Endoscopic brow lifting is my preferred method of aesthetic brow reshaping. I use the word reshaping because the primary lesson I have learned from 20 years of brow lifting is that the procedure should focus on brow shape and contour more than height. This is the single most important caveat of brow lifting and will allow better results and happier patients.
Over the last 4 years I have primarily utilized a temporal endoscopic plane approach (between the superficial and deep temporalis fascia) with or without the use of the endoscope to reshape the brow contour. My focus has been a temporal lift only. In my experience, in most cases, lifting the medial brow is an error which changes normal eyelid and periorbital, and ultimately, facial proportions. Most who need medial brow elevation also have bunching of glabellar tissue, and I have found benefit most from a central pretrichial approach (with tissue excision) combined with the temporal lift described below.
The procedure proceeds with standard temporal approach sub-superficial temporal fascia access to the canthus. This plane is made continuous with the central subperiosteal space by dividing the conjoint tendon. Dissection continues to the arcus marginalis periosteum at the superior orbital rim. The periosteum is released from the supraorbital neurovascular bundle laterally to the canthus. It is critical to release the lateral orbital thickening. The temporal brow is fixated with 2 sutures (2-0 PDS) from superficial to deep fascia. The lift is superior and nasal to avoid brow splaying and provide the best temporal elevation. No cautery is used for bleeding (vascular tourniquet is created with dilute anesthetic and added pure saline as needed – bleeding is controlled with mechanical pressure from volume of injection). Only staples close the wound and no scalp is excised. These are critical steps to avoid alopecia. Post-op regional supraorbital and lacrimal nerve blocks are given as is local anesthetic infiltration of staple sites – all to control pain. Preoperative Emend (substance P receptor antagonist) is a reliable way to control post-op nausea (I highly recommend this – look it up). Post-op pain control is with your narcotic of choice prn.
I have recently reviewed 162 such cases with the following findings.
94% of patients stated a high satisfaction with the brow lift.
The remaining patients were satisfied except for 2 who desired a revision for more temporal lift. Keep, in mind – all patients knew the procedure performed this way would not address glabellar or forehead rhytids. This was not their expectation. Most received post-op neuromodulation for this purpose. This avoids the numerous issues with selective myotomy/myectomy (another topic of discussion).
More than temporary motor nerve injury (first week or so) occurred in 2 patients (1.2%), which is slightly less than the reported 1.5% previously reported. Both these patients had previous coronal lifts (ie both revisions).
Sensory issues beyond 4 weeks (numbness, tingling, itching, etc) occurred in 3.8% of patients – far less than the previously reported 7%-8%. To achieve this, it is critical to stay subperiosteal when making the temporal sub-superficial temporal fascia plane continuous with the central subperiosteal plane (when dividing conjoint tendon). This protects the distal segment of the deep (lateral) branch of the supraorbital nerve. Also as the periosteal release is lateral to the supraorbital nerve egress, the proximal superficial (medial) branch of the nerve is less prone to damage.
We have paid more attention to motor injury than to sensory injury because morbidity is worse. However, always remember that sensory injury is more common.
It has been reported that post-op pain is present in up to 75% of traditional endolift surgery patients. In this technique, with injections described, I have noted its presence in approximately 30% of cases.
Alopecia at the incision site is a tough parameter to judge. Approximately 10% have made mention of it – close inspection most likely shows it is more common. However, at 1 year after surgery it is rarely suggested by patients.
It is important to share such knowledge as we continue to evolve our surgical procedures. I welcome other’s experiences so we can grow and learn together and deliver the best of care.
Recently our fellow and I reviewed my long term data on results to lower lid blepharoplasty. I could not find such an extensive review of data with this case number in the literature. The surgical series is over a 10 year period and includes 640 cases. Important to consider is that I only perform transconjunctival surgery so the information only applies to this approach. Appropriate surgical adjuncts were included when clinically deemed necessary. These additional procedures included: canthal suspension, skin excision, fat transposition (repositioning), oseocutaneous ligament release, fat grafting and orbicularis plication (suspension).
Below are the results identified from the data collected:
- 640 cases total
- Women – 505 cases; Men – 135 cases
- Average age - 56 years
- Average F/U - 14 months
- Transconjunctival blepharoplasty only - 60 cases (9%)
- Transconjunctival blepharoplasty with fat repositioning - 580 cases (91%)
- Chemosis - more than mild at more than two weeks post-op 41 case (6.4%)
- Trichiasis - 9 cases (1.4%) - all needed intervention
- Revise fat re-excision - 9 cases (1.4%)
- Hollows - 30 cases (4.6%) - most lateral lid/cheek junction – 25 of the 30 cases (83%) were pre-warned this may occur, but refused interventions to prevent.
- Complaints of wrinkles or skin excess post-op - 14 cases (2.2%)
- Cicatricial entropion requiring buccal graft - 3 cases (0.5%) - All had fat transposition.
- Ectropion (no skin manipulation) - 1 case - related unaddressed laxity
- Lower eyelid retraction (all mild) - 6 cases ( 1%); 4 cases (0.6%) had skin/muscle manipulation (ie. pinch); 2 cases (0.3%) had no skin/muscle manipulation – but did have prominent eyes with gradient (vector) worsening (even with fat transposition)
- Periorbital fat grafting - 83/640 patients (9.6%). 7 of these (1.4%) developed contour issues (most with older larger (2 mm) harvest cannulas). 4 of these patients were revised and happy. 2 patients tolerated their final outcome. 1 patient unhappy and actually angry.
- Infection/severe inflammation - 7 cases (1.4%).
- Satisfaction study not done
- Satisfaction study of last 86 patients with fat transposition only was done with 4.8/5 average score on 5 point Likert scale: 1: Very unsatisfied, 2: unsatisfied, 3: neutral, 4: satisfied, 5: Very satisfied. The procedure found to be safe and effective
What this has taught me is that 79% of surgery is on woman in their mid 50’s. In general complications are rare and treatable. Fat grafting contour issues occur in 8.4% of cases, which I feel is unacceptably high – but not surprising. This complication rate is most assuredly lower with the newer (smaller port) harvesting cannulas. As expected, patient satisfaction is high.
I certainly learned a lot from this lower blepharoplasty data. I hope it is of help to others.
Ptosis surgery is a procedure that lifts an upper eyelid that has dropped. It is surgery on the elevating muscles of the eyelid (Mueller’s muscle or the Levator muscle/aponeurosis). This is very different than blepharoplasty surgery which is the more simplistic removal of variable amounts of skin, muscle and fat from the upper lids (typical cosmetic eyelid surgery).
Dr. Guy Massry is a Beverly Hills oculoplastic surgeon who specializes in ptosis repair surgery. Patients fly in from around the world to have surgery with Dr. Massry because he is internationally recognized for his ability to provide patients suffering from droopy upper eyelids with the best results possible.
With this basic framework in mind, Dr. Massry will tell you how to attain the best results to ptosis surgery:
1. Only have a qualified and experienced ptosis surgeon do your repair. This is always a board certified oculoplastic or ophthalmic plastic surgeon – the only surgeons with specialized ptosis training. Dr. Massry has this training and experience.
2. Have the correct surgery selected - ptosis repair, not a blepharoplasty. Dr. Massry will help you with this. Surgery can be performed from inside the eyelid (no skin cuts/scars) which requires no patient cooperation during surgery. Alternatively, it can also be performed through the skin (more complex and requires patient cooperation during surgery). To do it from inside of the eyelid (which most surgeons prefer as it is easier on patient and surgeon) some findings on examination must be present – Dr. Massry will identify this.
3. Make sure your surgeon has vast experience with ptosis surgery, as Dr. Massry does. Ptosis surgery complications can be troublesome, but you can avoid this by choosing a surgeon with extensive expertise in this area of surgery.
4. Make sure your surgeon has an aesthetic eye. In addition to his surgical techniques, Dr. Massry has an artistic eye to provide his patients with not only functional results, but also with fantastic aesthetic results.
5. Get the most out of your consultation. It is the time for you to ask a lot of questions and get a very thorough understanding of the procedure. You should leave feeling 100% comfortable and confident with your surgeon and the upcoming ptosis repair. Dr. Massry will spend as much time with you as necessary to make sure this is achieved. "The only bad question is the one not asked," Dr. Massry.
Schedule Your Ptosis Repair Consultation Today!
If you are experiencing droopy upper eyelids and are ready to learn more about your surgical options, please call us to schedule your consultation with Dr. Massry today - 310.657.4302!
More Information On Ptosis Repair:
Dr. Massry tells all his patients that having any elective cosmetic surgery procedure is a big decision which requires a commitment of time, energy, and money. It is a decision that should not be taken lightly. This is especially true when it comes to eyelid surgery (blepharoplasty).
Eyelids Are Delicate Structures
The eyelids are delicate facial structures which are more prone to bruising, swelling, and prolonged recovery than other areas of the face. This is because the eyelid tissue is thin and there are many small, yet vital, layers and structures within the eyelids which must be manipulated during all types of eyelid surgery (blepharoplasty, canthoplasty, ptosis repair, eyelid fat grafting, eyelid fat repositioning, etc.). The surgical procedure is a form of trauma (although controlled) and the eyelids do not handle trauma as well as other arrears of the face.
Recovery After Cosmetic Eyelid Plastic Surgery
So what can you, the patient, do or not do to attain the best final result from blepharoplasty or other kinds of eyelid surgery (canthoplasty, ptosis repair, eyelid fat grafting, eyelid fat repositioning, etc.)? These are Dr. Massry’s recommendations for the best results:
Ice the eyelids
First, you want to do all you can to reduce bruising and swelling. This is important so as not to stretch or potentially stain (discolor) the thin eyelid skin. The most important thing you can do to achieve this is to apply ice to the eyelids at frequent intervals for the first two days after the eyelid surgery. Applying ice for 10 minutes every hour while you are awake is an appropriate icing regimen. Dr. Massry recommends using frozen peas as they contour to the eyelids well.
Refrain from strenuous exercise
Dr. Massry asks patients to refrain from strenuous physical activity for the first week after eyelid surgery. Obviously this means absolutely no gym activity. In fact, his basic tenant is no bending, stooping or lifting for this time period. Dr. Massry will let you know when you can resume your exercise routine.
In addition to reduced physical activity, sleeping with two pillows at the head of the bed is also of benefit as it reduces swelling in the surgical area during sleep.
Over the counter treatments
There are a number of over the counter homeopathic medications which may speed up the post-operative recovery (reduce bruising/swelling) after blepharoplasty and other forms of eyelid surgery. At your pre-operative appointment, Dr. Massry and his staff will explain which supplements to take and the healing benefits of these products.
It is very important to reduce the risk of infection after surgery. The eyelids are such a well vascularized area (good blood supply) that infections are rare. That being said, Dr. Massry feels applying topical ocular (appropriate for eyes) antibiotic ointment (with a Q-tip) three times a day and at bedtime to the stitches is important. Dr. Massry prefers Erythromycin ophthalmic ointment, but others are also useful. Washing your hands before applying ointment to or touching the eyelids is important.
Showering after cosmetic eyelid plastic surgery
Dr. Massry does not feel taking a shower is a "don't," as long as care is taken not to put pressure on the eyelids or get them overly wet. Use similar judgment when washing your face.
Other activities after cosmetic eyelid surgery
Dr. Massry feels it is ok to go out, watch TV, and read as you feel comfortable. You should only drive a car when it feels safe. In this instance, refrain from applying ointment to the eyelids for a few hours before driving as this can blur vision.
Finally, following the post-operative instruction regimen, informing the Dr. Massry of any questions or concerns about surgery or healing, and using common sense in regards to wound care is important.
When patients follow the above recommendations closely, Dr. Massry feels recovery from surgery becomes easier. Remember, having surgery is a big deal, so be diligent about healing so that the outcome will be what you expect.
Talk To An Eyelid Surgery Expert Today!
If you have been thinking about eyelid surgery, now is the time to schedule your consultation with Dr. Massry! Call us today at 310.657.4302.
As we age, we can develop subtle (or not so subtle) hollows around the eyes and temple area. This happens as we lose volume or fat in our faces over time. Hollow or sunken temples, specifically, make he face appear much older. Luckily, there is a quick and instant fix for hollow temples!
To restore volume and soften the appearance of the hollows, expert oculoplastic surgeon Dr. Guy Massry, can inject Restylane (a filler) for immediate results. The picture below shows a patient immediately after filler injection on the right side. You can compare this to the left side that has not yet been filled with Restylane by Dr. Massry. The right side of her face looks much more youthful (fuller) as a result of the restored volume.
Dr. Massry performs this non-surgical treatment in his office and it takes less than 15 minutes. The results of this hollow temple treatment last for at least 9 – 12 months. Patients who undergo filler injections for hollow temples love the subtle anti-aging results Dr. Massry provides them with.
How much does a hollow temple treatment cost?
The cost of filler injections for the temples varies from patient to patient and depends on how much filler is needed to provide the best results possible. Dr. Massry will examine your hollow temples during your consultation and determine how much Restylane you need. Once examined, Dr. Massry’s staff can give you the specific cost of your treatment.
Do filler injections for hollow temples hurt?
Prior to the treatment, Dr. Massry will use a local anesthetic to numb the area so that the treatment is painless. Additionally, the filler itself contains lidocaine to further reduce any pain or discomfort.
Are there any other treatments that can be combined with my hollow temple treatment?
If you have lost volume in your temples, it is likely you have lost volume in other areas of your face, like the mid-face or under eyes. In these cases, Dr. Massry can also perform mid-face filler injections or under eye injections to add additional volume to face to create a facial balance and harmony. Dr. Massry treats every patient as an individual and determines which treatments will make him or her look their best.
Schedule your hollow temples treatment today!
If you are unhappy with the appearance of hollow or sunken temples, schedule your consultation with Dr. Massry today! Dr. Massry is world-renowned for his expertise in surgical and non-surgical treatments for the eyelids and surrounding areas. You can rest assured that you will be in the best hands possible with Dr. Massry!
Call us at 310-657-4302 today to schedule your consultation with Dr. Massry! Or click here to fill out our online contact form.
You may also enjoy reading - How to Rejuvenate Your Eyes Without Surgery
One of the hallmarks of previous blepharoplasty gone bad is a shortened eyelid opening. Patients complain that their “eyes look smaller.” Dr. Guy Massry, Oculoplastic expert in Beverly Hills, California has devised a solution for this very complex problem. He calls this canthoplasty (canthal reconstruction) with horizontal eyelid lengthening or the “CHEL” procedure. Briefly, Dr. Massry opens the shortened eyelid opening and performs a complicated procedure called “conjunctival flaps” to line the new and lengthened eyelid opening to make the eye look more normal (like it used to be). The tradeoff is that the part of the lids that are opened will not have lashes (as they were lost from previous surgery). However, the opening will be returned. This is a big deal and patients have been so happy with this new and novel technique. Dr. Massry has spent years perfecting this procedure and has patients fly in from all over the country and the world with this problem. Below is one patient example:
This young woman had previous lower lid blepharoplasty, which “shortened her eye opening” (see figure below). After Dr. Massry’s CHEL procedure there is a much more normal appearance. There has yet to be a consistent way to correct this. Dr. Massry is very happy and proud of this technique, which has now helped many patients return to a more normal appearance and confident outlook on life.
Below is same woman from the frontal view. As you can see the eyes are more natural in appearance and the sad look has been reduced.
Contact Dr. Massry Today!
If you have undergone a previous surgery that left you with eyes that are too small, please schedule your consultation with Dr. Massry today – 310.657.4302. Dr. Massry is the only surgeon performing this surgery and help you restore your appearance. We look forward to helping you!
Upper eyelid blepharoplasty is a very common procedure to remove upper eyelid bags and improve the appearance of the eyes. Traditional blepharoplasty involves the excision of varying amounts of skin, muscle, and fat. This has been referred to as subtractive surgery. The main aesthetic problem with this approach to blepharoplasty is the potential to hollow the upper lids which leaves a gaunt and potentially unattractive appearance. Contemporary blepharoplasty has focused on fat redistribution and preservation (see surgical video by Dr. Massry which includes these procedures to avoid upper eyelid hollows after surgery).
When the unfortunate circumstance of eyelid hollows occurs following blepharoplasty, a specialist uniquely qualified to correct the problem, like Dr. Massry, is needed. Guy G. Massry, MD is a board certified ophthalmic plastic surgeon who practices in Beverly Hills, California. He is one of the leading experts in his field and one of the most qualified specialists to correct eyelid hollowing.
One method Dr. Massry employs to address this problem is the use of eyelid fillers (Restylane, Belotero, etc.). Dr. Massry uses a blunt cannula to deliver the filler to the hollow areas. This reduces the incidence of bruising and potential other complications related to the treatment. These two videos demonstrate Dr. Massry’s technique for upper and lower eyelid filling:
Filler for Upper Eyelid & Brow
Filler Under the Eyes
Below are a few examples of upper lid filling of hollows after blepharoplasty.
Left: Patient after blepharoplasty that left upper eyelids hollow
Right: Patient after upper eyelid fillers with Dr Massry
Left: Patient prior to filler injections with Dr Massry to address upper eyelid hollows
Right: Patient with Dr Massry immediately after filler injections to the upper eyelids
If you have eyelid hollows after blepharoplasty and are interested in a minimally invasive correction with fillers please contact Dr. Massry at (310) 657-4302 or email us at email@example.com.
Anophthalmia is the absence of an eye. It is a condition that can be congenital (born without an eye) or acquired (loss of an eye from trauma, disease, etc.). Lack of an eye not only leads to an abnormal function of the eyelid and socket, but also to an abnormal appearance.
The traditional approach to anophthalmia surgery is correction of the functional components of the eyelid and surrounding areas and creating the ability to wear a fake eye (ocular prosthesis). But this type of surgery is generally never approached with aesthetics in mind. Guy Massry, MD specializes in correcting the eyelid and socket deficiencies associated with anophthalmia in not only a functional approach, but with aesthetics in mind as well. This dual approach provides his patients with the best possible results and allows the ocular prosthesis to appear as close to normal as possible
It is always Dr. Massry’s goal to make his anophthalmic patients look as natural as possible. He does this by applying the same cosmetic surgery principles he uses for his aesthetic ophthalmic plastic surgery patients.
This young man suffered the loss of his left eye due to trauma in an assault. He now has a prosthetic eye on the left side. In the before picture (picture left), you can see his left brow has fallen down, as have his left upper and lower lids. His right under eye is puffy, while his left under eye is hollow. You will also notice his left iris (colored part of the eye) points down. Overall, the eyes look very unequal and his facial appearance has become abnormal. Dr. Massry performed surgery on this patient with function and aesthetics in mind. Looking at the after surgery picture (picture right), you can see that his brows are much more equal now, as are the openings of his eyes. To further enhance this patient’s aesthetic appearance, Dr. Massry performed fat transfer to the lower left eyelid so the two lower lids look balanced now. Dr. Carole Stople is the ocularist who made the beautiful prosthetic eye. As a team, we were able to make this young man much happier and more confident.
Your eyes are one of, if not, the most expressive features on your face. So are you expressing youth, energy, and excitement, or fatigue, sadness, and aging with your eyes?
If your eyes are making you look older than you feel, then you may be a candidate for blepharoplasty, more commonly known as an eyelid lift.
So what causes your eyes to lose their youthful glow? Factors can include:
• Aging process
• Skin type
• Environmental factors (such as sun damage)
Any one or combination of these factors can cause the eyelids to sag and droop, or create bags and a heavy, puffy appearance, all of which can leave you looking sad, tired, or older than you truly are.
An upper blepharoplasty procedure can reduce the appearance of droopy or saggy upper eyelids.
The skin on your upper eyelids is among the thinnest anywhere on the body. A layer of muscle is located just beneath the eyelid skin and is separated from fatty tissue by a thin tissue membrane called the orbital septum. Muscle layers and the orbital septum weaken and sag with age. And fat deposits shift in response to weakened muscle, causing puffiness and drooping. Additionally, the collagen and elastin that provide support to the skin break down over time. This causes the skin to lose elasticity and become lax. Furthermore, eyebrows may droop with age, causing the upper eyelids to sag.
So what is an upper blepharoplasty?
During the procedure, Dr. Massry typically removes or redistributes fat deposits, as well as removes excess skin and muscle to improve the contour and shape of the upper eyes. Upper blepharoplasty is most commonly performed under local anesthesia with sedation at a Beverly Hills outpatient surgery center. Dr. Massry will make an incision in the fold of the upper eyelid and carefully remove the excess skin. In some cases, a small strip of muscle will also be removed. To reach the fat deposits, a small incision is made in the orbital septum so that Dr. Massry can reposition or remove the fat. While older blepharoplasty techniques exclusively removed excess fat, today, Dr. Massry repositions the fat to replenish volume in the proper areas of the upper eyelid, resulting in more natural outcomes. Finally, the incisions are closed with sutures and a lubricating ointment and bandage are applied.
What is the recovery like after blepharoplasty?
Patients may experience some mild pain, bruising and swelling after the procedure. Dr. Massry recommends applying cold compresses and taking some pain medication to keep you as comfortable as possible. You will need to avoid strenuous activity, such as exercise and heavy lifting, for a few weeks to allow your body to heal properly.
Upper eyelid surgery can provide beautiful anti-aging results that are long lasting. If you are interested in learning more about upper blepharoplasty with Dr. Massry, call our office to schedule a consultation – 310.657.4302!
Successful aesthetic rejuvenation of the eyelids and periorbital soft tissues requires a detailed knowledge of not only the relevant anatomy and normal aging changes, but also the advanced surgical techniques to comprehensively address the presenting deficits in order to attain natural results. Over the past few decades, a paradigm shift has occurred, in which it has become clear that facial aging is a more complex, three-dimensional process, affecting all tissue planes (skin, muscle, fat, and bone). As a result, it has become more common to see surgical and nonsurgical treatments combined for optimal results.
This article focuses on minimally invasive options to rejuvenate the brow and upper lid complex, with a review of the relevant anatomy and contemporary concepts in upper facial aging. Below is a summary of the key points of the article:
- Aging if the brow and upper eyelid occurs in all tissue planes and involves cutaneous changes, volume loss, and tissue descent.
- Volume restoration and neuromodulation have become an integral part of eyebrow/eyelid aesthetic rejuvenation.
- Surgical lifting techniques alone, without addressing volume loss, are insufficient to address aging of the brow/upper eyelid complex.
- Preservation and restoration of skin quality can have dramatic rejuvenating effects to the brow and upper eyelid.
The increase in injectable treatments has been driven by reduction in procedural risk, recovery, and cost. As such, for surgeons to stay current and provide a complete array of treatment options to patients, it is incumbent to become familiar and comfortable with the varied nonsurgical interventions.