What should I know before getting eyelid surgery?

The next time you flip through Vogue or Allure (guys, just grab one at the checkout stand) take a close look at the eyes of the models. In most of them, women in their teens and twenties, you will see only a sliver of the upper eyelid, if it is visible at all. In many, the upper lid is completely obscured by soft tissue fullness between the brow and eyelashes, which I sometimes refer to as the 'brow roll'. Perusing the fashion magazines provides quick confirmation that the youthful upper lid is not a skeletonized upper lid.

My approach to upper eyelid surgery is to be conservative with skin excision, and to reserve excision of fat for patients with significant fat excess. In my opinion, aggressive removal of upper eyelid skin and fat is a 'skeletonizing' procedure which risks making eyes appear more deep-set and aged, rather than younger. In fact, in many patients I perform structural fat grafting (using the patient's own fat, from the abdomen or hips) to help restore soft tissue volume around the eyes.

Structural fat grafting provides a mean for restoring or enhancing this 'brow roll' area. In patients that have always had, or who with age have developed a deep recess between the upper lid and brow, the addition of soft tissue volume can dramatically rejuvenate the appearance of the eyes. This novel aesthetic enhancement of the upper lids does not look like eyelid surgery - it just looks youthful.

First you should know if you are a good candidate for blepharoplasty (eyelid surgery). Anyone who has dry eyes should have an ophthalmologic evaluation to determine the degree of dryness as it can worsen in the postoperative phase.

A patient should have specific goals in mind regarding how you hope blepharoplasty will change the appearance of your eyes and if you want both upper and lower blepharoplasty done at the same time.

It is wise to do some research for a surgeon who is board certified and experienced in performing successful blepharoplasties.

Blepharoplasty is defined as "any operation which corrects a defect in the eyelids." This can be an upper eyelid procedure or a lower eyelid procedure. While it is important to know about both, lower eyelid surgery poses a greater challenge. Lower eyelid blepharoplasty usually aims to get rid of bags under the eyelids and produce a less tired look.

It is important to consult with a qualified surgeon before undergoing any surgical procedure and this article poses a few questions to ask the surgeon during a consultation.

What type of incisions will you use?
There are several approaches that can be used to access the lower eyelid. Some incisions are made on the inside of the lower eyelid and are not visible. Others are made just below the lash line and when healed, are nearly imperceptible. The approach used depends on many factors and the surgeon can discuss these thoroughly.

For the upper eyelids, the incisions are generally the same and involve an incision along the natural upper eyelid skin crease.

Is my lower eyelid loose?
When performing lower eyelid surgery, it is important to ensure that the lower eyelid is tight enough. If the eyelid is not tight enough, there is a greater risk of pull down of the eyelid after surgery and resulting dry eyes and eye exposure.

To test if the lower eyelid is loose, the surgeon will pinch the lower eyelid and pull it out. If it takes a long time to retract or requires a blink or two to return to a position against the eye, the lower eyelid is loose. If the lower eyelid is loose, a procedure can be performed to tighten the lower eyelid. This can be performed at the same time as lower eyelid surgery and should be discussed before proceeding with surgery.

Will this surgery take away the bags and lines under my eyes?
Most patients who have bags under the eyes have what is called pseudoherniation of fat. This means that the fat that normally exists around the eyeball has pushed out past the edge of the bone of the eye socket, producing the bags.

In some patients, the bags under the eyes are actually on the cheek and lower eyelid surgery will not fix this. In addition, if discoloration of the skin is a concern, it is important to ask the surgeon if just operating on the lower eyelid will fix the discoloration. Most of the time, the dark circles under the eyes are due to shadows from the fat. At times though, this discoloration is due to pigment in the skin. If pigment is the problem, additional procedures may be required to address just the discoloration below the eyes.

For upper eyelid surgery, do I need a brow lift?
For some people, a combination of an upper eyelid blepharoplasty and brow lift is needed. A crude means of determining if brow lifting is necessary is to manually elevate the brows and determine if the eyebrows are still in a good position and if some of the problem of the upper eyelids has resolved. Sometimes it is the brows that make people look tired, not just the upper eyelids.

What is my recovery time?
While every patient is different, bruising, swelling, and bleeding are generally the limiting steps for return to normal activities. Different approaches to the lower eyelid will produce different amounts of bruising and swelling. Be sure to consult with your surgeon about expected time away from normal activities.

Above all, research the procedures you are thinking of having and research the credentials of the surgeon you are considering. While this is not a complete list of questions you might want to ask, it is a starting point. It is of utmost importance to discuss your expectations with your surgeon to ensure that your goals can be reached.