What is the latest and greatest in eyelid surgery (Blepharoplasty) by S. Larry Schlesinger, MD, FACS in Honolulu Hawaii

By S. Larry Schlesinger, MD, FACS

What is the latest and greatest in eyelid surgery (Blepharoplasty) by S. Larry Schlesinger, MD, FACS in Honolulu Hawaii

What is the latest and greatest in eyelid surgery What is the latest and greatest in eyelid surgery? Well, let’s go back and review some of the problems that occurred in the past. The first one is too much skin taken out of the upper eyelid. This one truly is not a problem if you choose the right Board Certified plastic surgeon.

Lower eyelids have been a problem for plastic surgeons for a long time. Patients want to get rid of the bags, extra skin and wrinkling. The bags are little pouches of brown fat. However, this fat is not brown in color, but the specific biochemical makeup of this fat is the same that brown bears live off when hibernating. You have all the fat you will ever have in this area when you reach puberty. It is normally held back by a piece of tissue known as the septum orbitale and it relaxes or fails at different ages depending on your genetics. Also, smoking and drinking do not help to preserve the integrity of the septum orbitale. Once this septum weakens, the fat pushes forward and looks like little bags under the eyes.

Historically, the treatment of choice to improve the appearance of the lower eyelids was to remove skin, muscle and fat, often leading to eyelids being pulled down, the white of the sclera showing above the rim of the lower eyelid, a very unattractive look. This problem of lower eyelids being pulled down is referred to as an “entroprian”. The reason this occurs is because the lower eyelid is held up by only two ligaments, one connecting to the medial or inner side of the orbit and one connecting to the outer side of the orbit. When you take skin and muscle out from below the lower eyelid, the resulting vectors of force are all downward, and unless one creates some upward vectors, the eyelid will pull down creating an entroprian.

Finally, any attempt to remove all the fat bulge under the eyes often leads to excessive fat removal and a hollowed look which can be even less attractive than the pre-existing bulging fat. A new technique has been developed which can push the fat backwards, therefore allowing the surgeon to take less fat and eliminating that hollowed look. It also eliminates most of the wrinkles because wrinkles at rest in the lower eyelid are not from excess skin, but rather from loose muscle. This new technique takes a portion of the oblicarius oculi muscle, passing it under the lateral ligament that supports the lower eyelid, and sews it up to the covering of the orbital bone superiorally and laterally. This muscle sling not only keeps the eye from having an entroprian, but it also pushes the fat backward.

A salutary effect of this lower eyelid surgery is that it pulls up cheeks. Because the orbicularis muscle is positioned under cheek bone fat, when you pull up part of it under the lower eyelid, in effect it also pulls up the cheek. The entire procedure takes about 2.5 hours. The sutures are out in 3 days and bruising is usually very minimal.

How can this lower eyelid muscle do so many things? The answer is that the face, unlike the body muscle and skin come from the same source, ectoderm. Since fat and skin are both closely related to ectodermal muscle of the eyelids, this muscle sling, as I call it, can do a whole lot more than we were ever able to do previously in a lower eyelid blepheroplasty.

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