I've noticed droopy eyelids in recent photos, is there a solution to this problem?

Droopy eyelids is known in medical terms as eyelid ptosis. There are many potential causes of droopy eyelids, going from medication related (opiates), autoimmune disorders, tumors, paralysis of the muscle that lifts up the eyelids (elevator aponeurosis), mechanical, or related to aging. Some children are born with ptosis and this is known as congenital ptosis. 

The first step in the management of droopy eyelids is to determine if this is an acquired condition or if the patient was born with it. Most cases of ptosis are acquired. 

As a plastic surgeon, the majority of the cases I see are related to aging and laxity of the connective tissues (aponeurosis) that connects the levator muscle to the tarsal plate of the upper eyelid. This is known as senile ptosis. There is a surgical procedure known as tarsolevator advancement that re-attaches the levator muscle and the tarsal plate in a better position to then allow for contraction of the muscle to elevated the eyelid.

It is important when performing a blepharoplasty (or removing skin from the upper eyelid) that we identify any patient that has underlying ptosis as these patients will continue to be unhappy and will continue to complain of looking tired post-op if the droopy eyelid is not corrected. 

This is the importance of finding a board certified plastic surgeon with additional training in advanced oculoplastic techniques.

Doctor, I had a lower blepharoplasty and now my lower lid is droopy. My doctor wants to do surgery, but I'm only 10 days post-op. What should I do?

The short answer is no surgery until 3 months post-op at least. As I analyze your pre-op photos, you were at an increased risk for this complication considering the negative (or downward) tilt of your lateral eyes. You also had already some roundness of the lower lids that was more prominent on the left lower eyelid. When I treat patients with these anatomic variants, lower lid support during the initial operation is needed. The most commonly used techniques to support the lid are either a canthopexy or a canthoplasty depending how lax is the lower lid and if it needs to be shortened. Some patients with severe scleral show (showing the white part of the eyeball between the lid and the iris), will need graft support also but this is much less common specially in a primary case. 

All these being said, the worse time to do surgery is now because all the tissues are inflamed and the sutures won't hold. In the mean time, what I would suggest is that you tape the lateral aspect to the eyelid up to provide support. I do think you should at least to the upwards "push ups" or massages to at least keep the scar tissue at its minimum. Use Refresh eyedrops 4x a day, and Refresh ointment at night so that your eye does not get dry from exposure during sleep. 

It is very likely that further surgery is needed in the future, but I would wait at least 3 months. In terms of the procedure that you would need, likely a canthoplasty vs. canthopexy. A cartilage graft is needed when the central aspect of the lid is still not touching the inferior limbus (black part) when you push with 1 finger on the lateral canthus. A physical examination will be needed to determine the best procedure in your case. But what ever you do, please don't have surgery now! Patience will pay off in this particular case. You don't want to go through surgery and end up with the same problem. Also, look for a plastic surgeon with training in oculoplastic surgery. 

Hope this was helpful. Good luck!

Anything I can do for my droopy eyelids?

Eyelid ptosis or droopy eyelids as is commonly known, is an acquired condition in most cases associate to aging and tissue laxity in the muscle attachments that is responsible for lifting the eyelid itself. Other more serious causes most be ruled out during your consultation. If it is acquired, bilateral, and has progressed gradually it is most likely senile ptosis and no further testing is required. When the problem is unilateral, then a more thorough evaluation is required.

A droopy eyelid is a very different problem than just having a little extra skin in the upper eyelid.  Interestingly enough, patients with either problem will complain of the same thing, I “Doctor, look tired all the time”.  It is very important to identify and differentiate a droopy eyelid from excess upper eyelid skin as the surgical approach is different. In many case, both problems exist. If a patient with droopy eyelids is treated with a conventional blepharoplasty he or she will be unhappy with the results as he or she would still have a tired-looking appearance. 

Cases like this require advanced techniques that I have learned during my oculoplastic fellowship and that I routinely use in my practice to be able to help patients with more complicated eyelids and periorbital problems.
 




 

Bruising after injectables? How bad is it?

This is one of the main concerns of patient's coming in for Botox and/or facial fillers.  There is always a possibility of minor bruising anytime the skin is penetrated with a needle.  That being said, most patients that have Botox and/or fillers do not bruise.  

Patient's that are taking blood thinners such as aspirin, Plavix, warfarin (Coumadin), fish oil, and even herbal supplements are definitely at a higher risk and must be told about this prior to treatment.  I must mention, that this is not an absolute contraindication.  In fact, I perform injections in many patients taking daily baby aspirin for preventive reasons and as long as I am careful with the technique, I have not noticed an increase risk of bruising.  I must mention, that I am more careful with this patient's when they are requesting treatment closer to an event and I might recommend in this scenario to have the injections afterwards if they do not want a risk showing up at any event with a bruise.
How can we prevent bruising then? I encourage patients to start taking arnica pills for 2-3 days prior to their injectable appointment and to continue taking them for 3-5 days after. From a technical standpoint, injecting Botox with careful attention to those small veins that are sometimes noticeable through the skin, will prevent  injecting into a vein which will result in bruising. In terms of fillers, many surgeons believe that using blunt cannulas could decrease the chances of bruising. This being said, a surgeon that is used to inject with needles rather than cannulas, does not necessarily have a higher bruising rate.  Therefore, there is much to do with technique than with the actual use of a needle versus a cannula.

What are the most common areas treated with Botox?

The most commonly treated areas are:

1.  In between the brows - also known as the "elevens"

2.  Forehead - horizontal lines that form when lifting your eyebrows as when you are surprised

3. Crow's feet - wrinkles on the side of your eyes when you smile

4. Bunny lines - those lines that form on the sides of your nose when you smile

In the lower face, Botox can be used to reduce the size of the masseter muscle (the muscle that bulges on the side of your jaw when you clench your teeth), or to weaken the muscle that pulls down on the corner of the mouth.

On the neck, Botox works well treating those neck bands that form in the midline or on the sides. These bands are caused by a hyperactive platysma muscle underneath.

 

Botox or Dysport?

These are for sure the 2 most commonly used injectables for facial wrinkles.  Botox has a greater market share and many times the brand name is used broadly even when referring to any of the other 2 available neurotoxins (e.g. Dysport, Xeomin).  From a medical standpoint, their efficacy is comparable.  In general terms, patient's usually have Botox when they are introduced to neurotoxins for the first time. and this could be based on doctor's preference or patient request. There is a small subset of patients that report less than desirable outcomes with Botox, which then prompts them to use Dysport and in many cases they do see a better response.  The same can happen vice versa.  Dysport contain cow's milk protein and lactose. Therefore, someone with allergies to these ingredients might be a better candidate for Botox.
In my practice, I would say approximately 90% of my patients are treated with Botox, 9% with Dysport, and less than 1% with Xeomin.  The patients treated with Xeomin usually have done it before at another practice and they come to me requesting this particular product.  For a first-time user, I tend to use Botox as my treatment of choice.
It is important to mention, that the price point for Dysport could be at times cheaper than Botox and more affordable for patients.  Considering the efficacy is comparable, many patients may elect to have Dysport just for financial reasons.

When can I start doing Botox?

Great question! Treatment of facial wrinkles with Botox or any of the other 2 neurotoxins (medical term) available in the U.S. (e.g. Dysport and Xeomin) has gone from being a treatment modality to more of a preventive measure. Patient's are not waiting anymore until they are 50 years old to treat their wrinkles.  In fact, they are now trying to prevent them from forming. 

I often see patients in my practice in their early 20's that are seeking treatment because of noticeable frowns in the upper face.  The majority of the young patients that I see are concerned about the famous "11's", which are the vertical frown lines that form in between the brows.  These wrinkles are formed by the contracting forces of 2 muscles named "the corrugators" (medical term), which aim to pull the brows down and together.  This facial expression is commonly done when a person is furious, but in a lot of patients the muscles can be very active even during passive activities such as reading giving the patient the appearance of being mad. 

It is never too early to start exploring what Botox is all about. This being said, I would only consider Botox for cosmetic reasons in an adult patient (18 or older). The most important thing is to do your research and find a board certified plastic surgeon with vast experience with injectables in order to minimize any potential complications.

 Hope this was helpful.  Good luck!