Cosmetic surgery is rapidly evolving into a very specialized medical discipline. There are numerous sub-specialists within the field with varied backgrounds in training, ranging from specialists in general, facial, nasal, ophthalmic, and dermatologic or body plastic surgery. This trend within cosmetic surgery reflects the general trend in medicine and surgery of the super-specialist. It stands to reason that nose jobs (rhinoplasty) should be performed by those trained in nasal surgery, or that breast augmentation should be performed by plastic surgeons with specific training in this area. Similarly, cosmetic eyelid surgery should be performed by ophthalmic plastic surgeons (board certified ophthalmologist with separate subspecialty training in cosmetic surgery of the forehead, eyebrows, eyelids and middle face (cheeks).
The eyes may be the most distinguishing feature of a person’s face. The goal of good cosmetic surgery, first and foremost, is to maintain health and function; and then to provide an improved and natural appearing outcome. Too many times cosmetic eyelid surgery results in an “operated look” or with visual problems.
The best way to reduce the risk of these occurrences is to have surgery performed by the best-trained and most experienced surgeon. In this area it is clearly and ophthalmic plastic surgeon.
I am often asked about the use of LATISSE for eyelash growth.
LATISSE solution is a prescription treatment used to grow eyelashes, making them longer, thicker and darker.
If you are using, or have used, prescription products for any eye pressure problems, only use LATISSE under close doctor supervision.
Using LATISSE may cause increased brown pigmentation of the colored part of the eye (iris) which can be permanent. So if you have light colored eyes be careful with its use.
Eyelid skin darkening may also occur which may be reversible. Only apply LATISSE at the base of the upper eyelashes. The manufacturer does not recommend the medication for the lower eyelid lashes. Hair growth may occur in other skin areas that LATISSE solution frequently touches. If you develop or experience any eye problems or have eye surgery, consult your doctor immediately about continued use of LATISSE. The most common side effects after using LATISSE solution are itchy eyes and/or eye redness. If discontinued, lashes will gradually return to their previous appearance.
Blepharoplasty (cosmetic eyelid surgery) can be performed on the upper lids, lower lids, or both. The eyelid skin and muscle are always either excised (removed) or left in place if they are not in excess. The last component of the eyelid which must be addressed is the fat compartments. The upper lid has two fat pads (the middle and central). There is no outer fat pad but rather a tear gland (lacimal gland) in its place. The tear gland must not be confused for fat, as if it is excised it can lead to permanent dry eye and other complications.
The lower lid has three fat pads (middle, central and outer). This is an important distinction between the upper and lower eyelids which the surgeon must be aware of.
Traditionally we have excised fat from eyelids to make them look less puffy (prominent). What we have seen is that this can, over time, give a hollow or skeletonized appearance to the lids. As we have come to understand this very important concept, our evolution of eyelid surgery has changed from primarily one which removes fat, to one which preserves it when appropriate. The preservation process is called fat repositioning, whereby eyelid fat is not removed, but rather shifted into placed where it is deficient to fill in hollows (just as Restylane or Juvederm does). This is a great asset to surgery as it allows us to use our own fat to fill depressions and may avoid the need for the use of filler (such as Restylane and Juvederm).
Fat repositioning is typically performed on the lower lids, and has recently been shown to also be useful in upper blepharoplasty. A peer reviewed publication on upper lid fat repositioning written by Dr. Guy Massry (Beverly Hills Ophthalmic Plastic Surgery) has recently been accepted for publication in the Journal Ophthalmic Plastic and Reconstructive Surgery (it is now in press). The manuscript is titled "Nasal Fat Preservation in Upper Eyelid Blepharoplasty." The research has also been presented at national metings.
If cosmetic upper lid surgery (upper blepharoplasty) is performed alone, many patients desire surgery under local anesthesia only. That means only numbing the lid with small injections. This may scare some, but in reality is a great way to go as no drugs are given systemically (to the whole body) by IV injection. This makes immediate recovery much easier. The procedure can be very comfortable if performed by a surgeon experienced with eyelid surgery (oculoplastic surgeon).
What I do is apply a numbing cream to the eyelids for 20 minutes before proceeding with surgery. In the operating room I then apply ice to the area of injection before actually injecting. With this preparation, when I place the needle through the skin, rarely is anything ever felt. This technique typically makes injection of local anesthetic pain free.
I start by injecting anesthetic to the outer part of the lid. This elevates the skin off the lid (from the underlying muscle) and makes the injected skin look white (it blanches). You can see this in the photo below on the left. I then use a gauze to massage the anesthetic solution towards the inner part of the lid. This is called hydrodissection and allows the anesthetic solution to progress to the area desired without re-injecting. This is demonstrated on the photo below on the right. I call this the "anesthetic crawl." It is a great technique of numbing without pain.
Now the lid is numbed and ready for surgery which will be pain free!!!!
Upper eyelid blepharoplasty is a procedure whereby skin, muscle and fat are removed from the upper lid to imprve appearance and/or field of vision. Tissue removal is performed by direct excision. After the lid is appropriately de-bulked of tissue excess, the wound is closed with sutures. Marking of the amount of skin to be excised is critical. This is one of the major factors in determining final eyelid appearance and function (ie. the ability to close the eye). As I have stated before, having an eyelid specialist (ophthalmic plastic surgeon) perform this surgery is the surest way to ensure the best outcome and reduce the incidence of ocular complications.
The eyelid crease (lower marking of skin to be excised) is drawn first. The crease is drawn slightly lower in men than woman, and lower yet in Asian patients. The peak of the crease is in the central portion of the eyelid and it tapers towards the inner and outer parts of the lid. To determine the upper part of the of the marking, the excess skin is pinched together with a forceps with the eyes closed (with lower part of forceps engaging the previously drawn crease), and the upper part of the excess is marked at various points. Thse points are then connected. This is called the eyelid pinch technique. The eyelid crease and upper marking are made continuous with an upward sloping line at both ends. In the end an ellipse of skin to be excised is created.
Below is an example of (left) the eyelid pinch technique to determined the amount of skin to be excised, and (right) the final marking of the skin excision.
Beverly Hills, CA - Dr. Guy Massy, M.D. will be a guest lecturer at the 7th Annual Las Vegas Cosmetic Surgery Symposium (An International Multi-Specialty Symposium). The symposium is taking place in Las Vegas, NV, June 22-26, 2011 at the Bellagio Hotel.
Dr. Massry’s subjects will include:
- Surgical Pearls for Successful Endoscopic Browlifting
- Aesthetic Management of the Lateral Canthus
- Innovative Use for the “Nasal Fat Pad” of the Upper Lid
The Multi-Specialty Foundations Vegas Cosmetic Symposium is unique is unique in that it provides truly multi-disciplinary cross talk, sharing and cooperation. It is the only educational venue that features the best and brightest in the fields of dermatology, facial plastic surgery, oculoplastic surgery, plastic surgery, practice management and business development. More information is available at www.vegascosmeticsurgery2011.com.
In addition to the Las Vegas speaking engagement Dr. Massry will be conducting a course at the Annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery in San Francisco, California Sept 8-11, 2011
His course is titled: Comprehensive lower lid rejuvenation
Presentation is: Saturday, September 10th , 2011 at 5:30pm - 6:20pm
The meeting syllabus will be available at www.aafprs.org
The American Academy of Facial Plastic and Reconstructive Surgery is the world's largest specialty association for facial plastic surgery. It represents more than 2,700 facial plastic and reconstructive surgeons throughout the world.
Blepharoplasty, or cometic eyelid surgery, involves the removal of excess skin and muscle from the upper and lower lids, and the removal or repositioning of excess fat. These procedures redrape and recontour the eyelids to improve their appearance.
Often times additional procedures are needed to attain the best final outcome. One such procedure is ptosis repair. Ptosis is the condition when the upper lid muscle becomes "lazy" and allows the lid margin (where the lashes are) to fall so that the lid impinges on the pupil.
Ptosis repair involves tightening the internal (lifting) muscle of the eyelid. It is a highly specialized procedure performed primarily by oculoplastic (ophthalmic plastic) surgeons. It is imperative to assure that ptosis is diagnosed and addressed with any blepharoplasty procedure when appropriate.
Please open the link below to read a published article by Dr. Massry on ptosis repair for the cosmetic surgeon
Blepharoplasty is an intricate surgical procedure which must be custom tailored to each patient. The patients motivations, desires, presenting findings, and expectations must be thoroughly discussed and understood before proceeding with surgery. This form of comprehensive evaluation and intervention is critical to attaining good surgical results.
Only an experienced expert in eyelid surgery should perform this kind of surgery
Dr. Guy Massry (Beverly Hills Ophthalmic Plastic Surgery) has such experience and specialized training. He would be happy to see you in consultation. He can be reached through his web site drmassry.com or by phone (310) 453-8474.
Open link below to read a recently published manuscript by Dr. Massry's on his comprehensive approach to lower lid blepharoplasty
Sutures are a critical part of all surgical procedures and it is important for the surgeon to be familiar with suture makeup and options.
Suture thread is made from a variety of materials. Early on sutures were made from biological materials, such as catgut and silk. Most modern sutures are synthetic, including the absorbable (naturally biodegradable in the body) materials such as polyglycolic acid, polylactic acid, and polydioxanone as well as the non-absorbable material such as nylon and polypropylene. Newer still is the idea of coating sutures with antimicrobial substances to reduce the chances of wound infection. Sutures come in very specific sizes. They are numbered sequentially with the higher number being the thinner suture (ex. 4-0 Nylon is thicker than 7-0 Nylon), Sutures must be strong enough to hold tissue securely but flexible enough to be knotted. They must be hypoallergenic and avoid the "wick effect" that would allow fluids and thus infection to penetrate the body along the suture tract.
In surgery attention must be given to every detail of the procedure. In plastic surgery the wound closure is very important to final appearance. The take home message – “Know your sutures well.”
In modern medicine the closure of wounds is typically performed with a surgical suture (thread) connected to a surgical needle. There are many different kinds of suture and as many different needles. Surgical needles have been made of many materials including bone (early on) and later from metals such as silver and copper, and wire material comprised of bronze or aluminum
Needles can be traumatic which means they have holes or eyes and are supplied to the hospital separate from their suture thread. The suture must be threaded on site, as is done when sewing at home. Needles can also be atraumatic with the suture pre-attached to an eyeless needle. The suture manufacture swages the suture thread to the eyeless atraumatic needle at the factory. There are several advantages to having the needle pre-mounted on the suture. The doctor or the nurse does not have to spend time threading the suture on the needle. More importantly, the suture end of a swaged needle is smaller than the needle body and causes minimal trauma when passing through tissue – hence the name atraumatic needles. In modern medicine we primarily use ataumatic needles when performing surgery.
There are several shapes of surgical needles. These include straight, 1/4 circle, 3/8 circle, 1/2 circle, 5/8 circle, compound curve, half curved (also known as ski), and half curved at both ends of a straight segment (also known as canoe). Needles may also be classified by their point geometry; examples include: taper (needle body is round and tapers smoothly to a point), cutting (needle body is triangular and has a sharpened cutting edge on the inside), reverse cutting (cutting edge on the outside), trocar point or tapercut (needle body is round and tapered, but ends in a small triangular cutting point), blunt points for sewing friable tissues, side cutting or spatula points (flat on top and bottom with a cutting edge along the front to one side) for eye surgery
Finally, atraumatic needles may be permanently swaged to the suture or may be designed to come off the suture with a sharp straight tug. These "pop-offs" are commonly used for interrupted sutures (individual bites rather than a continuous suture), where each suture is only passed once and then tied.
We can’t perform good surgery without the right surgical needles. Understanding these needles, and how the various types work is critical to getting good results.