
or eyelids pulled down or ectropion or eyelids turned out. In addition, I’ve seen many
people who felt their eyes didn’t look the same due to rounding of the lower eyelids.
When choosing a surgeon for your blepharoplasty, make sure you ask about their knowledge and
experience with advanced eyelid surgery techniques so you can look your best after your blepharoplasty.

Why do My Eyes always Look So Tired? Should I See an Eye Surgeon or a Plastic Surgeon?
In my experience, tired looking eyes can often be caused by hooded and sagging upper eyelids
as well as puffy under eye bags and loose lower eyelid support.
Plastic surgery of the eyes is unique in that this type of surgery can have a significant
effect on the function and health of the eyes.
It is critically important that when you consider plastic surgery for the eyes, that you feel
confident that the surgeon you choose has a deep understanding of eye health and has
a high level of expertise in eyelid surgery.
As a practicing Cosmetic Oculofacial Plastic Surgeon for over 20 years, I have helped many
people who underwent plastic surgery for their eyes and unfortunately needed revision surgery
to protect the health of their eyes and restore their appearance.
It’s important to understand that terms such as Board Certified Plastic Surgeon does
not in any way indicate any specialized training or expertise in this area.
Cosmetic Surgery is a separate specialty from Plastic Surgery and I would emphasize that
looking for expertise with eyes, artistic ability and extensive experience as characteristics
which will help you differentiate between doctors who perform eyelid surgery.
It’s important you understand this to avoid unnecessary risk and improve your chances
of getting the results you desire.