The eyelids are areas subject to changes not only associated with aging, but also with chronic sun exposure, lifestyle qualities and/or intrinsic skin characteristics. All these changes can result in a tired and fatigued appearance. In the upper eyelid, these changes are distinguished by development of droopy skin and fatty tissue resulting in puffiness. Unlike the upper eyelids, the lower eyelids play an important role in the transition from the eye area to the cheeks. As we age, not only does skin and fat accumulate, but the sagging of the cheeks causes noticeable demarcation in the under eyes. It is for this reason, in addition to removing excess skin and fat, one of the objectives of lower eyelid surgery is to create a harmonious transition between the lower eyelids and the cheeks.
Dr. Couto is a Cleveland Clinic trained plastic surgeon, and one of the few plastic surgeons in Latin America to have completed an American Society of Aesthetic Plastic Surgeon (ASAPS) endorsed subspecialty training in Aesthetic Surgery and Medicine.
During his training, Dr. Couto had the privilege to have mentors that are considered top leaders in the field of facial aesthetic surgery. This includes, Dr. James E. Zins, one the largest contributors to the field of facial rejuvenation. Because of his strong passion for facial rejuvenation, Dr. Couto has co-authored multiple scientific articles and book chapters about facial rejuvenation. Furthermore, Dr. Couto has been an invited faculty member of the annual American Society Plastic Surgery (ASPS) face and neck rejuvenation course.
Eyelid surgery or blepharoplasty is a procedure aimed to reverse aging changes that occur in the upper and lower eyelids, which typically produce a fatigued and tired appearance. This operation has three main objectives:
1) removal of droopy excess skin.
2) elimination of fat producing eyelid bags.
3) softening of the skin wrinkles around the eyes.
The upper and lower eyelids can be treated separately or at the same time, depending on the patient’s needs.
The consultation is divided into five parts:
1. Health and Medical History Evaluation
A comprehensive evaluation of the patient’s medical history is performed. During this part of the consultation, we focus on identifying any potential risk factors for the surgery. It is important to tell Dr. Couto of any recent eye surgery, such as Lasik or cataracts procedure. Furthermore, we need to be informed of any medications, supplements, or other drug intake, as these can have a big impact on the surgery. An example is aspirin or blood thinners, which can lead to the formation of a hematoma after your procedure. These are common risk factors that can be easily modified with lifestyle changes. Although this procedure has a low risk, our patient’s health and safety will always be our main priority. We like to set the patient for success, not for failure; therefore, modifying any potential risks is essential to obtain the best possible result.
2. Discuss with the Patient About Surgical Goals
Dr. Couto has a deep discussion with the patient to learn about their concerns and goals. Listening to their interest is crucial, since it is our priority to determine if we can meet our patient’s expectations. We focus on learning whether the patient is particularly interested in addressing an specific area of the face or if the patient is interested in a face and neck rejuvenation.
3. Physical Exam
A complete systematic analysis of the face and neck is performed. Dr. Couto treats the face and eyes holistically, not by areas, since a youthful appearance is marked by harmonious transitions between different areas of the face and eyes. Consequently, Dr. Couto not only examines the regions the patient is mainly concerned with, but also those surrounding areas and structures of the face and eyes that could help achieve a balanced and refreshing look.
4. Recommendations & Surgical Plan
Following the physical exam, Dr. Couto develops a personalized surgical plan aimed to meet the patient’s expectations, achieve optimal aesthetic results, and maximize patient safety. During this time, Dr. Couto discusses with the patient the indicated surgical techniques and explains in detail everything pertaining to the procedure and its recovery.
5. Pricing and Scheduling Information
Once the evaluation has been completed, our team will provide an individualized quote that is tailored to the procedure(s) discussed during the consultation and review the steps involved to book the procedure with us.
Individuals bothered by aging changes in the eyelids that produce a tired and fatigue appearance are great candidates for these procedures. These changes are characterized by droopy skin excess, eyelid bags, and skin wrinkles.
Upper Eyelid
This technique allows the removal of droopy excess skin and fat which produces a fatigued appearance through an incision that is hidden in the natural crease of the upper eyelid (Figure).
The upper eyelid lift is a quick procedure that can be either performed in the office under local anesthesia or sedation.
Lower Eyelid
Unlike the upper eyelid, numerous lower eyelid surgery techniques exist. Therefore, the treatment is highly individualized.
Patient’s exhibiting eyelid bags but no skin excess may be candidates to a transconjunctival or a “scar less” approach. Fatty tissue producing the puffiness appearance is removed through the inside of the lower eyelid. This technique requires no external incision and is appropriate only for the removal or redistribution of fat; it cannot be used to remove excess skin. Therefore, it is not the best choice if there is significant lower eyelid skin wrinkling.
Those patients exhibiting lower eyelid skin laxity will benefit from skin excision through a subciliary approach. This technique consists of placing the incision just underneath the eyelashes, which results in a scar that is unnoticeable since it gets hidden by the lashes and blends perfectly with existing skin creases.
Several weeks before the procedure, a preoperative appointment will be scheduled. During this appointment, we will discuss the surgical plan again, and clarify any questions involving the surgery. Furthermore, we will thoroughly review with the patient the preoperative/postoperative instructions and medication regimen and schedule the future post-operative appointments.
We always emphasize to our patients that medication (e.g. aspirin, ibuprofen), vitamins and herbal supplements (e.g. Fish oil, Omega-3, Garlic or Tumeric pills, Ginko Biloba) should be stopped at least 3 weeks before surgery, as this increases the risk of bleeding. Furthermore, we remind them that nicotine affects a person’s capacity for healing; thus, affecting wounds and scars. During the initial consultation, Dr. Couto will ask the patient to stop using nicotine containing products at least 8 weeks before the operation to reduce the risk of complications.
Patients with a history of diabetes mellitus must have a glycosylated hemoglobin (HbA1c) of 7 or less to be able proceed with surgery. If it is above this level, Dr. Couto will refer the patient to their primary care physician or endocrinologist to optimize their medications or diet to help lower the HbA1c levels.
Lastly, nutrition is crucial for an effective healing and recovery process. Therefore, we recommend to our patients to optimize their protein intake and avoid foods high in salt/sodium after any surgical procedure.
Several weeks before the procedure, a preoperative appointment will be scheduled. During this appointment, we will discuss the surgical plan again, and clarify any questions involving the surgery. Furthermore, we will thoroughly review with the patient the preoperative/postoperative instructions and medication regimen and schedule the future post-operative appointments.
We always emphasize to our patients that medication (e.g. aspirin, ibuprofen), vitamins and herbal supplements (e.g. Fish oil, Omega-3, Garlic or Tumeric pills, Ginko Biloba) should be stopped at least 3 weeks before surgery, as this increases the risk of bleeding. Furthermore, we remind them that smoking, vaping, or using any nicotine products may affect the results and recovery process. Nicotine affects a person’s capacity for healing; thus, affecting wounds and scars. During the initial consultation, Dr. Couto will ask the patient to stop smoking at least 6 weeks before the operation to reduce the risk of complications.
Patients with a history of diabetes mellitus must have a glycosylated hemoglobin (HbA1c) of 7 or less to be able proceed with surgery. If it is above this level, Dr. Couto will refer the patient to their primary care physician or endocrinologist to optimize their medications or diet to help lower the HbA1c levels.
Lastly, nutrition is crucial for an effective healing and recovery process. Therefore, we recommend to our patients to optimize their protein intake and avoid foods high in salt/sodium after any surgical procedure. This could be easily achieved with supplements available in our practice.
We provide our patients with a detailed postoperative protocol to ensure that they have a comfortable and quick recovery. The patient will need to apply cold compresses on their eyes to help minimize swelling and bruising, which are to be expected and can be noticeable for a week. It is rare for patients to experience pain or discomfort following this surgery and very unusual for a eyelid lift patient to require narcotic pain medications. We normally recommend our patients to take 7 days off from work (less if working from home). Patients can resume their exercises 3 weeks after surgery.
There isn’t! Every person ages in a different way and at a different rate; therefore, there isn’t a correct age to undergo an eyelid rejuvenation. The timing for an eyelid surgery is mainly determined by an individual’s skin quality and degree of eyelid bags. These intrinsic characteristics are not only influenced by age, but also by genetics, weight changes, sun exposure, history of smoking and other lifestyle qualities. For that reason, we perform a systematic analysis of the entire face, not only the region of the eyes, during the consultation. This enables us to develop a customized surgical plan that is based on the patient’s facial features, personal needs, and aesthetic desires.
A frequently asked question amongst patients is when to do fillers and when to do surgery. During the consultation, Dr. Couto will explain what changes are occurring on the eyes, and most importantly the reason why they are happening. This is crucial to determine if the patient is a candidate for a non-surgical or surgical treatment.
Non-surgical therapies, such as hyaluronic acid fillers are great for patients undergoing early aging changes around the eyes, where volume restoration and enhancement of shape are mainly required. On the other hand, patients exhibiting significant loose skin or prominent eyelid bags, surgical treatment may be more beneficial. Eyelid surgery is a procedure designed to specifically achieve those goals: remove excess skin and eliminate fatty tissue which produces a fatigued appearance.
Dr. Couto specializes in both surgical and non-surgical facial aesthetic treatments. Therefore, an objective and unbiased recommendation will always be provided during the consultation. The ability to know firsthand what can be accomplished non-surgically and when a surgical intervention is required is a unique and essential quality in the field of facial aesthetic surgery.
Uncontrolled diabetes can affect the ability of the body to heal wounds properly. Therefore, it is crucial for diabetic patients to have their blood sugar levels under control for this procedure. Patients with an HbA1c of 7 or less are candidates for this procedure.
There are numerous scientific studies showing that smoking cigarettes and/or using nicotine products increase your risk of postoperative complications. Nicotine affects the vascularity, and thus prevents the body from healing wounds properly following surgery. We recommend patients to stop smoking or use nicotine products at least 6 -8 weeks before surgery.