Everything A Plastic Surgeon Wants You to Know About Eyelid Rejuvenation

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Our eyes are often the first thing that people notice when looking at us. According to New York facial plastic surgeon Edward S. Kwak, MD, with our eyes at center stage, it will continue to be a huge aesthetic focus for the year. “Right now with everyone wearing masks, our eyes are really often the only part of our face that we’re presenting to the world, to our friends, our family, and our new social acquaintances, says Dr. Kwak. “So we’re scrutinizing ourselves, even more about our eye appearance. A tired or sterner appearance to the eyes can present the wrong impression, especially if that’s all we’re seeing. That’s why I believe there’s so much interest in treatments for the eyes right now.” We spoke with Dr. Kwak to learn more and understand his approach to eyelid rejuvenation.

What are the top requested and performed eye-rejuvenating procedures?
My most requested treatment is for rejuvenation of the upper eyelid appearance. As we age, the upper eyelid skin changes very predictably. This skin is sensitive to aging due to its thinness along with the known changes related to aging such as loss of collagen and exposure to gravity. As a result, the skin becomes redundant on the upper eyelid and that can hood over, lowering the upper lid crease height and potentially obstructing the opening to the eyes. The aesthetic consequences are faces that appear sterner or tired. The upper eyelid blepharoplasty is a procedure that can re-establish a youthful upper eyelid.

What advice can you give a prospective patient when researching procedures and surgeons?
The best advice I can give my patients and prospective patients is to see a plastic surgeon who specializes in eyelid surgery. There are subtle nuances to this surgery that the experienced surgeon can incorporate to achieve natural outcomes safely.  

What do you consider to be an ideal outcome for upper blepharoplasty?
One that achieves a natural shape to the eye, blending in with the rest of the facial features. The youthful upper eyelid has a youthful eyebrow that does not encroach onto the eyelid, a defined, delicate, and properly positioned upper lid crease, fullness centrally and laterally, and proper eyelid opening. 

What are the risks associated with the procedure?
The upper blepharoplasty in general is a very safe procedure. Typically, it can be performed in the office under local anesthetics, or for some who are doing multiple procedures, can be performed under mild sedation or “twilight” anesthesia. The most common risks are more cosmetic in nature, specifically asymmetries and cosmetic irregularities. Every patient should understand that surgical procedures do carry risks—some of the less common risks include dry eyes, scarring, infection, bleeding or bruising.

What can a patient expect in terms of the recovery process and follow-up?
In terms of the timeline, this procedure is done in our office and takes approximately one hour to perform. Patients are able to go home immediately afterward. The first week there is some expected swelling and mild bruising. The upper eyelid region has sutures in the area that patients take care of with the use of bacterial ointment. Approximately one week after surgery, I see patients back in my office to remove sutures on the upper eyelid. By this time, most of the bruising is usually at its tail end, and after this visit swelling tends to dissipate quicker. Most patients are able to return to work or engage in social activities usually around 10-14 days. For the first 3-4 weeks, we don’t recommend strenuous activities or exercising. If they have a big event or have an engagement where they need to be photo-ready, we usually recommend a 4-6 week cushion.

What do you consider to be an ideal outcome for lower blepharoplasty?
For the lower eyelid, the ideal outcome is to have a contour that seamlessly transitions into the midface and cheek regions with an overlying skin that is smooth and consistent in color. Oftentimes this surgery entails removal or repositioning of lower eyelid fat. This fat is normally found around the eyes and is not subject to fluctuations in weight, but it does change in position due to time, gravity and genetics.

What can often make the lower lid age in appearance is the prominence of a groove between the eyelid and the cheek called the nasojugal groove (tear trough deformities).  The groove can be addressed by softening the transition between the eye and cheek either by removing redundancies in the fat or by repositioning the fat within the groove. To further soften the transition out laterally, a facial fat transfer (harvesting one’s fat from either the abdomen or flanks and repositioning in the face) can be incorporated to build up the cheek. Once the deeper contours of the eyelid have been addressed, the overlying lower eyelid skin often needs to be addressed for skin redundancies, wrinkling, or color discrepancies. For these, a lower lid skin pinch or a skin laser resurfacing can be included in the treatment regimen. 

What are the risks associated with the procedure?
The lower eyelid blepharoplasty is a very safe procedure. To perform safely, I recommend mild sedation or general anesthesia. One of the biggest concerns after the surgery is preserving or maintaining the lower eyelid position. In some patients, especially patients seeking treatment for age-related lower eyelid changes, they may also have a coexisting laxity to the lower eyelid tone. If this is not corrected or identified preoperatively, a lower lid blepharoplasty could lead to exacerbations of laxity or lower eyelid retraction.

What can a patient expect in terms of the recovery process and follow-up?
In general, the lower eyelid blepharoplasty heals fairly predictably. The first week, the patient can expect some swelling and bruising that’s appropriate for surgery. I have patients who come in usually one week after surgery to monitor their progress and for suture removal. By the second week, the bruising and swelling are resolving and I tell most patients are able to resume social activities and return to work usually after 10-14 days afterward. If they have a big event to plan around, it’s safe to recommend on average around 4-6 weeks of leeway.

What do you consider to be an ideal outcome for a brow lift?
As we all age, the upper third of our face descends, creating deeper furrows or wrinkles along the forehead. The brow encroaches onto the eyes creating a hooded appearance extending to the lateral canthus and lateral orbital rim. To correct this, a forehead lift or brow lift can restore the brows to a more youthful position. Ideally, for women, we want the brow to taper upward above the orbital rim peaking between our lateral limbus or lateral canthus. For men, we want to set the brow slightly lower where the brow position is around the level of the orbital rim.

What are the risks associated with the procedure?
A brow lift is a very safe procedure. This surgery typically involves four small hidden incisions within the hairline. To perform this surgery, we use small cameras and microscopic instruments to be able to release the structures that hold the brow position in place. Once the brow is released, the brow can be precisely repositioned to a more youthful position. Some common side effects are bruising and swelling that subsides within 1-2 weeks. Some patients experience temporary numbness along the forehead and crown region.  

What can a patient expect in terms of the recovery process and follow-up?
The brow lift is performed as an outpatient surgery under mild sedation. This procedure takes approximately 90 minutes to perform and patients leave with a compression dressing and, occasionally, a surgical drain to minimize swelling and bruising. The patient will return the following day to remove the dressing and surgical drain. We will then apply a removable compression dressing that’s recommended to be on as much as possible for the first month. Following one week, the patient will come back to our office to remove the sutures which are hidden in the hairline. After this visit, the swelling and bruising are resolving. Usually, towards the end of the second week, patients are returning to work and engaging socially. Patients tend to heal from this in a predictable fashion, patients are usually looking well-healed at around 3-4 weeks.

What do you consider to be an ideal outcome for eyebrow transplant?
The ideal outcome for an eyebrow hair transplant is one that accounts for the facial shape and blends into the eye and face naturally. In addition to density concerns, a natural outcome involves mimicking the existing hair follicle orientation for the transplanted hair follicles.

What are the risks associated with the procedure?
Eyebrow hair transplantation is an extremely safe procedure to perform and is often performed under local anesthetics in the office. The hair follicles are harvested from the back of the head or occipital region. Individual hair follicles are harvested and transplanted in the eyebrow. Common reactions after the surgery are swelling, redness bumps along the transplant side, and mild bruising.

What can a patient expect in terms of the recovery process and follow-up?
The eyebrow hair transplantation typically is a half-day process and is performed under local anesthetics. The hair that is harvested from the back of the head is harvested using a technique called follicular unit extraction (FUE). These transplanted hairs are placed individually to the recipient sites of the eyebrow. Patients leave the same day, the first 24-48 hours there is mild soreness, swelling, and spotting in the donor and recipient sites. Patients are usually able to begin exercising about 10-14 days after surgery. As healing occurs, some small scabs can develop. These usually occur 1-2 weeks after surgery. Gradually the new hair follicles will grow, with final outcomes about a year after the procedure. Most patients do well with one treatment session, however, some patients who have previous scarring or trauma may require additional procedures.

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