|Home||Dr Palmer||The Palmer Code™||The Palmer Code Institute||Procedures||Media||Contact Us||Reviews & Testimonials||What's New|
Recently voted "One of the Worlds Best"
Aesthetic Plastic Surgeons
Eyelid Surgery (Blapharoplasty) in Beverly Hills
Blepharoplasty or Eyelid Surgery is a Plastic and Cosmetic Surgery Procedure designed to make the eyes look more youthful. Eyelid Surgery entails evaluating the entire eye area. According to world-renowned Beverly Hills Plastic and Cosmetic Surgeon, Dr. Francis Palmer’s Palmer Beauty Principles™. The eyes are the second most important facial feature in determining how attractive you are. The eyes are the first facial feature to show signs of aging and therefore Blepharoplasty Procedures are one of the first Plastic and Cosmetic Surgery Procedures performed. Eyelid Surgery Procedures are also one of the most common Plastic and Cosmetic Surgery Procedures. Approximately 500,000 Blepharoplasty Procedures were performed last year in the US alone. Taking into account the entire world the number of Eyelid Surgery Procedures would be over a million. Eyelid Surgery typically is the within the top three Plastic and Cosmetic Surgery Procedures performed each year. Let’s take a closer look at Blepharoplasty Procedures:
Blepharoplasty/Eyelid Surgery Indications:
Blepharoplasty is indicated to reverse the signs of aging of the upper and or lower eyelid. The eyes are the first facial feature to show signs of aging. Gravity begins to pull the upper eyelid skin downward towards the eyelashes creating extra creases and folds in the upper eyelid. For women, the first hint that Eyelid Surgery may be indicated are difficulty applying makeup and eye shadow to the upper eyelid do to these increased skin folds and creases. The tissue layer supporting the eyelid fat also becomes weak and bulges begin to appear along the upper eyelid. Blepharoplasty is designed to remove the excess skin and fatty tissue of the eyelids. Eyelid Surgery removes the excess tissues of the eyelid but let’s look at how this excess tissue develops. It turns out that the fatty tissue that creates excess bulges of the eyelids that is removed with a Blepharoplasty is somewhat unique in origin. The eye ball sits within a hard bony eye socket. To cushion the eye a fatty tissue layers surrounds the eye and the eye muscles. This fatty tissue does not increase with weight loss or weight gain. The fat that is removed during a Blepharoplasty represents fatty tissue that is held in place by a tough connective tissue layer within the eyelid. With aging and gravity, this connective tissue layer weakens allowing the fatty tissue around the eye ball to bulge outward. That’s the bad news. The good news is that because this fatty tissue will not accumulate with weight gain, once it is removed with Eyelid Surgery it typically won’t reappear for years. The Blepharoplasty, if performed properly, will remove the appropriate amount of excess skin, eyelid muscle and fatty tissue. With aging, some 10-20 years or more, some fatty tissue may again fall downward creating bulges in the eyelid. Because Eyelid Surgery may be repeated to selectively remove these excesses however, the procedure may not ever need to be done again. But what does a youthful eyelid look like? Let’s take a look and see. Here’s a figure from Dr. Francis Palmer’s upcoming book on Beauty, Plastic Surgery and the “Palmer Beauty Principles” ™. The upper eyelid has a defined crease that has a gentle curve following the curve of the upper eyelid. The eyelashes are turned upward and there is no excess skin or fatty tissue bulges of the eyelids. Blepharoplasty should ideally restore a female’s eyelids to this point. Obviously, Eyelid Surgery can be used to remove a small amount or an extreme amount of aging from the eyelids but regardless, this should be the endpoint no matter what needs to be accomplished.
Males and Females differ dramatically when it comes to Blepharoplasty indications and ideal endpoints of the Eyelid Surgery Procedure. Why is this? Blepharoplasty differs in what it is trying to accomplish for men and women because of two reasons.
First: Females and males have very different ideally shaped eyebrows. Female eyebrows ideally are shaped like the figure above. Club shaped initially, the eyebrow arches to a point measured by an imaginary vertical line drawn down from the outer Iris (colored portion of the eye). The eyebrow then begins to gently taper until its termination as measured by a tangential line drawn from the corner of the nostril through the outer canthus or corner of the eye. At its outer portion, the eyebrow should be approximately 1 fingers-width above the eye socket. Men’s eyebrows, on the other hand, are flat across the forehead without tapering or arching of the eyebrows. Why should this matter in a Eyelid Surgery Procedure? It affects the Blepharoplasty because the Plastic and Cosmetic Surgeon must take into account the amount of excess skin of the upper eyelid. If the female eyebrow is droopy the amount of perceived excess upper eyelid skin will falsely be seen as increased. That’s why it’s critical for the Plastic and Cosmetic Surgeon to elevate the female eyebrow into the ideal position, described and illustrated above, during the Blepharoplasty consultation. This maneuver allows an accurate assessment of the amount of excess skin of the upper eyelid to be removed during the Eyelid Surgery Procedure. For men, this is far less important until the eyebrows are so low as to literally obstruct the vision, which typically occurs ony with advanced age. What happens if this maneuver is ignored during the Blepharoplasty consultation? We will discuss how the Eyelid Surgery is performed later in this section but I want to explain why the eyebrows play such an important role in the planning stages of a successful Blepharoplasty Procedure. As the eyebrows fall, they add to the amount of excess skin visible on the upper eyelids. If this amount of skin is removed during Eyelid Surgery the eyebrows will be pulled down further. During the Eyelid Surgery Procedure, an incision is placed within the upper eyelid crease. Excess skin above the crease is then removed and the edges of the incision are brought together to close the surgical wound. The edge of skin within the eyelid crease is attached to the cartilage that makes up the upper eyelid plate and does not move. However, the other skin edge will move towards the crease allowing the Blepharoplasty area to be closed. If eyebrow skin was mistakenly removed during the Eyelid Surgery Procedure, because it wasn’t recognized as being caused by a droopy, as the upper skin edge is brought to the crease skin edge the eyebrow will be pulled into a lower position. Once this skin is mistakenly removed during the Blepharoplasty it may be impossible to correct. Even after the Eyelid Surgery Procedure, if it is recognized that the eyebrows are now lower, they may not be able to be raised without preventing the eyes from closing. During the Blepharoplasty planning stage it is paramount, in women, to accurately assess the position of the eyebrows and determine if the eyebrows are contributing, or not, to the amount of visible excess upper eyelid skin. This is done during the Eyelid Surgery consultation by the Plastic and Cosmetic Surgeon standing behind the seated patient and manually elevating each eyebrow to the ideal position that Dr. Francis Palmer has outlined above. As the eyebrow is raised to it’s ideal aesthetic position the amount of excess upper eyelid skin will either remain the same or be decreased by some amount. If during this maneuver the upper eyelid skin does not change, the eyebrows are in the ideal aesthetic position and the entire amount of excess upper eyelid skin may be removed with the Eyelid Surgery. If the amount of excess upper eyelid skin is completely gone with this maneuver, this indicates that the eyebrows are low and the only source of the perceived upper eyelid fullness...this indicates that the Blepharoplasty is not the appropriate procedure but rather some form of Brow Lift Procedure should be performed instead. If there is some reduction in the amount of upper eyelid skin with this maneuver this indicates that the eyebrows are lower than the aesthetic ideal but that there is still some excess upper eyelid skin that can be treated with a Eyelid Surgery. It does further indicate however, that only the amount of upper eyelid skin may be removed during the Blepharoplasty Procedure without causing the eyebrows to drop further in position. This is accomplished during the Eyelid Surgery by performing the same maneuver during the skin marking phase of the Blepharoplasty Procedure. This accurate marking of just the excess skin that truly belongs to the upper eyelid is one of the keys to a successful Eyelid Surgery outcome in Dr. Francis Palmer’s opinion.
Second: Men and women differ in the amount of upper eyelid that should be visible after the Blepharoplasty has been performed. Women ideally have a well defined crease in the upper eyelids without any excess skin of the upper eyelid. Men on the other hand tend to look best with a bit more skin and less visible upper eyelid. This means that during Eyelid Surgery that men will tend to have less upper eyelid skin removed than women.
During the Blepharoplasty consultation, the woman in this Image would be evaluated in the following manner. Using Dr. Francis Palmer’s suggested maneuver the eyebrows are noted to be in the proper aesthetic position. This means that the amount of excess skin visible in the upper eyelids (indicated by arrow) could be completely removed with Eyelid Surgery. This would open the eyes further and give a softer, more feminine appearance to the eyes. There is no evidence of excess fatty tissue of the upper or lower eyelids in fact there is a telltale sign (if you know what to look for) that warns against taking any upper eyelid fat. If fat is removed during Blepharoplasty the eyes will look too hollow. This horizontal crease is an important hint and warning. (right arrow)
Eyelid Surgery can also be done as a revision or secondary procedure to remove skin and fatty tissue. This may be a result of skin and fat that was missed during the original Blepharoplasty Procedure or tissues that have fallen with additional aging. The areas where residual fat are common are the inside (by the nose) portion of the upper eyelid and the outer (by the ear) portion of the lower eyelid. Revision Lower Blepharoplasty may create lower eyelid drooping. Certain Eyelid Surgery techniques have been known to cause this more than other Blepharoplasty techniques. The various Eyelid Surgery techniques will be discussed in detail below.
Blepharoplasty/Eyelid Surgery Techniques:
There are several ways to perform Blepharoplasty. The Eyelid Surgery technique varies from upper to lower eyelid. Let’s look at Upper Eyelid Blepharoplasty Techniques first:
Image from Clemente’s Anatomy shows the muscles of the eyelids. The arrows point to the circular eyelid muscle that is beneath the skin of the eyelids.
The fatty tissues, of the eyelids, lies below the eyelid muscles behind a dense fibrous tissue barrier called the septum. The septum weakens, with age, and the fatty tissue begins to create bulges in the upper and lower eyelids. There are two fatty tissue pockets in the upper eyelids. One is by the nose (medial pocket) and the other is in the mid portion (central pocket) of the upper eyelid. There is no fatty tissue pocket in the lateral portion (by the ear) of the upper eyelid as this is where the tearing gland is located. If an inexperienced surgeon looks for fatty tissue in this region, during the Eyelid Surgery Procedure, the Tear (Lacrimal) gland may be damaged and dry eye syndrome may develop leading to corneal irritation and or abrasions and ulcerations. Conversely, The lower eyelid has three fatty tissue pockets and are called the medial, central and lateral fat pockets.
This Image from Dr. Francis Palmer’s scientific paper on Transconjunctival Blepharoplasty: Archives Otolaryngology Head/Neck Surgery Vol. 119, September 1993. The fat pockets of the upper and lower eyelids are seen within the bony eye socket. The fatty tissue is there to cushion the eyeball within this bony orbit. The fatty lies below the circular eyelid muscles seen in the Image above. During the Blepharoplasty Procedure, this fatty tissue will be removed to provide a more youthful contour to the upper and lower eyelids.
Another Image from Dr. Francis Palmer’s paper that shows the fatty tissue of the lower eyelid and the relationship of the fat with the eyeball (arrow). During the lower eyelid Blepharoplasty, an incision will be made into the orbital septum to gain access to this fatty tissue. The excess fatty tissue will be removed in order to give the lower eyelid a more youthful contour. The bulging tissue seen in an aging lower eyelid represents this fatty tissue (lower arrow). Care must be taken not to remove too much of this fatty tissue or the lower eyelids will appear hollow.
In the Image (left) from Dr. Francis Palmer’s paper, the lower eyelid is being retracted away from the eyeball in order to gain access to the inside of the lower eyelid. An incision is being placed on the inside of the lower eyelid for access to the fatty tissue. Once the fatty tissue is identified, it is secured with a small curved clamp and cauterized with a surgical cautery device. Fat has numerous blood vessels running through it that need to be cauterized during the Blepharoplasty Surgery. The incision can be made with a Laser, scalpel or a needle tip cautery. In Dr. Francis Palmer’s opinion, the needle tip cautery offers the thinnest incision line while offering cautery as the incision is made. Dr. Francis Palmer uses a conjunctival flap technique during his Transconjunctival Lower lid Blepharoplasty that allows better visualization of the surgical area while providing protection to the eye.
The Image (right) from Dr. Francis Palmer’s Scientific Paper on Eyelid Surgery Procedures depicts the eye and the eyelid contents from a side cut. Arrows show the fatty pockets that lie deep to the eyelid skin and muscle layers. During the Blepharoplasty Procedure the excess fatty tissue is removed from either the inside (Transconjunctival Blepharoplasty Technique) or through the skin from the outside (Transcutaneous Blepharoplasty Technique) of the eyelids. This view also makes it easy to see how removing eyelid skin and muscle during the Eyelid Surgery Procedure can allow the eyelids to have a less shallow, more aesthetic appearance.
Transconjunctival Lower Eyelid Blepharoplasty is performed through an incision on the inside of the lower eyelid. The fatty layers are identified in the medial, central and lateral fat pockets. Once the orbital septum is dissected open, the excess fat can be teased out of each pocket in turn. The fat is clamped, cut and meticulously cauterized with a surgical cautery device. Cases of electrical current being conducted along the optic nerve have been reported. Blindness has resulted in some of these cases and it is generally suggested that a bipolar cautery device be used during this stage of the Blepharoplasty as the bipolar cautery ‘s current is confined to a much smaller area thereby decreasing the possibility of the current traveling to the optic nerve. Once all three pockets of fat have been identified and the excess fat removed, it’s a good idea to look at the lateral fat pocket a second time as this is the most common fat pocket where residual fat is overlooked. The medial fat pocket is the most common area where residual fat occurs after an upper eyelid Blepharoplasty. How do you know when the appropriate amount of fat has been removed from each fat pocket? Gentle pressure on the eyeball causes the fat to move upwards towards the incision and the lower eyelid bony rim. When the fat is just below the bony rim with this maneuver, the appropriate amount of fat has been removed. If more fat is taken, hollows in the eyelids may occur. If some fat is left in any fat pocket, the eyelid(s) may have bulges after the Eyelid Surgery Procedure has been performed. No stitches are used to close the incision on the inside of the eyelid as the stitches would irritate the inside of the eye and the incision closes and heals rapidly. Antibiotic drops are prescribed for three days. Steri strips (reinforced tape may be applied to the lower eyelid skin for 3-5 days) following the Blepharoplasty/Eyelid Procedure.
The Transconjunctival Lower Eyelid Blepharoplasty technique does not remove excess skin from the lower eyelid per se as the incision is performed on the inside of the lower eyelid. If there is excess skin of the lower eyelid, it’s a good idea to perform a snap-test on the lower eyelid before deciding to remove the excess skin. The snap-test is performed before Eyelid Surgery during the preoperative consultation and evaluation. With the patient seated and looking forward, the Plastic and Cosmetic Surgeon gently grasps the lower eyelid skin with two fingers and pulls the eyelid away from the eyeball. The eyelid is then released and the Plastic and Cosmetic Surgeon listens carefully to hear if the lower eyelid snaps back on the eyeball. This creates no discomfort but tells the Plastic and Cosmetic Surgeon some valuable information about the strength and tone (or laxity) of the lower eyelids. If a snap is heard, there is adequate tone of the lower eyelids and the appropriate amount of skin could be removed without creating potential complications after the Blepharoplasty Procedure. If the lower eyelid drifts slowly back to the eyeball or worse, stays in the retracted position...this indicates danger of potential complications if skin is removed during the lower Eyelid Surgery Procedure. Lower eyelid malposition (eyelid is pulled into or away from the eyeball) with eyelid retraction and ectropion the extreme forms, can be a serious complication after Blepharoplasty with dry eye developing that could progress to corneal ulceration. We will talk more about that in the Blepharoplasty complication section. For now, it’s important to remember the snap-test and be sure that your Plastic and Cosmetic Surgeon perform this test before your Eyelid Surgery Procedure.
Transcutaneous Lower Eyelid Blepharoplasty Technique:
Transcutaneous Lower Blepharoplasties are an older technique where the incision is placed in the skin of the lower eyelids just below the eyelash margin. If you look at the Pictures above of eyelids, you’ll see that the excess fatty deposits, of the lower eyelids, lie below the lower eyelid muscle. The incision must therefore go through this lower eyelid muscle and then into the orbital septum in order to gain access to the fatty tissue to be removed. This has the potential to create complications that I will discuss at the conclusion of this section. Once the fatty tissue is identified, it is removed in a similar manner as described with the Transconjunctival Blepharoplasty of the lower eyelids. Once the fat has been removed, the excess lower eyelid skin (and muscle) is trimmed and the incision is closed. The potential complication with this type of Eyelid Surgery Procedure arises from the fact that the eyelid muscle was cut and trimmed during the Blepharoplasty. Dissection under the eyelid muscle may cause scar contraction in the vertical plane. This may pull the lower eyelid down (and sometimes away) from the eyeball which is defined as lower eyelid malposition. This lower eyelid malposition (ectropion is the most severe form of malposition) may cause dry eye and lead to corneal irritation and ulceration. Some Plastic and Cosmetic Surgeons open the patient’s mouth before trimming the excess skin and muscle as this provides a margin of error against removing too much tissue. Opening the mouth pulls the lower eyelids down and decreases the amount of visualized excess skin/muscle during this stage of the Blepharoplasty Procedure. Complications of dry eye and lower eyelid malposition may still occur, even with this maneuver. Dr. Francis Palmer published a research paper in 1993 that highlighted this potential complication. Dr. Palmer’s paper concluded that the Transcutaneous Lower Eyelid Surgery Procedure had a 50% incidence of lower eyelid malposition ranging from a mild case to the more serious ectropion. In contrast, the Transconjunctival technique of Blepharoplasty had an incidence of 0%. You can read the original paper
“Transconjunctival Blepharoplasty Complications and their Avoidance” Archives of Otolaryngology Head & Neck Surgery Volume 119, September 1993.
Transcutaneous Lower Eyelid Lipolysis techniques:
Because, as we have discussed, residual fatty tissue may remain or show up years after your Eyelid Surgery Procedure, Lipolysis has gained popularity as a way of avoiding a second (revision surgery). In this technique, fat is dissolved without creating a Blepharoplasty incision. Fat dissolving material may be injected into the fatty tissue (mistakenly referred to sometimes as “Mesotherapy”) or an electrical cautery needle is placed through the skin into the fat pocket causing the fat to dissolve. (Mesotherapy is a technique of delivering vitamins, minerals and other injectable solutions into the dermal layers of the skin. Because fat lies deep to all the layers of the skin, this term does not apply and the correct term is “Lipolysis). These techniques have the problem of non-observational fatty tissue removal and as such may be less effective than a Revision Blepharoplasty Procedure. It should be noted that revision Eyelid Surgery caries additional complications over a primary Blepharoplasty Procedure however, an experienced Plastic and Cosmetic Surgeon should be able to modify the Blepharoplasty to limit these from occurring. For example, if lateral residual fat exists in the lower eyelids, a small incision in only that area may be performed during the Revision Eyelid Surgery instead of creating the entire incision. This would obviously carry less risk of post-Blepharoplasty complications.
Finally, I’d like to make something quite clear when it comes to making Eyelid Surgery incisions and methods of removing the fatty tissue. You may see ads and statements that a Laser is used to perform the Blepharoplasty Procedure. Let’s talk about the Blepharoplasty incision first. A scalpel makes an extremely thin incision in the skin. A Laser is a focused beam of light that typically is ~ 1-2
mm’s in diameter...compare this to this tell me which one is smaller. Now for fat removal. Laser melts fat but may create excess heat that could burn the skin. Electrical cautery devices create fat lysis with more control in Dr. Francis Palmer’s opinion. Laser does offer a method of removing lower eyelid wrinkles and tightening the skin but chemical peels like TCA can also be used for this purpose. The take home message from Dr. Francis Palmer is that a particular surgeon and his aesthetic judgment and experience is what matters for a favorable Eyelid Surgery outcome, not technological devices.
Blepharoplasty/Eyelid Surgery Recovery:
The Blepharoplasty Procedure is performed as an outpatient surgery. Dr. Francis Palmer a world-renowned Beverly Hills Plastic and Cosmetic Surgeon, Director of Facial Plastic Surgery for the Dept. of Head/Neck Surgery for The University of Southern California School of Medicine and Medical Director for the Beverly Hills International Center for Aesthetic Surgery performs Eyelid Surgery at his fully accredited outpatient surgical facility in Beverly Hills, California. People from all over Los Angles, Orange County/Newport Beach, San Diego, San Francisco, all over California, Southern California and all over the world fly to Los Angeles for Dr. Francis Palmer’s Blepharoplasty Procedure. Eyelid Surgery can be performed in about 1 hour. Bruising and swelling are quite minimal and routine activity may be resumed as early as 4 days after the procedure, although strenuous activity should be avoided for about 2 weeks. Dr. Francis Palmer clears his Blepharoplasty patients for air travel 1 week following their Eyelid Surgery Procedure. Dr. Francis Palmer’s Beverly Hills office is conveniently located in Los Angeles and easily accessible from all major Los Angeles Freeways. We are located 5 minutes from Rodeo Drive in Beverly Hills, 10 minutes from Brentwood, 10 minutes from Pacific Palisades, 35 minutes from Los Angeles Airport and a short flight from San Diego, San Francisco and all California Cities. Our out of town Blepharoplasty patients may send us photos of their eyes for Dr. Francis Palmer’s evaluation. As for all of our Plastic and Cosmetic Surgery Procedures hyperlink to procedures page, we offer e-mail photo evaluations and telephone or e-mail consultations.
Blepharoplasty/Eyelid Surgery FAQ’s:
Eyelid Surgery performed by Beverly Hills Plastic and Cosmetic Surgeon, Francis R. Palmer III, M.D. can restore a youthful appearance to your eyes. Your Eyes...the window to the soul...are the first to show signs of aging. Why don’t look as young as you feel?
Listen to what the international media has to say about Dr. Francis Palmer, recently voted "One of the World’s Best” Plastic and Cosmetic Surgeons.
You deserve the best...
Contact us Today You’ll be glad that you did!
Dr. Francis Palmer performs Blepharoplasty Procedures at his Beverly Hills Surgery Center called “The Beverly Hills International Center for Aesthetic Surgery” located in Southern California. Centrally located in the Los Angeles area, Dr. Palmer has performed Eyelid Surgery Procedures for over 16 years. His clients come for Eyelid Surgery Procedures from all over the world. Out of town Blepharoplasty Procedure patients are asked to remain in the Los Angeles area for 7 days following their Eyelid Surgery Procedures, after which they are cleared for air travel back to California and beyond. Many of our Blepharoplasty Procedure patients are from the Los Angeles, Southern California and California area. Our Beverly Hills office is freeway close to all major Southern California and California Cities. We are located about 10 minutes from downtown Los Angeles, about 20 minutes from Los Angeles International Airport, about 10 minutes from Santa Monica/Brentwood and Pacific Palisades, about 30 minutes from Orange County/Newport Beach, 1 hour by air from San Francisco and 45 minutes by air from San Diego. If you live in Los Angeles, Beverly Hills or in a nearby city in Southern California or California like Newport Beach, San Francisco or San Diego, you are close enough to come to our Beverly Hills office for a personal consultation with Dr. Francis Palmer about your Eyelid Surgery Procedure. Dr. Francis Palmer is the Director of Facial Plastic Surgery for a major medical school in Los Angeles and has instructed resident surgeons in Blepharoplasty Procedures for over 16 years. Whether you live right here in Beverly Hills, Los Angeles or elsewhere in Southern California, California, across the U.S. or you live abroad, Dr. Francis Palmer has the experience and expertise for your Eyelid Surgery Procedure. We look forward to seeing you in our Beverly Hills office.
|Frequent Q/A ·
Choosing Your Plastic Surgeon ·
Beauty Quiz ·
Plastic Surgery Blog ·
Patient Financing ·
Facelift · Eyelid Surgery · Rhinoplasty · Liposuction · Tummy Tuck · Breast Augmentation · Botox · Lip Augmentation · Francis R Palmer III, MD, FACS
Phone: 310-652-9583 - Fax: 310-652-0009
8500 Wilshire Blvd #900 Beverly Hills, CA 90211