The eyes and eyelids together are the most complex and expressive area of the face. As the focal point of the face and the area that tends to age most rapidly, the eyelids, once restored, can make a tremendous difference in your appearance. Far from "just taking the skin out," there are nuances to treating the lids that are second nature to an oculoplastic surgeon and will result in your most beautiful and comfortable result.
The most commonly performed procedure for the lids is called a "blepharoplasty." The purpose of a blepharoplasty is to restore the lids to a more pleasing contour and rid the eyes of a tired or worn-out appearance. (Men, take heart. My technique for you is entirely different than it is for women and you will not look weird). In either event, the procedure is individualized for each patient. With any of the facial features, we're dealing with very small "aesthetic units," in which even a half-millimeter is a much larger percentage of the whole than it would be, say, on a thigh or a breast. So although the written procedure in our medical books may seem pretty straightforward, the difference between a mediocre and a truly beautiful result is in the skill of the surgeon.
A facelift is a great antigravity device. If your face truly has "dropped" and your skin is in decent condition, this would be a procedure to consider. A well-performed facelift, sometimes with the addition of fillers, will look completely natural without sacrificing the amount of restoration that you receive. In other words, a natural-looking facelift doesn't mean we did less; it just means we did it correctly and realized that we're working in three dimensions, not two. It also means that each facelift is going to be a little different because each face is a little different from the others. Almost always, a facelift includes a necklift.
A necklift can either be performed alone or as part of a facelift. What it does is restore the contours of the neck, remove the "turkey wattle," and/or sculpt down the heaviness of the neck. If you have a necklift without a facelift, it can be performed through a little incision under your chin in a place that renders it almost invisible.
We have myriad ways to tighten skin. Most involve some kind of laser, light, radiofrequency wave or chemical peel. Some work better than others, and the newest thing (and I’ve had a few) may just be the thing that hasn’t had a chance to demonstrate how poorly it actually works -- or lasts -- yet.
Non-fractional (or “ablative”) CO2 laser skin resurfacing – when done with optimal technique -- is closer to a magic wand than any other light or laser. It remains the gold standard for treating truly damaged skin and is a home run in my office virtually all the time. Does this mean we can guarantee a perfectly flawless face with it? No, but we can get closer to a perfectly flawless face on the most flawed individual with the CO2 laser than with anything else on the planet!
So what’s the catch? Is it painful? No. The catch is about 12 days of downtime and looking unsightly (a charitable term) for a good part of that time. By that 12th day however, the vast majority of patients, albeit rosy, already are thrilled with their results. Then for a couple of weeks, you can tone things down a bit with our Jane Iredale mineral powders (no heavy green spackle necessary), although I think the rosiness looks rather cute most of the time. Usually, by the end of four weeks, you don’t have to come up with any stories about sunburns in Florida anymore, and you can now let your beautiful, foundation-free skin show itself gloriously!
You've probably heard everything from 5 years to 20 years. The reality is that after a well-performed facelift, at any time down the road, all things being equal, you're going to look better than you would have without the facelift. Think of the lift as turning the clock back, and then as soon as you're vertical again, the clock starts to tick and gravity resumes its business of doing what gravity does. This is where the all-important lifestyle choices can make a huge difference. If you take care of yourself, that clock will tick a lot more slowly than it did when we were not paying enough attention to issues like sun damage or nutrition. Even mannerisms (and I can help you learn about these) make a difference. Genetics and attitude also affect how we age. And lastly, at what point does any one individual look in the mirror and say, “It’s time for another lift”? That is a big factor right there.
Because it's surgery, I want my patients to realize that they need to be kind to themselves and not go out to dinner the following evening. Any procedure is going to be a little slam to the immune system. From a cosmetic perspective, it all depends on any bruising or swelling that occurs. Bruising is usually minimal because I insist that my patients not go near any foods that will thin their blood. We will give you a list. Still, Mother Nature can throw us a curve ball occasionally. Some people can look a little chipmunky for a week, but again, there are a lot of variables involved. I usually stay on the safe side by telling my patients that it will be a week or two before they're looking normal to themselves.
Technically, there will always be a scar where an incision was made because that is how the body heals. The issue then, is to make that scar as inconspicuous as possible. With the newer procedures, we are able to minimize the size of your incisions relative to the facelifts of decades past. The fact remains that the size of the incision will be determined in part by how much we have to do to restore any particular face with the lift. I consider inconspicuous incision lines to be a major factor in the success of a lift and devote considerable effort to that end.
Years ago, we thought that when people wanted to look younger, they got facelifts. We're way ahead of that now and savvy enough to know that what we associated with the term "younger" was really about looking fresh, vital and radiant. Sometimes a facelift is what's indicated for that -- and sometimes it isn't. If, for instance, a facelift is used to pull the wrinkles out of skin that's lost its elasticity, that might look great for about a nanosecond, but the real problem will not have been addressed. The way you restore damaged skin is addressed elsewhere on this site, but it's not with a facelift. Now while we can move volume in the face from South to North with a facelift, we can't replace volume without -- replacing volume. That's where fillers make their entrance. Now, if you look in the mirror and scowl and wrinkle up your nose and bare your teeth and put on your nastiest face, what you're looking at is a lot of muscle contraction. A facelift won't solve that either. A properly placed muscle relaxer (neuromodulator, in medical terminology) such as Dysport, Xeomin or BoTox will relax the "nasty" muscles that pull the face down and in, and it will allow the "happy" muscles that pull the face up and out to work unopposed. So the bottom line is that there isn't one magic bullet to restore our faces, but we have a lot more of the tools we need now to effect a restoration of the face in a meaningful way. Some of those tools last longer than others, and I give great thought to maximizing the longevity of any treatment for my patients. The most important part of this is that we treat any particular condition with the correct procedure.
Think of your skin as being on a continuum from babyhood to say, 110 years old. Since the resurfacing creates a physiologic change in the skin by resurfacing it, shrinking it and stimulating collagen formation, it is effectively taking the skin to a younger, healthier state altogether. Also, since we know that the vast majority of the “aging” of the skin is due to lifestyle choices rather than the sheer passage of time or genetics, we can put you on a simple and effective skincare regimen afterwards, along with a good dose of awareness, so that the clock going forward ticks a lot more slowly than it did when we were young and silly and thought our tans were so cool. I have patients in their 80’s who still have skin like angels after 12 years or more! (Does that look strange? No. What looks natural does not look strange. It looks gorgeous and so does their self-confidence). Whatever you do, choices notwithstanding, your skin will always look that much better than it would have without the laser resurfacing.
At 12 days, we get you into whatever level of make-up makes you comfortable – our Jane Iredale cosmetics are beautiful, safe on your new skin and actually help in the healing process – and we get you into one of our excellent sunscreens. At that point, you can start to live like a human again, but you must delay the golfing, sailing, etc., that would have you in the sun for any period of time. After about 6-8 weeks following the procedure itself, you can do whatever you want without my having to lose sleep worrying about you getting brown patches (“post-inflammatory hyperpigmentation” in medical terms), but this is when you make decisions about whether you want the results forever or not.
My patients are so thrilled with how they feel with their firm, smooth, glowing skin, that with rare exceptions the issue takes care of itself. It usually does not involve serious lifestyle changes, just an awareness about sun protective hats, reapplying sunscreen periodically, etc., and treating yourself as though you matter. Lastly, in answer to patients who protest that they need a tan to look good (and this is invariably before we do the procedure, not after), my reply is, “How many times have you looked at a baby’s face and thought, ‘That kid needs a tan.’?”
In descending order of severity: The worst risk would be scarring. While no ethical surgeon can make guarantees or promises, I can tell my patients that after almost 20 years, thousands of procedures and extensive teaching of my technique, I’ve never scarred anyone yet, and the likelihood of any one person being the first at this point in time, is probably not worth their losing sleep over it.
Another risk is the hyperpigmentation that I mentioned above. Part of my job is to determine if someone’s skin is too dark naturally to have the procedure done without incurring an unacceptable risk of this. In borderline cases, the patient and I will discuss the risk, how we would handle it if it occurs and whether they want to go ahead. We can also prep the skin ahead of time to help avoid hyperpigmentation. The good news is that it is rare, and in any event we can treat it quite successfully with topical skin preparations. The bad news is that its resolution can take several months and even blue-eyed blondes can get it if they go out in the sun too soon after the procedure.
Rarely, and I haven’t seen one in about 10 years, someone will pick up a little skin infection, and if this happens I can diagnose it on the 5-day post-op visit and start a weeklong course of oral antibiotics. These go away pretty quickly and do not affect the final result.
Lastly, the CO2 laser can produce some acne-like eruptions, called milia. Although in the medical literature the CO2 laser is notorious for this, it actually happens in a minority of patients and usually clears up within weeks. Occasionally it can last longer and be very disturbing for the patient while it’s there. We will support you with any additional facials you need at no extra charge, and it does go away.
With the right laser and the right technique, that should never be a problem. Waxy, shiny, pasty is poor technique. There will be a luminous glow however, and that is because the healthy skin will be reflecting highlights from the ambient light rather than absorbing it. Regarding pastiness, the question of “hypopigmentation” (loss of the natural pigmentation of the skin) has been batted around in the medical literature for years, and it certainly is more likely when repeated procedures (very rare) are done. Every once in a while a patient will comment that they think their skin has become quite light. Remember that the laser will remove the accumulated color, muddy that it is, from years of sun exposure. When we compare the color to a patch of skin on the patient’s body that has never seen the sun, it’s usually actually a shade darker than that never-exposed area. Also, the laser procedure stimulates the formation of collagen; and collagen supports the blood vessels; so while the skin may be much closer to the color you were born with, the added efficiency of its blood circulation, gives it more of that little baby flush.
You won’t see that out of my office. I blend. The only time I’ve seen that happen is over several years afterwards when patients are using sunscreen on their faces and stopping it at the jaw line.
Oculofacial Plastic Surgeon, Sarasota, Florida
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