Is there anything more sensitive on the human face than our eyes? In this installment of Inside Cosmetic Surgery, we speak with Dr. Nancy Swartz, an ophthalmic plastic surgeon in Philadelphia, about the advantages of seeking a specialist for your cosmetic eye surgery, or blepharoplasty.

Not all cosmetic eye procedures are invasive. Dr. Swartz also talks about the evolution from surgically invasive procedures to now being able to treat many conditions with dermal fillers like Botox or Restylane.

Listen to the full interview, or read through the transcript below!

Sharon Odom (SO): Hi everybody, this is Sharon Odom from Cosmetic Surgery Today and welcome to another episode of our continuing series Inside Cosmetic Surgery. Our special guest today is Dr. Nancy Swartz. Hi Dr. Swartz, how are you?

Dr. Nancy Swartz (DNS): Hi Sharon, how are you?

SO: I’m great. Well, Dr. Swartz is an ophthalmic plastic surgeon with offices in the Philadelphia area and she’s in practice with her husband, Dr. Marc Cohen, and today we are going to be discussing cosmetic eyelid surgery. And there is another name for that, Dr. Swartz, and what is it?

DNS: Yes, the actual technical name for cosmetic eyelid surgery is blepharoplasty.

SO: That’s it, yes. So today we are going to discussing that, and so the first thing we need to find out is when should someone come to see you instead of an ophthalmologist.

DNS: Well, I’m an ophthalmic plastic surgeon, and ophthalmic plastic surgery is a subspecialty of ophthalmology. There are a lot of specialties that perform blepharoplasty well, but the advantage of seeing an ophthalmologist that specializes in plastic surgery is that we are specifically trained to take care of your eyes. Ophthalmic plastic surgeons are ophthalmologist first and then specialize in plastic surgery.

SO: How did you get into plastic surgery? You started out doing ophthalmology-type cases and then you moved into plastic surgery?

DNS: Yes, that’s correct. Ophthalmology has a lot of different specialties. Actually, I did fellowships in two of them, ophthalmic plastic surgery and neuro-ophthalmology. My practice is limited to ophthalmic plastic surgery though.

SO: Okay, so you deal specifically with the eyes. This is your specialty.

DNS: Yes, ophthalmic plastic surgery has really expanded over time and many people now call it oculo-facial surgery and we do only face surgery, but don’t limit it only to eyes anymore.

SO: What percentage of patients actually are seeking a solution to improve their functionality instead of just improving the aesthetics?

DNS: Well, when your eyelids are droopy enough that they cover part of your pupils, the black pupil in your eye, they make it difficult for you to see things that are above you and sometimes to the side as well, and people whose vision is blocked by their eyelids often complain of a tired or a heavy feeling because they lift their eyebrows to see better all day long and the muscles get tired.

I would estimate that maybe 20% of my patients that I see for blepharoplasty are considering surgery for improving those symptoms, but most of the patients who do this for symptomatic relief and also appreciate the improvement in their appearance.

SO: Now, that brings up a question, if it’s something that they need in order to see better, is it sometimes covered by insurance?

DNS: That’s correct and there are tests that insurance companies ask us to do for our patients and provide information so that they can assess whether or not it’s blocking their vision.

SO: To prove that [insurance] should pay for it. Do you combine procedures sometimes like an upper eyelid lift with a lower lift all at the same time?

DNS: We combine procedures all the time. People often have their upper and lower eyelids done at the same time and we often combine blepharoplasty with injectable treatments like Botox and fillers.

SO: Because eyes are such a sensitive area, what sort of precautions do you take to make sure they aren’t damaged during the procedures?

DNS: Well, safe eyelid surgery really starts when you first visit your doctor. A good examination is important to evaluate the health of your eyes. Conditions like dry eye syndrome and eye allergies tend to get worse temporarily after surgery, so they need to be controlled first.

During surgery, a protective contact lens is placed in the eye to protect them and I use a laser when I do blepharoplasty surgery. So I use a special contact lens that’s designed specifically to protect the eyes from the lasers. After surgery, we use eye drops and ointments to keep the eyes moist and protected.

SO: When someone comes to you, what are they usually coming for? The initial visit is usually to just talk about the eyelids. What’s the typical first visit?

DNS: So yes, people often see changes as they age in their eyes before other places. When we look at people, we look directly at their eyes for a good part of the time, so it’s a place that we see and we pay attention to. Women put makeup on their eyes because it is such a focus of our appearance and so a lot of people come to me because they notice that their eyes don’t look the same as they used to. Sometimes, they are more hollow, or sometimes, the skin is loose, and so those are typical things that people come to me for.

SO: What about that little hollow area right under the eye?

DNS: Yes, that’s a common problem that people have. They get hollow under their eyes and sometimes when they are hollow, when they lose volume and get hollow, they start to see bags right above the hollow.

And those are all very common problems that people have that we address sometimes with surgery and sometimes with other injectable fillers.

SO: That area under the eye can be filled with fillers, or does it require invasive surgery?

DNS: It depends on the person. If the person really has too much fat or very loose skin or their lids have stretched, those people need surgery, but most people really don’t need surgery now. Most people have changes in their eyes because they’ve lost volume and those people do really well with fillers.

SO: You know it’s funny. So you lose volume in some place, right? So there is a little dent under the eyes, and then you have fat in other areas, right?

DNS: Right. Most of the time, the fat that you see, the bags under the eyes and other places have always been there, but you didn’t see them because you had fat under your skin that kind of gave you a more full look and kind of hid what was underneath.

And when you lose that fat, you start seeing what’s underneath it.

SO: What are the trends? Are there certain eye shapes that patients are requesting more than others?

DNS: Well, the trend right now is really to look natural and to look like yourself. People don’t want to look like somebody else. A lot of my patients come in and they ask me about celebrities that they have seen that have had surgery and are now hard to recognize and they want to make sure that doesn’t happen to them.

They want to look refreshed and they want to look natural. They don’t want to look like they had surgery. They just want to look like themselves.

SO: Just a fresher, rested version of themselves. Are all the procedures invasive?

DNS: Not all the procedures are invasive. Blepharoplasty is a surgical technique and all surgery is considered invasive and all eyelid rejuvenation is not invasive. The neuromodulators like Botox, Dysport and Xeomin are, in office, we consider them minimally invasive procedures. We use them to soften wrinkles, to shape the brows and sometimes to open the eyes.

Fillers like Restylane and Juvéderm, we use those for wrinkles as well. But what most people don’t realize is that they can be used to rejuvenate the facial contours so they can fix the hollowness and hide the bags and make people look like they did when they were younger.

SO: Do you use fat transfer as well.

DNS: I don’t use fat transfer. Fat transfer can be a very valuable tool in some parts of the face. I don’t think it does well under the eyes. It’s a technique that some of the fat tends to lift more than others and lower eyelids are a place that if it goes away in an irregular pattern, you will see that, so lower eyelids do much better with fillers than they do with fat. With other parts of the face, you can do very well with fat.

SO: Do you usually do a combination of surgery and fillers or it just depends on the patient?

DNS: It really does depend on the patient. It used to be when I started practice that when people came in for eyelid rejuvenation, really the only thing we had to offer was surgery.

We have so many options now. It depends on your anatomy and your lifestyle and what you are looking for.

SO: All of the options are just wonderful.

DNS: It’s a lot of fun and it’s going to keep getting better.

SO: So what are the potential risks or side effects?

DNS: Well, anytime you do surgery around the eyes, you have risk to your eyes, to your eyelids, to your vision. Fortunately, eyelid surgery is really very safe and problems like that are very rare. One of the problems that is a serious complication of eyelid surgery is having difficulty closing your eyes after surgery, and that happens when too much skin is removed and it is completely preventable just by avoiding aggressive skin removal.

SO: They actually are not able to close their eyes?

DNS: That can happen if too much skin is taken out. You need to have enough skin to go from your eyebrow down to your eyelashes with your eyes closed, and if too much is taken out, it’s difficult to close your eyes.

SO: And I would imagine that’s a function of choosing the correct surgeon?

DNS: Yes. Absolutely.

SO: And that brings me to the next question, which is, what should patients be looking for when choosing a cosmetic surgeon for blepharoplasty?

DNS: So, with any cosmetic surgery, and eyelid surgery is no different, you want to surgeon who has experience doing that type of surgery. So your surgeon should have a lot of experience doing eyelids if that’s what you are going to have done.

Your surgeon should ask you about problems that you have with your eyes. They should ask you about your general health, your medications. They should evaluate your eyelids and your eyes before the surgery. You want to make sure you know exactly what the surgeon is planning to do and results they think they will achieve with the surgery.

You want to ask where the surgery is going to be done and what type of anesthesia you are going to get. You want to make sure that the operating room is accredited. If you are having anesthesia, and most eyelid surgery, there is anesthesia involved. You want to make sure that an anesthesiologist or nurse anesthetist will be with you the entire time you are having surgery.

SO: Is that general anesthesia?

DNS: Usually, it is not general anesthesia. Usually, it’s just sedation. But certainly that is something that different surgeons do differently and different patients want different things. So it’s a conversation you want to have with your surgeon.

SO: How soon can patients see results and then how long does the results last?

DNS: So usually, cosmetic eyelid surgery doesn’t need to be repeated. There are exceptions to this, but it tends to be something that you do once. That doesn’t mean that you don’t do other eyelid rejuvenation techniques over time, you see, if they want to do fillers or the neuromodulators like Botox, but the surgery tends to be one event in your life.

Eyelids are very delicate and they bruise and swell easily and the less bruising and swelling you get, the sooner it’s going to away so the sooner you are going to look good.

SO: So how long afterwards are they bruised? Immediately after surgery, how do they look?

DNS: Well, with the laser, most people have either no bruising and swelling or just a very small amount, but you can get some over the next few days, and you have a little bit of control over this so if you limit your activity, if you keep your head elevated and you use cold compresses for those first few days, you will see much less bruising and swelling.

A lot of patients look good in a week or two, but you certainly can’t guarantee that. I tell my patients that they should have at least a month or two before they have a big event, so that they have plenty of time to heal.

SO: The results aren’t obvious right after since there needs to be some healing first.

DNS: It completely depends on whether or not you have bruising and swelling. If you have none, you look good right away. If you have a lot, you have to wait for that to go away before you really see the results.

SO: Okay. Now, what if someone wears his contacts, can they wear them afterwards or not?

DNS: You need to wait until your eyelids heal before you can wear your contacts, and that’s usually about ten days to two weeks.

SO: So if there is someone like me who can’t function without contacts, I just need to stay in bed or just make that they wear a pair of glasses.

DNS: Or wear a pair of glasses. One of the reasons we wait with soft contact lenses is because soft contact lenses absorb your tears and make your eyes a little drier and you want your eyelids to heal well before that.

But with the harder lenses, that isn’t a problem. You would get back into yours a little faster.

SO: That’s good to know. Do you have any patient success stories you would like to share, not names, of course, but just examples of successful patients you’ve done? I know they are all a success, but just specific example.

DNS: Oh my, I’m having a hard time thinking of one person. I take my surgery very seriously as I know all surgeons do and I take it very personally, and I am very attached to my patients. And all of them are important to me to be a success and to be happy with their results.

SO: Well, is there anything we should know about blepharoplasty?

DNS: No, I think you’ve covered that very nicely.

SO: Would you like to tell our listeners about your practice and your website?

DNS: Sure. I practice ophthalmic plastic surgery. I have an office in Southern New Jersey and in the Main Line area of Philadelphia and I also see patients at Thomas Jefferson University Hospital. I’m in practice with my husband who is my partner at home and at work, Dr. Marc Cohen, and our website is www.cosmetic-eyes.com.

SO: Well, thank you, Dr. Swartz. It’s been a pleasure and we appreciate your time.

DNS: Thank you so very much.

As we age, our skin gradually loses its elasticity. The lack of elasticity, combined with the constant pull of gravity, results in wrinkles and excessive skin being formed in the lower and upper eyelids.

The excess skin collected in the lower eyelids creates bulges and wrinkles, while the excess skin right above the upper eyelids leads to the formation of an extra fold of skin, which could obstruct vision.

Bulges in the lower and upper eyelids could also be caused by the fat that cushions the eyeball from the skull. A thin membrane holds the fat in place. With age, the membrane weakens, allowing the fat to protrude into the lids.

Using surgery to remove excessive eyelid skin

Eyelid surgery, also called blepharoplasty, is a procedure that reduces bagginess from the lower eyelids and removes excess skin in the upper eyelids. The surgery involves the removal of the unwanted skin, muscle, and fatty tissue.

While most people go through the procedure for cosmetic reasons, it is an effective method for improving sight in older patients whose sagging upper eyelids are hindered by their sight.

The surgery is a great way to have smoother and more youthful-looking skin, although it does not remove crow’s feet, dark circles under the eyes, and other facial wrinkles.

Good candidates for the surgery

The best candidates for eyelid surgery are individuals who have good physical and mental health as well as realistic expectations. Most patients are aged thirty-five years or older. However, if the baggy or droopy eyelids are inherent, you may have the surgery at a younger age.

People with ophthalmologic, circulatory, or serious medical conditions should consider the diagnosis of a specialist to know if it is safe to go through the procedure.

Duration of changes made by the surgery

The surgical procedure will not stop your eyes from aging, but the benefits are usually long-lasting. Surgery for the upper eyelids can last from five years to an entire lifetime, while lower eyelid surgery sometimes needs to be done more than once.

Potential complications

In order to set the proper expectations, knowing the possible complications is crucial. As with any kind of surgery, there is some degree of risk involved, although they happen rarely.

The possible problems include:

• Bleeding

• Infection

• Dry eyes

• Abnormal discoloration of the skin around the eyes

• Eyelid skin that folds abnormally

• Inability to fully close the eyes

• Pulled down lower eyelid lash line or possible loss of vision

If any of these complications occur, you should contact your doctor as soon as possible.

Preparing for the surgery

Whether the eyelid surgery is for cosmetic or functional reasons, it is of paramount importance to choose a qualified facial plastic surgeon. Doing so will allow higher chances of a successful surgical procedure. The patient must also follow the presurgical and post-operative instructions given by the surgeon to recover faster and avoid some of the possible risks.

It is also important to prepare your home for the recovery period so that you can be comfortable while letting the wounds heal. Doing the housework beforehand can allow you to exert less effort around the house. Remember, limiting physical activities after the surgery will give your eyelids a chance to recover.