As of the time of this post, South Koreans have more plastic surgery per capita than any other country on earth. The United States is much larger, so more plastic surgery procedures are done in the United States; however, a higher percentage of the South Koreans have Plastic Surgery than Americans. Moreover, Dr. Millard may be at least partially to blame.
in 1954, Dr. Millard was recalled to active duty during the Korean War as Chief Plastic Surgeon to the U.S. Marine Corps during the Korean War. During his time in Korea, he took care of injured soldiers, but he also came into contact with many children born with cleft lips and palates.
Above – Dr. D. Ralph Millard reviewing before and after pictures of Cleft Lip and Palate surgery. His contribution of the rotation-advancement flap repair remains one of the most significant advancements in the field of congenital lip deformity correction.
The incidence of Cleft Lips and Palates is twice as high in Asian populations (1 in 500 births) as it is in the Caucasian population (1 in 1000 births), and four times as high as in the African population (1 in 2000 births). After studying photos of these defects, he developed the rotation-advancement flap cleft lip repair. He performed the first such procedure during the war, and it is now perhaps the procedure for which he is best know. His signature cleft lip repair is currently used around the world as one of the most versatile and predictable cleft lip repairs we Plastic Surgeons have in our arsenal.
From Cleft Lips to KPOP
During his year in Korea, Dr. Millard performed hundreds of reconstructive procedures for victims of war, most of whom were Korean. And like most plastic surgeons, he was not idol when the war lulled. In addition to cleft lip surgery, he also advanced “double eyelid surgery.”
Asian Eyelid Surgery can include refining an ill-defined eyelid crease in addition to removing upper eyelid skin redundancy and lower eyelid bags. The double eyelid before and after pictures above are of one of my patients, and show the improved, yet natural appearing results that are possible with Dr. Millard’s techniques.
It is believed that Double Eyelid Surgery or Asian Blepharoplasty was first introduced in late 19th-century Japan; however, it was during the Korean War that the operation became popular in Asia.
Why Change the Shape of the Eyelid?
There have been many heated debates about what drives us to have plastic surgery. Why double eyelid surgery is performed is no exception. In many Asian Eyelids, the upper eyelid fold, the superior palpebral fold, is absent or poorly formed. This leads to increased fullness of the lid, increased upper eyelid weight from less support for the eyelid fat, increased upper eyelid sagging, more visual obstruction, an epicanthic fold, and according to Dr. Millard, a more stoic expression.
The stereotypical Asian eyelid has a single fold at the bottom. The eyelid skin flows smoothly to the margin of the lid. The Caucasian eyelid is a double eyelid. One above the crease and one below the crease. Or if you rather, one inside and one outside. But like most stereotypes, it is not that simple. Not all Caucasians have well defined eyelid creases, while half of all Asians do.
K-Pop is short for Korean Pop, and can mean the performers or the music. Much like in the U.S., K-pop stats exemplify the ideal standard of beauty in South Korea. As the K-Pop phenomenon grows, so too does the Korean plastic surgery industry.
The goal of double eyelid surgery is to form a natural crease that is beautiful. Heavy upper eyelids are not considered attractive, especially for women. Heavy eyelids are more masculine, but also may be a sign of fatigue or inattention. Others respond to us better when we look like we are paying attention to them. Open, alert eyes are a visual cue signaling interest.
Most Asians, like everyone else undergoing eyelid surgery, are looking for improvement. Sometimes it is purely functional, but even then there is also an improvement in appearance. Last year, a million and a half people had double eyelid surgery. This accounts for about 15% of all the cosmetic plastic surgeries performed around the globe.
Back to Dr. Millard. So why is he responsible for the disproportionate number of Plastic Surgeries performed in South Korea well after his time there? Dr. Millard was well known for developing his cleft-lip repair during his time in Korea; however, his other equally groundbreaking work was the advancement and popularization of the double-eyelid surgery.
His initial work on the eyelids was done for reconstruction after injury. Reconstructive surgery is both humbling and educational. The exposure of the underlying anatomy can be as daunting for the reconstructive surgery as it can be enlightening. Methods that work well for reconstruction, can also be adopted to enhance otherwise normal anatomy, too.
Above are the actual before and after pictures of the Korean translator who approached Dr. Millard. Notice the dramatic changes in the eyelids and nose. Do you think he looks less stoic?
The story goes, during his time in Korea, a Korean translator approached him and asked to be “made into a round-eye.” He felt that because of the closed appearance of his eyes, Americans could not tell what he was thinking and consequently did not trust him. Millard later wrote. “As this was partly true, I consented to do what I could.”
Understand, racial intolerance in the U.S. was greater then than it is now. Although the War Brides Act in 1945 enabled American soldiers stationed overseas to bring home wives of a different race, interracial marriages were illegal in parts of the U.S. until the early 1960s, leading to more distrust and a desire to reduce racial features in order to blend in and avoid conflict. The world has evolved a little, but is still not a perfect place.
Dr. Millards’s Double Eyelid Surgery
Dr. Millard was aware that surgeons in Japan, Hong Kong, and even Korea were already performing double-eyelid procedures for both medical and cosmetic reasons. He was unable to find any publications about the surgery that were written in English, so he devised his own operations.
Dr. Millard decided to raise the nasal bridge and widen the eyes. He transplanted cartilage to the nose for Nasal Augmentation and performed Z-plasties to the inner fold of the eyelid to flatten it and open the inner aspect of the eye opening. He also removed fat resting above the eye and sutured folds of skin to the deeper structures, creating the attachment seen in double eyelids.
The results were pleasing to the translator, and like his cleft lip repair, the techniques are still used today in Korea and throughout the world. The combination of safe, predictable and functional results, aligned with an improved cosmetic appearance has caught-on in Korean pop culture, and Dr. Millard’s techniques seem to have been the catalyst.
Dr. Ralph Millard, Jr. (June 4, 1919 – June 19, 2011) as I remember him. He was described as “the most brilliant and creative plastic surgeon alive” at the time.
In the April 2000 issue of Plastic Surgery News, David Ralph Millard, Jr. (June 4, 1919 – June 19, 2011) was described as “the most brilliant and creative plastic surgeon we have alive.” He is perhaps best known for his versatile and widely-used technique for repairing cleft lips, but his contributions to Plastic Surgery, especially reconstructive Facial Plastic Surgery are too many to list. Dr. Millard may also be the person most responsible for the current explosion of K-Pop Plastic Surgery in South Korea, but more on that in the next week.
Dr. D. Ralph Millard
Dr. Millard’s portrait from 1937, as it appears on the Asheville Prep School’s notable alumni page. He is one of the 10 surgeons nominated “Plastic Surgeons of the Millennium” in 2000 by the American Society of Plastic Surgery.
Though his given name is David Ralph Millard, Jr., Dr. Millard went by his middle name, Ralph. I would only call him Dr. Millard. I read a later edition of his 1957 tome, The Principles and Art of Plastic Surgery Vol I and II, cover to cover, several times during my residency. It remains one of the foundations of modern plastic surgery. Co-authored with another World Famous Plastic Surgeon, Sir Harold Gillies (1882-1960), the first edition originally sold for $35, and is offered today on Amazon for $2500, used.
The Principles and Art of Plastic Surgery
The Principles and Art of Plastic Surgery began in 1564, with famous French barber surgeon Ambroise Paré. Yes, surgeons are descendant from barbers, not physicians, but that’s another story. Ambroise Paré Surgical Principles numbered five:
Take away what is superfluous
Restore to their places things which are displaced
Separate those things which are joined together
Join those which are separated
Supply the defects of the nature
The Ten Commandments of Plastic Surgery
In 1950, Dr. Millard published Sir Harold Gillies’ Principles, also known as the ten commandments of Plastic Surgery:
Thou shalt make a plan
Thou shalt have a style
Thou shalt honor that which is normal and return it to normal position
Thou shalt not throw away a living thing
Thou shalt not bear false witness against thy defect
Thou shalt treat the primary defect before worrying about the secondary one
Thou shalt provide thyself with a lifeboat
Thou shalt not do today what you canst put off until tomorrow
Thou shalt not have a routine
Thou shalt not covet thy neighbor’s plastic unit, handmaidens, forehead flaps, Thiersch graft, ox cartilage nor anything that is thy neighbor’s
These principles can be applied to most of life’s pursuits. Elaboration on how the commandments are applied to skating for example, is available in this publication from the Archives of Plastic Surgery entitled, “Plastic Surgery and Aggressive Skating: Can Business Mix with Pleasure?” The Articles from Archives of Plastic Surgery appears on the National Center for Biotechnology Information website and was collected from PubMed Central (PMC) as part of US National Library of Medicine and the National Institutes of Health. Interestingly, the footnote states, “Articles from Archives of Plastic Surgery are provided here courtesy of Korean Society of Plastic and Reconstructive Surgeons.” However, it is still not time to talk about Korean Plastic Surgery.
But Wait, There’s More
The Principles And Art Of Plastic Surgery -Sir Harold Gillies, CBE, FRCS, and D. Ralph Millard, Jr., MD, Assistant Clinical Professor of Plastic Surgery, University of Miami, Florida. Little, Brown and Company, 34 Beacon Street, Boston, 1957. In Two Volumes, Boxed. 690 pages, 2472 illustrations, 122 in color. Original price $35.00 new. Current Amazon price over $2500 used.
In 1957, six more principles were added in the book mentioned above, The Principles and Art of Plastic Surgery. Through the course of his life, eventually these became Dr. Millard’s 33 Commandments of Plastic Surgery. Most are aligned with the more fundamental and self deprecating KISS principle: Keep It Simple Stupid. The complete list can be found on the Internet Scientific Publication Website.
You Can’t Go Wrong With Good Principles
To me, these simple guiding principles are Dr. Millard’s greatest contribution to Plastic Surgery. Others will argue that one or another of the specific techniques he adapted or improved are more important, but commandments two, nine and ten say to me: Plastic Surgeons should keep evolving and not solely rely on the past or a technique. The commandments are a simple and yet effective framework with which to refine current techniques and to evolve the future of Plastic Surgery.
So What About South Korea?
Two of Dr. Millard’s most famous techniques are the rotation-advancement flap for the correction of the Cleft Lip and Palate Deformities, and the Double Eyelid Surgery or as it is called in the US, Asian Blepharoplasty. Both of these were developed while he was Chief Plastic Surgeon to the U.S. Marine Corps during the Korean War. How this led to the boom in Korean Plastic Surgery 60 years later is the subject our next San Francisco Plastic Surgery Blog post.
Miami, Florida, seems to be hot bed for Deceptive Plastic Surgery Practices, and is giving good Miami Plastic Surgeons a bad name. The most recent incident to make the national news is a Botched Brazilian Butt Lift at Encore Plastic Surgery. The clinic is linked to a chain that focuses on cheap plastic surgery for medical tourists visiting Florida for a procedure and a vacation.
Fake San Francisco Plastic Surgery
Miami is not unique, however. This year, Carlos Guzmangarza was sentenced to 20 years in prison for performing illegal plastic surgery out of his fake San Francisco, California “plastic surgery” clinic. His Mission District clinic preyed on many Central American immigrants. Allegations include: smoking a cigar during surgery, flushing Liposuction fat down the toilet, sexual assault, the injection of unknown skin fillers and leaving a four inch needle in a patient’s buttocks. Eventually, he was convicted of thirty-three felonies and eight misdemeanors.
Caveat Emptor – Let the Buyer Beware
In most cases, there are clues that everything is not up to the usual standard of care. In the case of Mr. Guzmangarza, not only was he not a Board Certified Plastic Surgeon, he was not a doctor. He did not have a medical license, and that’s something that anyone could check.
Check the Medical License
Notice the medical license is for a “Physician and Surgeon.” California, like all states, does not differentiate.
I am Certified by the American Board of Plastic Surgery. The only ABMS recognized board for Plastic Surgery.
The American Board of Plastic Surgery offers a free, online certification lookup. Click here to see if your doctor is certified by the American Board of Plastic Surgery. Most doctors claiming the title “Plastic Surgeon” are not certified by the American Board of Plastic Surgery. In fact, it is estimated that only one in twelve practitioners practicing plastic surgery are Certified by the American Board of Plastic Surgery. Does your doctor have the best training?
Check For Other Board for Certifications
I am also certified by the American Board of Surgery, because I completed a residency in General Surgery, too.
If your doctor is certified by the American Board of Ophthalmology, they are trained in surgery of the eyes. So if you are having Eyelid Surgery, they should have had the appropriate training. On the other hand, if you are having Liposuction, buyer beware.
If your doctor is certified by the American Board of Otolaryngology, the are trained in ear, nose and throat surgery, so Facial Plastic Surgery is within the scope of their training. If you are having Rhinoplasty, this is an appropriate board for certification. If you are having Breast Augmentation, buyer beware.
Non-Surgical Board Certification
The non-plastic surgery boards listed above are at least surgical boards. Some “cosmetic surgeons” have non-surgical board certifications. Certification by Family Practice and Internal Medicine Boards is not reassuring if you are having a surgical procedure. Proof of additional surgical training should be made available, and it should be years or training, not a weekend course.
Do Your Homework
A well trained, experienced practitioner will be up-front and honest about their training and abilities, but those who are not honest may be even more convincing. You need to do your homework. Use the links above to confirm what you are being told. If it does not fit, do not commit.
Eyelid Surgery, aka Blepharoplasty, remains one of the most popular Cosmetic Plastic Surgery procedures. Last year, according to the American Society for Aesthetic Plastic Surgery (ASPAS), it ranked number four, ahead of Breast Lifts, and behind Liposuction, Breast Augmentation and Tummy Tucks. The statistics do not break down the number of Occidental vs. Asian Eyelid Surgeries performed, but here in the San Francisco Bay Area, the Asian Blepharoplasty accounts for a significant percentage of all the Eyelid Surgery Performed.
You don’t have to be a Board Certified Plastic Surgeon to see that the Asian and Occidental eyelids have different shapes. These differences are directly related to ethnic changes found in the Eyelid Anatomy. While the goals of Blepharoplasty are the same, the techniques to achieve these goals must be modified for differences in the anatomy between Occidental and Asian Eyelids.
Asian Eyelid Surgery Video (Asian Blepharoplasty)
Below is a segment from my latest KRON 4, Body Beautiful show. Several Asian Eyelid Surgery Before and After Pictures are included, and narrated, to help illustrate what Asian Blepharoplasty has to offer.
Asian Eyelid Surgery Goals
The goals for Asian Eyelid Surgery depend on whether the problem is congenital or acquired. Congenital Eyelid Problems we are born with, and these are often caused by deficiencies in the eyelid’s anatomy. The most common problem is poor connections between the upper eyelid skin and the tarsus, causing a poorly formed eyelid crease and the skin to drop into the eye’s visual field. Acquired Eyelid Problems we earn over time and are caused by aging and relaxation of the soft tissues that protect the eye. Protecting the eye is the primary goal for both types of eyelid surgery. Plastic Surgeons aim to restore the normal anatomy and to provide you with eyelids that look good while they are doing their job.
Asian Eyelid Surgery
If you are considering Asian Blepharoplasty, be certain to choose an experienced and Board Certified surgeon who understands, and knows how to repair, your specific eyelid anatomy and achieve your goals. In the San Francisco Bay Area call (925) 943-6353, to schedule a personalized and private consultation appointment.
Attention Plastic Surgery Television viewers. Body Beautiful will be broadcast live on KRON4 this Wednesday, September 7, 2016, At Noon – Live. So tune-in to get the latest Plastic Surgery News, and see if I get it right on the first take.
Plastic Surgery Topics Will Include…
This week’s show will be thirty minutes packed with what’s new in Cosmetic Plastic Surgery. Topics will some of the most popular procedures here in the San Francisco Bay Area including:
Breast Augmentation Revision for…
Breast Implant Deflation
Breast Implant Exposure (Skin Erosion)
Breast Implant Malposition
Breast Implants too small
Gynecomastia Reduction (Male Breast Reduction)
Otoplasty (Ear Pinning for Prominent Ears)
Asian Blepharoplasty (Asian Eyelid Surgery)
There will be plenty of discussion and Before and After Pictures for illustration. Below is a sneak peek.
Breast Augmentation Revision
The patient below had a rare, but serious Breast Augmentation Complication, requiring staged Breast Augmentation Revision Surgery. Her breast implant nearly eroded through the skin on the bottom of her left breast. Oversized Breast Implants in small breasts with poor soft-tissue coverage are at greater risk. This is more commonly seen after Breast Reconstruction when the breast has been radiated to treat breast cancer. It is unlikely to occur in a young, otherwise healthy woman, but it did.
Breast Implant Revision: Sometimes breast implant revision is urgent. The square shape sticking out of the bottom of this patient’s left breast is her breast implant, and it’s about to fall out.
Breast Augmentation Revision Stage I – The Salvage Operation
The top row of photos are the before and after photos from the first stage of her Breast Implant Revision Surgery. The upper left photo shows that the patient’s left Breast Implant is eroding through the skin of the lower breast. It’s about to fall out, and the current breast implant needs to be removed, urgently. If the Breast Implant becomes exposed, infection quickly follows. After careful discussion, it was decided to proceed with Breast Implant Removal on both sides.
Breast Augmentation Revision – Stage I was urgent removal of the left breast implant, which had nearly eroded its way through the lower pole of the breast. It was elected to remove both implants during stage I, because replacing the original saline breast implants with smaller silicone gel filled breast implants was part of the plan to decrease the risk of recurrence.
Having one implant in and one implant out was an option, but would have left her with an almost undisguisable amount of asymmetry. Moreover, the plan was to use smaller replacement implants, to decrease the risk of another breast implant erosion. Leaving both implants out forever would also treat this problem, and completely eliminate any chance of it happening again.
Breast Augmentation Revision Stage II – Asymmetric Breast Augmentation
While the nearly Exposed Breast Implant problem was solved, there were two new problems: 1) obvious breast asymmetry and 2) breasts which are too small for my patient’s preferences. The Breast Asymmetry is two fold. The left breast is smaller than the right, and the left breast is higher and tighter on the chest wall.
Breast Augmentation Revision Surgery – Stage II. The second stage entailed lowering the left implant pocket, expanding the lower, contracted pole of the left breast and asymmetrically augmenting the breasts to decrease the size difference.
Breast Implant Revision Surgery was performed to asymmetrically increase the size of the breasts, and to lower the left breast to match the right. The initial results are shown above, just one week after surgery. An alternative approach would be to raise the right side with a Breast Lift; however, this would require additional, external scars on the right breast.
Breast Augmentation Revision Surgery – Stage II and a patient patient. As time marched on, the results improved. No additional surgery was performed after stage II. While initially the skin stretched well, the muscle was tight. Over several months the muscle relaxed and the symmetry improved, as expected.
The Breast Revision Before and After Photos above show the results after new, smaller Silicone Breast Implants were placed, and the breasts were allowed to heal. The left picture is one week after surgery. In this photo, the left breast mound is firmer, higher and more projecting, as would be expected when more stuffing is placed in a smaller pillow case.
As the breasts heal, the left breast skin and muscle relax, the left breast implant descends and her results improve. The right, after photo shows the results after a few months. A larger breast implant was used on the left, to correct the asymmetry, and while initially it may seem like her Breast Implant Problems are not completely corrected, over time, it settles down. It is a good deal better than the potentially life-threatening complication she presented with originally, as shown below.
Breast Implant Revision Before and After Photos – the left picture is how the patient initially presented. The second picture is a few months after completion of both stages (breast implant removal and breast implant replacement with pocket modifications).
Breast Augmentation Revision Consultations
Breast Augmentation Revision is considerably more complicated than primary Breast Augmentation. If you have problems with your Breast Implants, seek an experienced and Board Certified Plastic Surgeon for your revision surgery. If you are in the San Francisco Bay Area and would like to schedule a personalized consultation appointment call (925) 943-6353, today.
PS – Don’t forget to watch Body Beautiful live at noon, this Wednesday, September 7, 2016, on KRON4, the Bay Area’s New Station.
Blepharoplasty is the plastic surgery term for an Eyelid Lift. It literally means eyelid changing. For upper eyelids, the change is most often the removal of excess skin, which can make you look tired or block your vision. For the lower eyelid, the most common change is the removal of lower eyelid bags. Since the eyelids normally swell when we are overtired, the fullness caused by the fat under the eyes makes us look like we need a nap.
Eyelid Surgery on KRON 4’s Body Beautiful
Over the years, I have appeared on television many times to answer the frequently asked questions about cosmetic plastic surgery. Most recently, I had the opportunity to discuss Eyelid Rejuvenation on the San Francisco Bay Area’s News Station, KRON 4. The show is Body Beautiful, and over a hundred video segments covering many types of cosmetic plastic surgery can be found here on the San Francisco Plastic Surgery Blog. Just click on “videos” under the heading “Categories” in the column for a complete listing. Below is the most recent Blepharoplasty Video. You can also find them on my YouTube channel.
Blepharoplasty Video (Eyelid Lift)
Eyelid Surgery Consultations
An in-person consultation is the best way to get accurate medical advice about your eyelids. A brief exam and medical history are needed to be sure the procedure is right for you. Safety and predictability are the most important aspects of any surgery, but this is especially true of elective plastic surgery. If you would like to schedule a personalized consultation appointment, give me a call at (925) 943-6353.
When I started my San Francisco Bay Area Plastic Surgery practice in 1997, cosmetic procedures were performed one eighth as often as they are today.
In 1997, over 1.6 million cosmetic plastic surgery procedures were performed, and most of them were surgical. The breakdown was 55% (900,933) surgical and 45% (740,751) non-surgical.
In 2015, almost 13 million cosmetic plastic surgery procedures were performed. The number of surgical procedure performed more than doubled, from 900,933 to 1,912,468. Percentage-wise, however, surgery slipped to only 15% of all cosmetic procedures. There was a tremendous surge in the number of non-surgical procedures performed driven by new technology and expanded FDA approval. In 2015 10,879,909 non-surgical procedures were performed, a 1400% increase.
Non-surgical Plastic Surgery Procedures Then and Now
The nonsurgical procedures of 1997 were not the same as today’s. The sole filler was collagen, which only lasted a few weeks, sometimes months. Botox was available, but the use of Botox for wrinkles was not FDA approved. In 1997, using Botox for frown lines and wrinkles was strictly an off label, use confined to selective Dermatology and Plastic Surgery practices (like mine).
In 2016, there are a variety of FDA approved fillers are available, each lasting months, sometimes years. The most commonly used dermal fillers are Hyaluronic Acid based including: Restylane, Juvederm, Restylane Lift (Perlane), but Radiesse (Calcium Hydroxyapatite spheres) has also emerged for boney augmentation (Cheeks and Chins) and the nasolabial folds. Botox is FDA approved for wrinkles, and is now found in just about every spa in the San Francisco Bay Area.
Surgical Plastic Surgery Procedures Then and Now
Unlike their non-surgical counterparts, the majority of the surgical procedures performed today are largely the same. New techniques and material (sutures and implants), have developed, but the most popular procedures of 1997 are the most popular procedure of 2015 too. To date, they have not been replaced by non-invasive procedures because non-invasive procedures cannot accomplish the same results. Women continue to dominate men in numbers, so let’s break down the procedures desired by each sex.
Plastic Surgery for Women
The headlines read that Buttocks Augmentation is the fastest growing cosmetic surgery. The 30% increase is statistically true, but is magnified by the fact that not as many Buttocks Augmentation are done as Breast Augmentation. Looking at the number of cases performed in 2015 reveals the popularity of the procedures:
Buttocks Implants – 5678
Buttocks Lifts – 5008
Brazilian Butt Lifts (Fat Grafting to the Buttocks) – 15,705
Breast Implants – 305,856
Comparing Buttocks to Breast Augmentation, if 3000 more Brazilian Butt Lifts are performed this year, that will almost be a 20% increase. On the other hand, if 3000 more Breast Augmentations are performed, that will be an increase of less than 1%. It’s all relative to how many procedures are performed.
The most popular Cosmetic Plastic Surgeries for women are Liposuction, Breast Augmentation, Tummy Tuck, Breast Lift and Eyelid Lift.
The most popular Cosmetic Plastic Surgery procedures from women have been pretty consistent over the last 18 years:
Comparing the male and female procedures, Rhinoplasty, Facelifts and Breast Reduction are pushed out of the top five by Mommy Makeovers; however, they are next. Cosmetic nasal surgery was number 6; Facelifts was number 7, and breast reduction was number 8 for women. When it comes to Cosmetic Plastic Surgery, men and women seem to want the same things.
Cosmetic Plastic Surgery Consultation
If you are considering Cosmetic Plastic Surgery in the San Francisco Bay Area, call (925) 943-6353 today, and schedule a private consultation appointment. Every consultation is tailored to your specific needs. The decision to proceed, or even to explore, cosmetic surgery is personal. My goal is to provide you the information you need to make your own informed decision.
If we are lucky, Facial Aging is something we all experience. It can present as changes in skin tone or coloration, fine lines or deeper wrinkles, and even loose or saggy skin. It happens, if we stick around long enough. While Facial Aging cannot be altogether prevented, how you look is influenced by how you treat your skin. Some of our normal daily activities help, while others hinder the effects of time.
Good Genes and Bad Habits
We all know someone who never wears sunscreen, drinks, smokes and whose skin looks great. It’s hard to beat youth and good genes, but you can if you try hard enough. Skin likes Protection, Hydration and Circulation, so here’s how to earn your PhC in beautiful skin:
Protection – Prevention is the best medicine, and this is true for your skin, too. While we need a small amount of sunlight to activate vitamin D, the amount we subject our skin to, especially when we are young, is excessive. The high-energy ultra-violet light in the sun’s rays breaks the DNA inside the skin cells. At a minimum, sunshine dehydrates the skin, but it also damages the elastic fibers that keep skin supple, reduces the skin’s ability to heal itself and if too much damage is done, leads to the development of skin cancer. We would all treat cancer after it’s found, but why not treat it before it starts, by protecting your skin?
Skin cancer can occur even where the sun does not shine, but it is most commonly found in areas exposed to the sun. Moreover, the risk of Skin Cancer increases with the amount of sun exposure. Today, sunscreen is incorporated into many moisturizers, cosmetics and even fabrics. Hats and long sleeves help, but sunscreen is a must. Personally, I could not survive a trip to Hawaii without sunscreen, a hat and a swim shirt. When I was young, it may not have made me look cool, but it did allow me to have fun with my friends without a week of recovering from sunburns. Now, if you go to the beach, sunscreen and sun shirts are common, and using them shows that you care about your body.
Hydration – Our skin keeps us from drying out, but it is not impermeable. I remember a junior high school science project during which we placed a plastic bag over one hand. The water that is normally lost through the skin was trapped in the bag. It made it quite clear that we are constantly dehydrating.
If you’ve ever watched Naked and Afraid, or any of the other survivor “reality” shows, you know that water is more important than food. Keeping hydrated keeps us healthy. It improves circulation and allows the body to rid itself of toxins. Alcohol, on the other hand, tends to dehydrate us, so all things in moderation.
You can help your skin by using a moisturizer. Moisturizers do not supply moisture to the skin, but trap the normal water that is lost through the skin. Petroleum Jelly (Vaseline) is very effective. It certainly helps injured skin heal with better scars, but its sheen is a bit obvious and it greasiness makes using vaseline quite messy. Most moisturizers are not as good as Vaseline, but are easier to live with. It’s a compromise.
Circulation – Good hydration promotes good circulation. The blood is mostly water, and when we are dehydrated the skin suffers more than another other organ. Circulation is also effected by our habits. Good habits, like daily exercise, promotes increased circulation and may improve the look of our skin, too. Bad habits, like smoking, decreases circulation, and the skin is especially hard hit.
As a Cosmetic Plastic Surgeon, I am operating on the skin, and I need healthy skin and circulation to get the best results. Several cosmetic operations are known to have increased risk in people who smoke. For procedures like Face Lifts, Breast Reduction and Tummy Tucks, smoking increases the risk of wound healing problems by six-fold. Because of this, Plastic Surgeons recommend smoking stop at least four weeks before and after any elective surgery. If you can quit smoking for surgery, you can quit for life, literally your life.
Good Genes and Good Sense
There are many simple actions we can take to keep our face and skin happy, and earn our skin a PhC. You have probably heard many of them before, like eating right and sleeping, but good advice only works if you act on it. I will share additional pearls in additional posts.
If you would like to learn more about Facial Plastic Surgery procedures, feel free to follow the links in this post article to access more information, or give me a call at (925) 943-6353, to schedule a personal consultation appointment at our San Francisco Bay Area Plastic Surgery office in Walnut Creek, CA.
The Eyelid Lift or Blepharoplasty, is one of the most common cosmetic plastic surgery procedures, and there is no better time for Facial Plastic Surgery, like an Eyelid Lift than in the winter months. Winter months mean less sun, and less sun exposure during healing.
Eyelid lifts remove excess skin and fat from the eyelids, revealing a smoother, rested and more alert appearance.
Is Eyelid Surgery Painful?
Blepharoplasty literally means “eyelid changing.” It’s an outpatient procedure, that can be performed safely under local anesthesia or general anesthesia, if you’d rather not be awake. The recovery time is more dependent on how much explaining you want to do, rather than any physical discomfort. It should not be a painful operation. In fact, if you are having a lot of pain after eyelid surgery, you should call your plastic surgeon right away.
Eyelid Surgery Recovery
Most commonly, your eyes feel slightly achy, tired or dry for a few days after surgery. Artificial tears are usually enough to soothe the eyes, and sometimes a moisturizing ointment may help at night. Pain medication is not usually needed, and acetaminophen (Tylenol) is usually enough. The procedure needs to be individualized, so don’t do anything because you read it on the Internet. All medical treatment should be supervised by an experienced, Board Certified professional.
Who Performs Eyelid Surgery?
Before blepharoplasty, the excess upper eyelid skin is resting on the eyelashes, making eye makeup impossible to maintain.
Plastic Surgeons, Ophthalmologists and Otolaryngologists are all trained in eyelid surgery. How much training will depend on their training program and the motivation of the surgeon. I was fortunate to be in a training program strong in cosmetic plastic surgery. My first rotation was in the Bothin Burn Unit. It is a regional referral center, so we received patients with large percentages of their bodies burned from all over Northern California. The workload fluctuated, so when the burn care was finished, I was free to see what other procedures were being performed in the hospital.
Many of San Francisco’s finest Plastic Surgeons were members of our teaching faculty, so there was always something to see, and something to learn. During my time in the burn unit, I helped perform several miles of skin grafts, and countless dressing changes. I learned as much from the burn nurses as my professors.
Even on the burn rotation, I wanted to learn about the cosmetic side of plastic surgery. With some hounding, I was able to participate in cosmetic procedures between burn cases. Even though I was not on the cosmetic rotation, I was able to see more cosmetic plastic surgery procedures, including breast augmentation, tummy tucks, facelifts and blepharoplasties, than many plastic surgery residents see during their entire training. For the self-motivated, there were abundant opportunities to learn. You just had to ask, but the option was available. This is why the type of training a doctor has makes a difference. In other types of training programs, especially non-surgical training programs, the opportunities, and more importantly, the amount or responsibility shared is not the same. I am very thankful for those who volunteered their time to teach us.
What Does Eyelid Surgery Do?
After blepharoplasty, the upper eyelid crease is singular and more defined, while the lower eyelid bags have been removed.
Eyelid surgery removes excess skin to tighten and removes excess fat to smooth the eyelids. Upper eyelids tend to accumulate skin as we age. The excess skin can block vision, grab eye make-up and feel heavy. Lower eyelids can have excess skin too, but extra fat can fill the lower eyelid causing bags. All this contributes to make us look sleepy, inattentive and tired. Eyelid surgery can relive these symptoms and contribute to a rested and alert appearance.
If you are considering Eyelid Rejuvenation, a personal consultation is the next step. Give me a call at (925) 943-6353; we can review your concerns and find the best solution tailored to your eyelids. More information is available here on the San Francisco Plastic Surgery Blog, and my other websites in English and in Spanish, and questions are welcomed via the contact form in the margin.
This is part two of a series on Eyelid Surgery or Blepharoplasty. Last week, we reviewed Upper Blepharoplasty. This week, it’s all about the lower eyelids. Lower eyelids have different anatomy, different function and are operated differently than the upper lids.
Lower Blepharoplasty Before and After Pictures
There are four major components that distract from a pretty lower eyelid: bags, wrinkles, lower position and increased height of the lower eyelid. Lower Eyelid Lifts are designed to improve all these.
Lower Eyelid Surgery (Lower Blepharoplasty)
Last post we discussed the changes usually desired for the upper eyelids: removal of excess skin, removal of fat from the inner and central aspect of the upper lids if disproportionate, changing the upper eyelid fold and repositioning the lid margin to open the eye. These goals apply to the lower eyelids too, but the methods and priorities change. For Lower Eyelid Lifts the goals are: removing lower eyelid bags, tightening the lower eyelid skin, creating or maintaining normal lower eyelid position and shortening the length of the lower eyelid.
Removing Lower Eyelid Bags
The primary concern with the Lower Eyelids is the baggage. As we age, the facial fat over the lower eyelid thins and descends, revealing the fat pads located under the eyes. For some, these bags enlarge with age. For others, the large bags are present at birth and become more noticeable as the facial fat descends. Either way, Lower Blepharoplasty is designed to reduce excess fullness under the eyes.
Transconjunctival Lower Blepharoplasty
The heading above is a mouthful, but easily understood. Trans means across, or in this case through, and the conjunctiva is the pink lining of the eyelid. Lower blepharoplasty, from last post, means lower eyelid changing surgery. Transconjunctival Lower Blepharoplasty is a method of reducing the lower eyelid’s fat pads through the lining of the eyelid. The advantage is that the scar is completely hidden inside the eyelid. This method works best for younger patients who do not have excess skin and wrinkles on the lower eyelids as shown below, and is common enough to be shown on the Wikipedia blepharoplasty page.
Transconjunctival Lower Blepharoplasty Before and After Pictures
The Transconjunctival Lower Blepharoplasty before and after pictures above show how the lower eyelid is smoothed by removing the excess fat contained in the lower eyelid via an incision inside the eyelid.
In the Lower Blepharoplasty Before and After Pictures shown above, you can see the bulge in the lower eyelid caused by the excess fat this woman was born with. You can also see her attempt to minimize the appearance with a lighter shade of makeup over the bag. After her Lower Blepharoplasty, the eyelid is smooth and flat. Just enough fat is removed to flatten the bump the excess causes. Removing too much, will cause a hollow. If this patient had wrinkles of loose skin on the lower eyelid, the transconjunctival approach would not be used. Unlike the external approach described below, excess skin cannot be removed with the completely internal transconjunctival method alone.
Tightening the Lower Eyelid Skin
Bigger problems require bigger tools. When the excess lower eyelid fat is combined with loose baggy skin, a Subciliary Lower Blepharoplasty is preformed. Cilium is Latin for eyelash, so the subciliary incision is placed just below the eyelashes on the lower eyelid. This area heals very well, making the incision difficult to see, hidden in the shadow of the eyelashes.
The most frequently used approach for rejuvenating the lower eyelid is the external, subciliary approach. Not only can it remove excess fat like the transconjunctival approach, but it can also tighten the loose skin while lifting and supporting the lower eyelids.
The advantage of the subciliary approach to Lower Eyelid Lifts is the ability to remove excess skin at the same time as reducing the lower eyelid fat. The lower blepharoplasty before and after pictures above show a marked reduction in the lower eyelid bags with tightening of the lower eye skin using the subciliary approach. In this case, only removing the fat is treating only half the problem, and would leave a deflated bag of excess skin under her eyes.
While deep lines caused by skin folds are improved by Lower Eyelid Lifts, the fine lines within the skin need different treatment. The analogy made is between the eyelids and a quilt. Wrinkles in the quilt can be smoothed by gently tugging the quilt flat. This is what lower eyelid surgery does. However, no matter how hard you pull, you cannot smooth the quilting stitched into the fabric. This requires modifying the quilt, not how it lays. For the skin, topical treatments like chemical peels, lasers and dermabrasion are used.
Creating or Maintaining Normal Lower Eyelid Position
The normally positioned lower eyelid covers the lower edge of the colored iris and white sclera under the iris. When the lower eyelid weakens, more of the iris and sclera are revealed. This is termed scleral show, and is associated with a tired, stressed appearance. As the lid descends further, the lower lid may progress to frank ectropion – gapping away from the eye, and interfering with the lower eyelids function of protecting the eye. The pink conjunctival lining may be seen and the tears may not flow properly. This makes the eye feel dry and look red and inflamed. Lower blepharoplasty can be combined with eyelid tightening procedures to prevent or correct this problem.
Before and after photos of lower blepharoplasty with tightening of the lower eyelid support show how the lower eyelid moves up to its ideal position. On the other hand, simply removing the excess fat and skin without the lid tightening would most likely expose more of the white of the eye beneath the iris.
Lower Blepharoplasty for the above patient was more risky. He already had scleral show, and the normal lower blepharoplasty removes the excess fat and tightens the lower eyelid skin potentially removing support and pulling the eyelid down further. However, when the problem is recognized before surgery, the lower blepharoplasty is modified to include a lid tightening procedure. This improves the eyelid position and prevents the scleral show from progressing to hound-dog appearance of frank ectropion. Nothing against hound-dogs.
Shortening the Length of the Lower Eyelid
All the pictures above show a reduction in the overall height of the eyelid. More accurately, this is caused by a decrease in the how far onto the cheek the eyelid descends. As discussed above, supporting the eyelid during Blepharoplasty is important to preserving the function of the lower eyelid and for maintaining a rested, alert appearance. A shorter eyelid is also associated with youth. An infant’s lower eyelids are so short that often it looks like the cheeks are encroaching on the eye opening. As we age, the cheek drops, and the lower eyelid becomes more apparent. Around puberty, the eyelid appears as its own aesthetic unit, and as we age, it occupies more vertical space above the cheek, While blepharoplasty can help decrease this appearance, the underlying cause is the cheek descending. Cheek decent is more directly treated with a Facelift, or in cases where the cheeks are small or retruded, with Cheek Augmentation.
Blepharoplasty Consultation Appointment Available Now
If you are considering tightening up you eyelids, give me a call at (925) 943-6353. Eyelid surgery and other facial cosmetic plastic surgery procedures are provided by my San Francisco Bay Area private practice in the East Bay city of Walnut Creek, CA. Your personalized consultation will include reviewing the areas you want addressed and creating a plan specific to your goals.