Hello, this is Dr. Boris, I am in Culver City, California and I’ve been practicing for almost 50 years, which is a long time. Today we’re gonna do upper and lower blepharoplasty on this lady. She’s asleep. Dr. Rappaport was a cardiac anesthesiologist, his training was excellent, he is board certified, he is giving a little anesthesia – general, and so what we’re gonna do is put some local in here.
The Preparation
She has a lot of hooding and a lot of extra skin in the upper eyelid along with fat in the inner part of the upper eyelid that we’re going to take out. When I press down on the eye, on the globe, you can see the fat. She’s really got a lot of fat on a low lid.
There are two ways of taking out fat. Sometimes I do it from inside the eyelid, or sometimes I make an incision just under the eyelashes. It’s the same unless I want to take out some skin, then I would usually go with the external approach but even with an internal approach, I can take out a little skin if necessary.
But in her case, because she’s convex with the respect to the fat pushing on the eyelid, when I take it out the fat will become concave and the skin will occupy more surface area so there’s little less need to take out the fat. The concern is not the skin, it is really the fat that she has. So we’re going to focus on taking out the fat both in the upper lid and the lower lid and taking out skin in the upper lid.
So we are going to eliminate the hooding and that’s basically what we’re going to do today. I injected Lidocaine with epinephrine in the upper leaves in the lower lids.
The Upper Eyelid
Steps on the left side
Now I’m going to start with the upper lid. I’m going to take out the excess skin and then we’ll go for the fat. I made my incision in the area I outlined which is the excess skin. So I took out the skin now. This is a baculovirus muscle and we’ll take a little bit of the muscle which is going to help me define the crease of the eyelid and then I’m gonna take out some fat.
Now a lot of times I take this tissue, both the muscle and the fat, and put it into the face, like on in the nasal labial fold, the cut down on, or to improve the crease. So I’ve taken out a little fat muscle, sliver muscle, and now I’m going to go get the fat.
Okay, so the fat is right here, that’s what I’m concerned about. There’s a lot of fat here, see this heavy, this a lot of fat. You see all the fat, it’s been sticking under the skin, all the fat she’s got just hanging in here, look at this fat, extra fat just hang in and really gives a lot of fullness, heaviness to her upper lid. Look at just this fat! And there is a lot more, and I want to show you.
This was a baculovirus muscle, and if I move it over, you can see, that this is the levator muscle. This is an eyelid muscle that is attached to stretchable to the toss. This here, it stretches and elevates the eye. We’re far away from the eye itself and we’re far away from the vital structures. We don’t touch it or injure it at all. So as we complete, I have to do now is suture this, but first, before I do that, I’m going to do the other eye, the other side and then we’ll get to the closure.
Steps on the right side
I took out the skin now. I’m going to take out a little fat but a bit less muscle to help on the one mentioned with a nice crease. Ok now let me have a skin hook. There are a lot of blood vessels here but we’re pretty bloodless the way we’re doing it. I am taking out more fat. I am getting more fat out. Let’s get this yellow fat out.
So we did both eyes and now we are gonna close it, and on the upper lid, I always use a non-absorbable suture that comes out in a week. And the reason I do that is otherwise if it dissolves too quickly, it would open up and we don’t want it to open up so it really takes about a week for the healing perfectly.
The Lower Eyelid
Steps on the right side
So now we’ve completed the upper eyelids, they’re closed and they look really good. The fat is taken out, the extra skin is taken out and I am happy with that. Now I’m gonna make an incision just below the hairs to the eyelashes.
We’re gonna begin to see all the fat now coming out, as I dissect this. What I’m doing now is using these retractors to retract the muscle which is over this fat and I’m taking the fat out. I identified the fat, the fat is really significant here. I want you to just take a look at all this bulging fat here we got. Wow, just a lot of fat. I’ll show you some vital structures in a few minutes – like this significant muscle that moves the eye, but meanwhile, we’re just going to take out the fat.
All right, I haven’t even got to the middle part, missed doing the outer part, and I’ll get this. A lot of times, I take this fat in a pot and put it under the muscle because the groove could be what we call the nasal juggle angle depressed. So we could fill this up, but she doesn’t need that, she just needs his fat taken out.
Now, this is a muscle that controls what I call the inferior oblique muscle. I always identify it, and the point of identifying is for you don’t injure it. So we take out the fat between that muscle and the inner part and the outer part. And now look at the muscle, this is the muscle that is really vital to keep. The fat is taken out as much as we need to take out and let’s see.
We are ready to close. I’m very concerned with the upper and the lower lid, but I am going to just quarter the eyes a little bit, on the muscle, to cut down on the wrinkling that this muscle can create.
Steps on the left side
Okay, now I am doing the left side exactly what I did on the right. I’m gonna create an attraction on the lower lid and now I’m going to make my incision in the lower lid in a way that I can get out the fat skin. What I’m going to do now is to bring the muscle which is over the fat inferiorly or down below deep inferiorly below exposing the fat that’s under. I am pushing the muscle down, exposing the fat that’s underneath it. We’ve had a lot of fat right now, we’re gonna start taking it out now.
There is a lot of fat here that’s hiding, that doesn’t want to come out. If I didn’t look forward, and I closed her you’d see big bowls at the end of the surgery, and we don’t wanna do that, we want to get all that fat out so we’re looking for that fat here. Here look at this big vessel, here is the muscle, by the way, see the muscle the inferior oblique that we saw on the other side, you know we have the big vessels here we just cauterize them so they don’t bleed.
We’re closing with the absorbable stitches sutures that will fall out the next few days. That’s it.
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