Final verdict: Did she have Surgery or Fillers?

This particular patien below came to see me for the bags underneath her lids.  On exam, she has herniated lower lid fat pads which are resulting in her tired apperance. Prior to the advent of eyelid filler treatments, she would traditionally have required blepharoplasty surgery to rejuvenate her lower lids.  But we now know that two things occur with the eyelid aging process:

1) herniation of lower lid fat pockets (bags under lids)

2) and loss of volume below the fat pads resulting in tear trough hollowing (deformity) and in the midface area (which is the area between the eyelid and the nostrils)

In her case, we planned to first address the loss of volume (#2 above) in her tear troughs and midface area using hyaluronic acid fillers (ie Restylane and Juvederm).  This was done in a stepwise fashion such that a further filler augmentation was performed two weeks after her first procedure.  I don't like to place too much product at one setting; I rather reassess after two weeks to make sure the patient tolerates the filler material well.  

 

Pre treatment photos show herniated lower lid fat pads (bags under lids). But she also has hollowing of her lower rim and loss of midface volume, both of which worsen her lower lid appearance. 

Post filler treatment using hyaluronic acid fillers (ie Restylane and Juvederm) shows a dramatic improvement in her lower lid appearance. Although the fat pockets are still present, re-establishing her "normal" lower lid and midface volume allowed for the fat pockets to be less visible.  

Pre treatment side view shows the extent of the tear trough deformity (hollowing) and midface volume loss. 

Post treatment side view shows the improvement. 

So the answer is that this patient ONLY underwent filler injections to her lower orbital rim and midface volume and did NOT have surgery.

Natural appearing lip augmentation

Most of my patients that see me for lip augmentation really just wish for fuller lips that still appear natural.  I avoid the over-filled apperance and respect the natural appearance of a "normal lip" where the upper lip is slightly smaller (up to 33%) than the lower lip.  

I like to use the micro-cannula for my lip augmentation procedures. The patients do not require a dental block; topical anesthesia cream by itself is usually adequate for pain control.  In my experience, the patient's tolerate the procedure so much better than traditional needle injections and have much less incidence of bruising after the procedure.  

Pre injection photos show slightly reduced volume in the upper lip in comparison to the lower lip.

Post injection shows improvement in upper lip volume, a slightly more prominent vermillion border (where the skin meets the lip), and minimal increase in lower lip volume as well in order to preserve the ratio of volume between the upper and lower lip. 

Achieving symmetry in blepharoplasty surgery

Facial asymmetry is seen in almost everyone, especially around the eyelids. For example, one brow may be slightly elevated more than the other side or one eyelid may have more "excess skin" than the other side.  Aging is an evolving process that often accentuates the asymmetries we see in people. I often see people who wish to have upper lid blepharoplasty to remove the excess skin which may be overhanging onto their lashes.The excess skin results in not only a tired appearance, but also can result in difficulty seeing well in their far peripheral vision.  For example, this particular patient below has "excess skin" weighing down on his rigth upper lid resulting in difficulty seeing and lid asymmetry.  The goal was to perform an upper lid blepharoplasty surgery to help achieve better symmetry between the two lids and to allow the patient to see better

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You can see the improvment in symmetry once the right upper lid underwent skin-only blepharoplasty.  

 

 

Using fillers to correct lower lid tear trough hollows or "lower lid bags"

Tear trough deformity is seen in people of all ages.  They can be seen forming in as early as patients in their 20s and upwards. With age, the lower eyelid "trough" or hollow tends to become deeper and people commonly complain of a tired look.  

Patients commonly describe these hollows as "eyelid bags, puffy eyes, and eye bags." Interestingly enough, until recently, surgery used to be the only method for correcting tear trough deformity. As we now understand eyelid anatomy and the aging process better, we realize that the tear trough deformity mainly occurs due to a loss of volume in the midface which results in a hollowed-out appearance of the lower lid.  In order to best treat this volume loss and the tear trough deformity, Dr. Zoumalan uses advanced techniques with or without combination of surgery to rejuvenate this area of the face and to restore a more youthful, natural looking appearance. When performed in the office without surgery, Dr. Zoumalan uses hyaluronic acid filler injections (ie Juvederm and Restylane) to volumize the tear trough and the midface area.  

Picture above. The area of the tear trough deformity is located above the black arrow. It results in a shadow effect which actually worsens the appearance of the hollowing. 

Pre-injection photo above. In order to address this deformity, in office hyaluronic acid fillers were injected using a micro-canula technique.  Note the hollowing (tear trough deformity) with some early los of volume in her midface.   

Photo above: After filler treatment to the eyelid and midface. This photo was taken several weeks after the procedure. The procedure took approximately 45 minutes and was all done in the office using only local anesthesia with no sedation. The patient went home and had little swelling and minimal bruising.    

The tear trough deformity (orbital rim hollowing) has been corrected and midface volume has also been naturally augmented. This particular patient had hyaluronic acid (HA) filler injections consisting of Restylane and Juvederm. Note that this patient did not undergo any sort of eyelid surgery. 

Read our new publication in Plastic and Reconstructive Surgery (PRS) Journal

Little is known about surgical adhesives and their antimicrobial role.  We assembled a team of plastic surgeons and microbiologists to investigate the role of Mastisol and compound tincture of benzoin, both very commonly used adhesives in surgery, in fighting infections. In summary, we show that compound tincture of benzoin and Mastisol manifest antibacterial activity against surgical-site infection-related pathogens, including methicillin-resistant S. aureus. (MRSA). 

Antibacterial Analysis of Surgical Adhesives.

Joseph JM, Voldman A, Zoumalan CI, Lisman RD, Iovine NM.

Plast Reconstr Surg. 2012 Feb;129(2):402e-404e. 

 

 

Case presentation: Ptosis Surgery (Droopy Eyelid Surgery)

This patient was unhappy about her droopy left upper lid. She was a long-time contact lens user, which has been associated with ptosis in younger patients.  She was unhappy about not only her appearance but also was having difficulty seeing well with her peripheral vision.  She underwent ptosis repair to help improve her appearance and also see better.  The surgery takes no more than 20-40 minutes and can be performed using mild intravenous sedation.  There is minimal downtime with this particular type of ptosis surgery as well.  

Figure above shows a ptotic, droopy left upper lid. 

This photo was taken 6 weeks after undergoing posterior-approach ptosis repair surgery. Note the improvement in symmetry and lid height.

Read more about ptosis surgery at Dr. Zoumalan's website:

Ptosis surgery--Dr. Zoumalan

Upper lid blepharoplasty

Upper lid blepharoplasty surgery is a very gratifying surgery for patients.  Dr. Zoumalan is one of a handful of surgeons that exclusively specializes in upper and lower eyelid blepharoplasty surgery. Blepharoplasty is an eyelid surgery which involves the removal of excess skin and fat pockets in the upper and lower eyelids. In the upper eyelids, excess skin can result in a tired appearance to some, while in others, it can actually result in difficulty seeing in the top gaze of your vision (also referred to as limitations in super visual field). 

This particular patient had excess skin blocking her visual fields and resulting in a tired appearance (termed dermatochalasia). She has mild droopy lids (ptosis) as well in addition to a mild left brow ptosis. She underwent bilateral upper lid blepharoplasty, mild ptosis repair, and a left-sided brow lift. 

Preoperative photo of left upper lid dermatochalasia (extra skin), mild lid ptosis, and left brow ptosis. Note the slight asymmetry of the left upper brow resulting in mild asymmetry.

 

Post op photo taken 4 months after surgery showing an improved upper lid and brow contour, appearance, and symmetry.  

Read more about upper lid blepharoplasty surgery on Dr. Zoumalan's website at:

Upper lid blepharoplasty surgery---Dr. Zoumalan