Hello and welcome, Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk and welcome to another installment of our podcast series. This one is on blepharoplasty. So what is a blepharoplasty? It’s a scientific name for the surgical manipulation of the upper and/or the lower lid to improve the contour and appearance and shape of the eye. It may address some functional issues such as lower lid laxity or dry eyes, but principally it’s the cosmetic enhancement of the upper and lower lid through surgical treatment.
Who is a candidate for a blepharoplasty? Well, individuals that find they have aging changes of the upper and/or the lower lid and the two lids, although they’re the same age and they’re like brother and sister, they’re twins. The upper lids tend to descend and encroach upon the eye with fleshiness and a bag and a droopy brow and it makes you look tired. It makes you look beleaguered and so brow position and upper lid skin and extra fat is usually a good indication for an upper lid blepharoplasty with, without a mini tail of the brow lift. An upper lid blepharoplasty involves the removal of an ellipse of skin in the upper eyelid together with excess muscle and often unwanted fat pads to create a more open upper lid appearance, not Too much. You don’t want that deer in the headlight, too much skin removed, but you don’t want the hoodedness.
You want to have a nice even line called the supratarsal fold or the line above the eye, the crease if you will, and not much flesh between the crease and the eyelashes so it allows the average female patient to apply upper lid eye mascara and makeup without smudging. So the upper eyelid is usually going to help with hooding and beleaguered look, that heavy look. The lower lid is often a combination of wrinkles and crepey skin, lower lid fat pads, and sometimes some loss volume and hollowing. So the lower lid is usually going to be a removal of skin or laser resurfacing of the wrinkles with fractional lasers to have the skin tight and smooth.
We remove unwanted fat pads that bulge out, the lower lid fat pads, and they can be either repositioned into the hollowness under the eyes, acting as if their own permanent soft tissue filler or the fat pads can be removed. Finally, if there is some loss of volume in the tear trough, fat grafting or soft tissue fillers can be used to volumize the inner aspect of the eye and the incisions for the lower lid are often made on the inside of the eye, the pink called conjuntivum and little skin pinches are performed with a little scar under the eyelashes for the lower lids. So generally the incisions and the scars are very discreet. They heal extremely well, and the overall gestalt, if you will, or the rejuvenative goal and outcome from blepharoplasty is to create a fresh look, an awake look, an alert look, an engaged look. So often, what we project around the eyes is one of being tired. A blepharoplasty well performed will make you look a little youthful, but mainly it makes you look fresh and rested.
So when considering a blepharoplasty, who is a good candidate? Individuals are generally in their 40s or 50s. They’ve had some loss of support and the upper lids starts to fold over and encroach upon their eyelid. They may have fat pads that bulge. They may have crows feet on the side of the eye. They may have bags and loose skin of the under eye. So they’ve got the aging changes that would benefit from excision or tightening.
What are the pros and cons of a blepharoplasty? Well, the advantages of a blepharoplasty, you’d get a very significant rejuvenation in about a one to one and a half hour procedure that lasts the rest of your life and rarely recur. So if you do a good blepharoplasty procedure in your 40s and 50s, it’s not the type of thing you have to repeat every few years. You’re not going to regrow skin or regrow fat. So it’s a longterm improvement, it’s relatively safe surgery. It can performed under local anesthetic and is relatively simple in the grand scheme of cosmetic surgeries. It’s one of the more common procedures. If done well, it’s not very detectable and you’ll just look rested and fresh. No one’s going to say, “Oh, who did your eyelid job?” It’s also not very painful. The recovery after blepharoplasty is very tolerable, generally about a week of downtime. So those are the advantages.
The disadvantages over some of the nonsurgical treatments like Botox, soft tissue fillers, energy based devices. It does require some cutting. It does require a scalpel. It does require some stitches. You want to pick a very good and experienced blepharoplasty surgeon, that could either be a certified plastic surgeon, certified facial plastic surgeon, or oculoplastic surgeon, and whether they come from one of those three specialties, you want to make sure that they do a lot of blepharoplasties. In my practice, I do close to a couple of hundred blepharoplasties every year for the last 24 years. So I’ve done thousands of blepharoplasties and that leads to the kind of experience that you often want to search out when looking for a blepharoplasty physician.
You don’t want to just rejuvenate the eyes and leave the rest of the face looking old and tired. So if you’ve got aging changes in your lower part of your face and aging entire change around your eyes, you may have to do a little bit of work on the bottom of the face so that you don’t lose … You don’t get a mismatch look of a youthful upper look and a more aged, jowly looks. So keep the facial aging elements in harmony with each other. The disadvantage, it does require the surgery that’s a little more costly than noninvasive treatments, but it’s usually very good bang for your buck because that improvement is spread over then the rest of your life without the need for any maintenance.
Can you protect your investment after blepharoplasty? Yes, there are some energy based treatments, soft tissue fillers and Botox that may protect and enhance the result. But even if you never did any of that, the results of your excisions, of your blepharoplasty should last a lifetime.
So who is not a good candidate? Who is not able to undergo blepharoplasty, should be cautious? What are the contraindications? Well, first of all, individuals that are not medically well. If you’ve got uncontrolled diabetes, if you’ve got really bad heart disease, if you’ve got an autoimmune disease like Lupus or rheumatoid arthritis, you’re probably not a good candidate for a cosmetic procedure that’s around the delicate tissues of your eye. If you have ocular pathology, you have very, very bad dry eye syndrome, or you have really lax lids and you’ve got white showing or an ectropion or turning out of your eyelid. If you’ve got a corneal diseases or retinal diseases or you’ve got some loss of vision in one eye or the other, you’re not a good candidate from an ocular perspective.
One of the main contraindications is a perfectly fit patient who has all the right findings for a blepharoplasty, but their expectations are unrealistic. They hope to look 40 years younger or they have unrealistic expectations about having no lines and no wrinkles, so they hope they’ll do a blepharoplasty and get a new job or get a promotion or get a pay raise or save a failing relationship or get off antidepressants. These are not good expectations. They’re are unrealistic. We can’t change your life. We can improve your appearance. You’ll look fresh and rested, then you and your fresh and rested appearance need to make the changes in your life. You can’t associate the lid surgery from improvements in your day to day existence, but you will look fresh and rested.
Unrealistic expectations are those that hope that it will turn back the clock too far. It’s a great modest rejuvenative procedure, ought to make you look fresh and rested, maybe five to 10 years younger, but it’s not going to turn back the clock to your teenage years if you’re in your 60s. So individuals then that don’t have the kind of commitment for the recovery. It does take a good two weeks. You need to commit to that recovery before you can go back into your normal life’s activities. So those are the major contraindications that would really probably prohibit a patient from being a good client for a blepharoplasty surgery.
Blepharoplasty is an excellent solution for droopy eyes. What I mean by droopy eyes are the upper lids are encroaching upon the actual eyelashes and some patients so hooded you actually obliterate, you can’t see the eyelashes themselves. So why is blepharoplasty a good option versus Botox, fillers and energy based devices? Because it’s definitive. If you can actually map out and plan exactly how much extra flesh you need to remove to open up the eye immediately in one treatment, the results can be optimized by careful adjustment and measurement of what the patient wants to achieve and it’s a longterm solution. It doesn’t come back when the Botox wears off, it can last the rest of your life.
So a blepharoplasty is often the ideal solution for droopy hooded lids that are encroaching upon the eyelashes or bulging out in case of lower lids and really detract from looking fresh, rested, and youthful. Blepharoplasty is often your solution. Blepharoplasty is one of the most common plastic surgery procedures that we do. Breast augmentation, liposuction and the blepharoplasty in the top three, followed closely by rhinoplasty. Why? Because whether you’re Caucasian, Southeast Indian, Asian or Middle Eastern, the eyelids tend to grow old in different ways and as you age, everyone wants to look fresh and rested. Not tired.
It’s very annoying when patients come in and they say, “I’m really annoyed because everyday I get asked, ‘Did you get enough sleep last night? You look tired,” and they had the best sleep of their life. That gets a bit annoying over time. So people judge your appearance and your ability to perform tasks by whether you look fresh or rested and when you look tired and don’t feel tired, people may judge you that way. So most patients are great candidates for this type of procedure, no matter where they come from. However, there are specific needs of different ethnicities.
An Asian eyelid, for example, does not typically have a double fold on the upper lid and so some doctors will specialize particularly in Asian Blepharoplasty and creating a more Caucasian look to the eye, that are creating different looks and feels around the ethnicity of the eyelid that is presenting for surgery. Caribbean or African American patients have different needs than Caucasian patients. Middle Eastern and Southeast Indian patients, different needs than Caucasian patients. So it’s not really an ethnic cleansing through blepharoplasty where everybody wants to look like a North European Caucasian. So many doctors will specialize their blepharoplasty practice in specific markets such as the Asian eyelid.
In my practice where I’m in a city of Toronto, we’re very multicultural. We have lots of ethnicities. I perform blepharoplasty to all different types of ethnic backgrounds. The main issue there is to talk about what kind of lid anatomy, a fold or a double fold, how much fat contouring and how narrow they like the apertures to be to avoid removing the traces and signs of ethnicity when a patient doesn’t want to.
What kind of recovery can you anticipate following eyelid surgery, cosmetic eyelid surgery or blepharoplasty? If you do a double lid, just the uppers, but not the lower, so two lids, upper and upper, generally the recovery is about one week. There’s a little bit of bruising around the eye, the scar’s a little thick. It takes time to soften. But you could be in makeup and cosmetic camouflage within eight to 10 days. If you add just the lower lids, let’s say it’s a two-lid bleph with the lowers and it’s through a trends conjunctival inner eye approach with a little skin pinch, again, about a week to 10 days. The moment you add a laser, like a fractional Co2 or fractional radio frequency device, you’re going to have some crusting and weeping and some cleansing to look after until the eyelid is pink and be putting on makeup, that’s usually a two-week recovery.
If you then combine the upper and the lowers in the same session called a quad bleph or four-lid blepharoplasty, that’s often be two to three weeks recovery before you feel confident in the work environment or social environment where people are going to be critical and looking at you closely and you haven’t told anybody. Do yourself a favor and take the full three weeks off.
What is the pain like or discomfort like after blepharoplasty and do you need a general anesthetic to have it performed? In general, most blepharoplasty we do under the local anesthesia. So you don’t need to be under a risky general anesthesia. You can have a twilight sedation. The procedure can last anywhere from one and a half to two hours on average and you can usually go home a couple of hours after your surgery.
Most of the recovery is a mild discomfort, a burning or bruised feeling. On the scale of plastic surgery recoveries, let’s say breast augment, tummy tuck, liposuction, these are more seven, eight out of 10 on discomfort scales. This is more about a two or a three. It’s just that it’s very visible, it’s right in the center of your face, it’s hard to hide, and so you may need to cover up with nice big Elton John sunglasses for about seven to 10 days till the bruising resolves, till the redness resolves, if there happens to be a fractional resurfacing and you can usually be in makeup by about two weeks and back to your social and business engagements by three.
What should you be looking for in your eyelid physician and your blepharoplasty specialists? Well, first of all, it’s quite a specialized area of surgery, so you’ll want to make sure they are board certified, a board certified plastic surgeon, a board certified facial plastic surgeon, a board certified ophthalmologist that’s had some extra training in oculoplastic surgery. These are the three core specialists that manage most of the eyelid surgery in North America. You want to make sure that they’re board certified. Now there are board certified surgeons and plastic surgeons, facial plastic surgeon, oculoplastic surgeons that are better than others.
So what do you look for in your certified specialist? Experience, experience, experience. A good online and offline reputation. Make sure that they’ve got a wealth of before and afters and photo galleries and testimonies that they can share with you. Make sure during the consultation you’re empowered with a sense of confidence that they have a good plan for you that makes sense and ensure that you’ve researched their practice. Make sure that they have no complaints to regulatory boards, no act of lawsuits that might involve blepharoplasty patients, and most importantly, a great reputation, on reputation sites from third party individuals or from people that you know, friends that you know that actually had the blepharoplasty surgery with them. These are the variables I think you should consider and carefully weigh when selecting your blepharoplasty physician.
A blepharoplasty procedure, two-lid, upper two-lid, lower or four-lid quad bleph with the uppers and the lowers are one of the more affordable procedures in plastic surgery when compared to facelifts and tummy tucks and liposuction and a generally you’ll see ranges depending on the size of the city and the experience of the physician and the reputation of the physician. But generally a two-lid blepharoplasty, upper lid blepharoplasty can range from $4,000 to $7,000. A four-lid blepharoplasty can be somewhere from $8,000 to $12,000 depending on the complexity of the treatment.
So you want to source out your physician based upon their skills, their experience and their quality. But price also becomes an issue. Fortunately, many patients can finance their eyelid surgery, their blepharoplasty, and pay for it with affordable monthly payments with low interest rates over 36, 60, 72 months. So the cash flow is easier on your pocket book. By the end of the term of payment, you own your eyelids and they’re going to last the rest of your life and usually quite affordable interest rates. So in Canada, iFinance Canada and Medicard is the most common patient financing entity and generally if you’ve got a pretty good credit rating, they can preapprove you through the doctor’s office in 30 minutes or less.
Thank you for joining me, Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk for our latest podcast installment on blepharoplasty or cosmetic eyelid surgery. If you found that interesting, entertaining, please share it on social media channels and we will see back for our next podcast very soon.