Face and Eyelid Plastic Surgery Beverly Hills Los Angeles

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Eyelid Surgery – Variations and Techniques

Blepharoplasty (Eyelid Lift Surgery) Variations and Techniques

There are many different approaches to eyelid surgery based on your particular needs. Choosing an oculoplastic surgeon like Dr Hoenig confirms that your doctor is a board certified ophthalmologist and a specialist in eyelid plastic surgery. Below are some definitions of the particular types of eyelid surgery that Dr Hoenig performs.

What is upper blepharoplasty?
Upper blepharoplasty is a general term used to describe the most popular eyelid surgery through an incision in the crease of the upper eyelid to remove skin, protruding fat, and/or muscle. The amount of skin to be removed is carefully determined before surgery by pinching the skin to demonstrate and measure how much excess can be removed and still allow the eyelid to close. Upper blepharoplasty could also technically include asian eyelid surgery since this is surgery on the upper lids. (see asian blepharoplasty below)

What is lower blepharoplasty?
Lower blepharoplasty is also a general term to describe any surgery on the lower eyelids. This can be done through the skin just under the eyelashes (see trans-cutaneous blepharoplasty below) or through the inside of the eyelid (see trans-conjunctival below). Lower eyelid surgery using either technique can improve the contour of the under eye area, but it does not treat fine skin texture problems. A chemical peel or laser resurfacing is needed for fine wrinkling or loss of elasticity of eyelid skin.

What is transcutaneous or subciliary blepharoplasty? (Transcutaneous means through the skin. Subciliary means below the lashes).
For patients with significant excess of lower eyelid skin, an incision just under the eyelashes is made to remove the skin. At the same time, fat can be removed, repositioned, or added, if necessary, and this incision can also be used for a midface lift. Sometimes, removing too much skin can lead to the lower lid being pulled down (a complication called lid retraction) or turned out (ectropion) causing the eye to appear more round and/or more of the white part of the eye to show (scleral show). This is extremely rare in the hands of an experienced surgery like Dr Hoenig. If he can tell that you are more at risk for this type of adverse event, a canthoplasty (see below) can be done at the same time can help to prevent this.

What is transconjunctival blepharoplasty? – (also referred to as “transconj bleph”)
Trans-conjuctival blepharoplasty means eyelid surgery through the inside tissue (known as the conjunctiva) of the lid. The trend right now is to do the majority of lower eyelid surgery with this technique for patients needing fat removal, but not skin removal because there is no visible scar. Since no skin is removed, a chemical peel or laser resurfacing can be used to smooth the eyelid skin in conjunction with a transconj bleph. The transconjunctival incision can also be used for a midface lift. The trans-conjunctival incision is not a good option for patients requiring skin removal, those with poor lower lid elasticity, or for patients with festoons (see below) but it can be used to access the lower eyelid fat which can then be trimmed down or removed, leading to a smoother, less “baggy” lower eyelid contour.

What is eyelid ptosis surgery? 
Droopiness (also referred to as ptosis – pronounced “toe-sis”) or sagging of one or both upper eyelids caused by injury to the muscle, congenital defect, muscle disorders, nerve disorders, or aging can obstruct vision when severe and create a tired or aged appearance. It can be associated with rubbing of your eyelids, such as with environmental allergies, or can occur with medical conditions such as Myasthenia Gravis. Eyelid ptosis may also cause excessive forehead wrinkling, headaches from forehead muscle contraction, tipping back of the head to improve vision, and eye fatigue. Dr. Hoenig can correct this problem by repairing the muscle and supporting the eyelid. After surgery, your eyes will be open more and you have a more alert, less sleepy appearance. The most common surgical technique used to correct droopy upper eyelid muscle is called Muellerectomy, referring to cutting of the so-called Mueller eyelid muscle.

What is a SOOF lift?
SOOF is an acronym for Sub-Orbicularis Oculi Fat, meaning the fat that lies beneath the lower eyelid muscle at the top of the cheek. A SOOF lift raises the fat to fill in a depression or hollowness at the top of the cheek or under the eye. Frequently, a SOOF lift is inadvertently referred to as a midface lift, but a true midface lift is much more extensive and includes repositioning fat, muscle, and sometimes skin over the whole cheek. A SOOF lift can be done through the skin or through the inside of the eyelid.

What is fat transposition, fat repositioning or arcus marginalis release (AMR)?
Sometimes with aging, tissue sagging, and fat loss, the bone beneath the eye at the top of the cheek (known as the infraorbital rim) becomes more visible and creates a noticeable ridge. In patients with bulging fat just below the eyelashes, but absence of fat over the orbital rim (bone), the bulging fat can be rolled down under the muscle (called the arcus marginalis) to fill in the depression and cover the bone. This is done instead of removing fat, which can contribute to hollowness and accentuate the ridge. Although the fat is moved down and sutured into place over the bone, the fat remains attached to it’s blood supply so it should remain age normally as it would if it had not been repositioned.

What is fat preserving blepharoplasty?
The recent trend in eyelid surgery is not to remove any eyelid fat, unless it is truly bulging. Removing fat unnecessarily can create a hollow, sunken appearance when a youthful lower eyelid is ideally full and rounded. With fat preserving blepharoplasty the fat can be left attached but moved it into a better position (see fat transposition above), or left in place with additional fat transferred around it to create a smooth contour. (see fat transfer below)

What is fat graft / fat transfer / lipo-transfer / fat injection?
Instead of removing fat around the eyelid, it is often advantageous to add fat which is naturally lost with aging, or which never was present in the first place. This is done by removing a small amount of fat from another area of the body such as the abdomen or hips, and reinjecting it around the eye. To prevent lumpiness and fat reabsorption, the should be placed deep and should only be done by an experienced surgeon like Dr Hoenig. The fat can be injected either directly through the skin or through the inside of the eyelid.

What is canthoplasty or canthopexy eyelid surgery?
Canthoplasty and canthopexy refer to tightening of the ligament and/or muscle that support the outer corner of the eyelid. (A canthoplasty reshapes the eye, while a canthopexy supports without changing the eye shape.) This procedure can be used to prevent or correct pulling down of the lower lid, such as in lower transcutaneous blepharoplasty. (More advanced cases of lid retraction may require a graft to adequately repair it). Canthoplasty can also be used to create the “cat eye” look with an upwardly slanted outer eyelid corner.

What is laser blepharoplasty (laser assisted blepharoplasty)
Instead of making the eyelid incision with a scalpel, a laser is used in laser blepharoplasty to cut through the skin. Theoretically this can produce less bleeding and bruising since the laser cauterizes the blood vessels and stops bleeding as the incision is being made. Some surgeons have noticed irregular scar healing with the laser because it burns the skin edges, while others prefer the laser for it’s precision and cautery. If a scalpel is used instead of the laser, an electric cautery is used to seal the blood vessels instead of the laser. Dr Hoenig prefers using a scalpel rather than laser for cutting in order to minimize the collateral damage to the delicate eyelid skin. The remainder of the procedure is the same as with any blepharoplasty.

What does functional blepharoplasty mean?
When excess, overhanging eyelid skin obstructs vision, a functional blepharoplasty can be performed to remove skin and improve the “function” of the eye. Some people with overhanging eyelid skin do not adequately see objects in the upper or the peripheral fields of vision. Functional blepharoplasty is considered a reconstructive procedure when it improves visual fields, and insurance may pay for all or part of the procedure, however Dr Hoenig does not do any insurance billing or accept payment from the insurance companies. As required by your insurance plan, a visual field exam performed by an optometrist can document whether the vision is obstructed by overhanging eyelid skin.

What is asian blepharoplasty? (aka double eyelid surgery, eyelid crease surgery, anchor blepharoplasty)
About half of Asian people are born without a crease in the upper eyelid, creating the appearance of a full or puffy upper lid. Additionally, a normal asian lid crease when present is much lower (by about 3 to 5 mm) than a caucasian eye. The fullness is caused by missing, weak, or low positioned attachments that normally create the eyelid crease, allowing the fat normally held back by the attachments to push forward on the eyelid. The goal of asian blepharoplasty, then, is to create a fold in the eyelid and minimize fullness without losing the ethnic beauty of the patient. (If the fold is placed too high, it can look unnatural in an asian patient). The most prevalent technique currently to accomplish this is sometimes referred to as the “anchor blepharoplasty” in which the deep skin of the upper eyelid is sutured (“anchored”) to the connective tissue of the underlying muscle. This allows for a crease when the eye is open, and disappearance of the crease when the eye is closed.

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