Local anesthesia for upper eyelid surgery is a good option for patients who consider themselves “stoic” and have a relatively high pain threshold. In this technique, only numbing medications are used to provide comfort and so they are awake during the entire procedure.
Without general anesthesia that puts patients to a state similar to sleep, they avoid its common side effects such as nausea and lethargy, which in turn promote quicker recovery.
The patient receives local anesthesia alone during her upper eyelid surgery.
Leading Los Angeles plastic surgeon Dr. Tarick Smiley has recently demonstrated a surgery via Snapchat performed completely under local anesthesia. The patient requested for this procedure so she could drive herself home after surgery.
The patient was awake during the entire surgery, which involved removing some loose skin (and muscle) to eliminate the upper lid hooding that was aging her eyes and interfering with her vision.
A local anesthesia-alone surgery also precludes the need for fasting; this is not the case with general anesthesia in which the patients are required to avoid foods and drinks for 8-12 hours prior to the operation.
While local anesthesia for upper eyelid surgery is a reasonably safe option—some doctors would even compare this to a dentist visit involving cavity fillers treatments—Dr. Smiley says that not everyone is a good candidate for this approach, particularly those requiring other concurrent procedures like facelift, fat transfer, and brow lift.
Also, patients who are anxious are poor candidates for “pure” local anesthesia as they might experience increase in blood pressure, which can result in more bleeding and thus the surgery becomes more difficult. For these individuals, the use of local anesthesia with sedation or general anesthesia remains the most ideal approach.
For patients who want to avoid general anesthesia but may be too nervous to be awake during surgery, a good alternative is to combine local anesthesia with sedation, which means that they will have no memory of the surgical experience.
Furthermore, sedation does not involve placing a tube in the throat, which the general anesthesia entails.
When eyelid surgery and fillers are performed together they can provide a more natural result and a more potent rejuvenating effect, said renowned Beverly Hills plastic surgeon Dr. Tarick Smiley in his recent post on Snapchat.
Dr. Smiley has posted a series of videos demonstrating a female patient who received upper and lower eyelid surgery complemented by the most natural filler material—her very own fat collected from her tummy.
The fat was injected to create a smoother transition between her lower lid and cheek and to soften the nasolabial folds or “laugh lines.”
“The fat moves more naturally and so it provides more natural results than standard fillers. Also, fat cells expand and shrink as the patient gains and loses weight, further contributing to its natural outcome,” explained Dr. Smiley.
Furthermore, Dr. Smiley said that about 70 percent of the fat volume is expected to persist long term and therefore fat grafting is more cost-effective than traditional fillers such as Juvederm and Restylane, which on average require 6-12 months “retouch.”
The patient also had bulging orbital fat in the upper eyelid, which Dr. Smiley reduced before removing the loose skin that was causing the “hooded” appearance of the lid.
The excess orbital fat must be removed to eliminate the bulging or puffy appearance. Nonetheless, fat injection remains advisable to create additional carpeting right beneath the skin. Unlike the deeper fat that protrudes with aging, the superficial fat tends to shrink.
He also reduced the deeper orbital fat in the lower lid, which was causing the patient’s under eye-bags.
While reducing the orbital fat may sound counter-intuitive given that the patient also received a simultaneous fat transfer in her lower lid, Dr. Smiley said these two surgical maneuvers accomplish two different things.
“Reducing the deeper orbital fat in the lower lid eliminates the bulging, while injecting fat right beneath the skin creates this carpeting that results in smoother and more youthful transition, Dr. Smiley explained.
In terms of scar appearance, Dr. Smiley ensured that the upper eyelid incision was placed precisely at the skin fold for optimal scar concealment, while the lower lid incision was positioned immediately below the “root” of the eyelashes so it remains undetectable at conversational distances.
Aside from “precise” placement of incision, the celebrity surgeon said meticulous wound closure further ensures invisible scar.
For the vast majority of patients, Dr. Smiley said the eyelid surgery and fillers result in undetectable scar because the skin in the area is markedly thin and thus resistant to scar tissue.
Blepharoplasty with fat transfer is a modern approach in eyelid surgery that ensures natural and youthful results. It diverges from the antiquated technique in which the main focus is to remove the excess skin and fat with little regard to age-related volume loss.
The antiquated technique may cause skeletonized eye socket appearance especially along the lower eyelid. This is particularly true when the fat is entirely removed, leaving no “carpeting” beneath the skin to promote smooth results.
To prevent creating or aggravating the hollowed lower eyelid, Dr. Tarick Smiley of the California Surgical Institute says he often incorporates blepharoplasty with fat transfer. The idea is to create a smooth transition between the lid and cheek, which is one of the key elements of a youthful face.
In Dr. Smiley’s recent Snapchat post, he has shown a female patient who has had upper and lower blepharoplasty with fat transfer.
The patient’s upper blepharoplasty was performed to eliminate the hooding of the lid; this was done with incisions made precisely at the existing skin fold to hide the resulting scar. Only a very small amount of skin was removed to preserve the function or “normal blink” and to allow for proper wound closure, which is the key to optimal hidden scars.
While some doctors extend the incision into the crow’s feet, Dr. Smiley keeps it within the natural skin fold of the upper lid to ensure that the scar will remain hidden.
The patient’s lower blepharoplasty surgery, on the other hand, was performed with an incision placed very close to the lower lash line so her eyelashes can hide the resulting scar. The area has a markedly thin skin, which allows the scar to fade better into the background.
Meanwhile, the antiquated technique removes the entire fat in an attempt to remove the under eye-bags; however, this causes hollowness right after surgery or years down the road, as soft tissue volume decreases with aging.
There are several ways to prevent the appearance of hollowed lower eyelid, with fat transfer being the most popular option, says Dr. Smiley.
Other patients can benefit from the repositioning of their superficial fat (fat beneath the skin; this is different from the deeper “bulging” fat that often requires removal), specifically laying it over the upper cheekbone to maintain a smooth lid-cheek junction. Fat grafting or injecting can further fine-tune the results.
The surgeon’s eyelid surgery before and after photos can shed light on his artistic skills, which play a critical role in any facial plastic surgery. Hence, a prudent patient should insist to view this material before scheduling her surgery.
The before and after photos should have no classic surgical stigmata such as skeletonized eye socket, abrupt lower lid and cheek transition, unnatural height of the upper lid, retracted skin lid, and visible scar.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley has recently posted a Snapchat video demonstrating a patient who has had upper and lower eyelid surgery to correct age-induced skin and soft tissue laxity. To achieve a more natural and more youthful result, he combined the procedure with fat transfer.
Lower Eyelid Surgery with Fat Transfer
The idea of fat transfer, also referred to as fat injection and structural fat grafting, is to create a smooth transition between the lower lid and cheek. Occasionally, a lower lid-alone approach can create or worsen the appearance of tear trough, a problem best avoided when fats are injected beneath the skin to serve as padding.
While the superficial fat beneath the lower lid skin tends to shrink with aging, the deeper fat behaves differently: It becomes more prominent and saggy, leading a crescent-shaped bulge. Hence, the right surgical maneuvers reverse these age-induced effects.
The deeper lower lid fat is often removed or reduced during surgery to correct lid herniation or “bagginess.” This is typically followed by fat injection beneath the skin to create a smooth lid-cheek transition.
To further create a smooth lower lid and eliminate the crepe-like appearance, during surgery Dr. Smiley removed a small amount of excess skin with the use of a thin incision placed very close to the lower lash margin. This is expected to heal into a thin scar that is invisible at a conversational distance.
Upper Eyelid Surgery
The patient also received upper eyelid surgery to eliminate the hooding and fullness of the lid-brow complex.
“I placed the incision inside the new skin fold to hide the scarring,” Dr. Smiley said in the video.
The incision allowed Dr. Smiley to remove the excess skin and fat that was causing the “heaviness” and drooping of the upper lid. However, he made sure that sufficient fat pad would remain after surgery to avoid the skeletonized appearance, which in any way does not look youthful.
The skin excision aspect was also done in a highly meticulous manner to preserve “normal blink” and to ensure that the “new” upper lid would have a height that is consistent with the patient’s facial feature, gender, and race. For instance, female Caucasians often have a lid crease height that is between 8 and 12 mm; this generalization does not apply to men and other ethnicities.
Should I have dermal fillers vs fat transfer? This is arguably the most common question of patients wanting to rejuvenate their face with the use of “volumizers,” which can be combined with facelift surgery for a more holistic, more natural result.
Leading Beverly Hills plastic surgeon Dr. Tarick Smiley says that dermal fillers are readily available materials injected into the soft tissue, while fat transfer uses the most natural material possible—i.e., the patient’s own fat that is usually derived from the tummy and flanks, areas that typically carry “unwanted” fat cells.
Photo Credit: Restylane.com
In essence, dermal fillers and fat transfer fill in the cracks and depressions that are typically caused by age-induced facial volume loss, while facelift removes the loose skin and tighten the deeper structures.
Dr. Smiley says that patients older than 55 typically require both procedures because their aging appearance are caused by facial volume loss and soft tissue laxity (sagging).
The celebrity plastic surgeon says he prefers fat transfer to dermal fillers because of the former’s longer lasting results, averaging 12-15 years.
Fillers, meanwhile, are usually repeated at 3-4 month intervals to maintain the plump up appearance. Hence, it is safe to surmise that in the long run they are more expensive than fat transfer, says Dr. Smiley.
Aside from the “long term” cost of dermal fillers, many surgeons have suggested that fat transfer remains superior because it adheres to the core principle of “replacing likes with likes” and so the results are perceived to be softer and more natural looking.
Should there is a need to address deep depression and cracks at the time of facelift surgery, Dr. Smiley performs a simultaneous fat transfer; this is more convenient than having two separate procedures, which of course can lead to additional cost and multiple recovery.
Dr. Smiley often uses a simultaneous fat transfer to further soften the nasolabial folds, or laugh lines; and to create a smooth transition between the lower lid and upper cheek.
Failure to address the “abrupt” lid-cheek junction, Dr. Smiley warns, can lead to unnatural facelift results manifested by skeletonized eye socket and crescent-shaped bulge right below the lower lid. Simply put, fat transfer “fine tunes” the effects of facial rejuvenation surgery.
Meanwhile, Dr. Smiley typically reserves dermal fillers for first-time patients who need volumizers as a stand-alone procedure. Should they are happy with the results, they may ask for a more permanent treatment in the form of fat transfer later on.
While fat injections or dermal fillers can serve as an alternative to lower eyelid surgery, not all patients with under eye-bags can benefit from them.
The appearance of under eye-bag or “shadowing” is caused by different or even a combination of factors. Excess skin, herniated deep fat, loss or “shrinkage” of superficial fat (beneath the skin), or a combination of these variables may contribute to this aesthetic issue.
Before and after photos of a patient who have had fat transfer in her lower eyelid.
Basically, a “true” or standard lower eyelid surgery uses incision positioned very close to the lash line so the eyelashes can conceal the resulting scar. Referred to as an external incision technique, this allows the surgeon to remove excess skin and fat and possibly reshape the muscle.
However, not everyone with under eye-bags has excess skin. If the extra fat primarily causes this appearance instead, dermal filler injection (e.g., Restylane and Juvederm) can conceal the unsightly bulge.
The main purpose of dermal filler (as an alternative to lower eyelid surgery) is to make the lower lid bulge the same level as the upper cheek. This is a rather straightforward approach and does entail no or very little downtime; hence, it appeals in patients with busy schedule and cannot afford surgery and its ensuing “social recovery.”
But there is one caveat when dermal fillers are used to conceal the under eye-bag caused by excess fat: Touch-ups are generally needed at 6-12 months interval.
Meanwhile, fat injection or fat grafting is a method that provides longer-lasting effects than dermal fillers, with studies suggesting that its results last an average of 12-15 years. The procedure starts off with the collection of superficial fat (beneath the skin) usually in the tummy; only a few teaspoons are needed since the lower eyelid is just a small area.
The collected fat volume is then put in tubes and processed through centrifugation; the idea is to discard the oil, red blood cells, and other biomaterials except the fat cells. Afterwards, the purest form of fat is injected to conceal the bags.
It is important to note that fat injection and dermal fillers are basically volumizers (they add volume) and so they can also address the deep tear trough and the abrupt lid-cheek junction that come with aging.
It is not uncommon to combine volumizers with excision-based lower eyelid surgery to achieve the best results possible. This is particularly true for patients with excess skin, herniated deep fat, and abrupt lid-cheek transition, as suggested by leading Orange County plastic surgery expert Dr. Tarick Smiley.
Due to the laxity of skin and other supportive structures, the deep fat along the lower lid becomes prominent (i.e., it bulges out) with aging. In contrast, the superficial fat “shrinks” and thus gives the appearance of deep tear trough or abrupt transition between the lid and cheek.
To address the aforementioned problems, a small linear incision is made within the lower lid that allows the surgeon to remove the excess skin and reduce the deep fat pad. For additional fine-tuning, fat injection is used to create a smoother lid-cheek junction.