Monthly Archives: March 2014

An interview with Trudi Brewer for Next Magazine

Recently Mr Gilbert was asked to comment on tired eyes. An interview with Trudi Brewer for Next Magazine.  The issue comes out in May.  Below is what he said:

Q: Why do eyes look tired?

A heavy brow allowing the  eye brow itself to  drop and the skin below it to droop over the eyelashes  does tend to make you look half asleep; something male  board members fear. Excess skin and fat in the UPPER EYELID  has the same effect.

Marilyn Monroe was said to have’ bedroom eyes’ because her upper lids were often relaxed giving her a seductive look.

Aspiring female board members should be aware this is not the most appropriate look for them .

So ‘bedroom’ or ‘boardroom’ eyes can be corrected by a Brow Lift if  the  eye  brows are low,  with or without an UPPER BLEPHAROPLASTY to remove excess skin and fat. The brow can also be stabilised at the orbital margin by a deep brow pexy stitch  anchoring it there.

Fashions in eyebrow height change. Today beautiful young women have low slightly curved eyebrows with a subtle fullness just under the eye brows themselves giving them a more seductive look than the enquiring look of the high arched brow of yesteryear. This look goes very well with the modern emphasis on  a toned  curvaceous body.

But tired looking eyes are usually attributed to bags and wrinkles in the LOWER EYELIDS with dark rings below. The bags may be due to fat or fluid collection.

Fluid excess may be due to a medical condition such as kidney or heart failure, diabetes or even pregnancy.  It accumulates here when you  are lying down so bags in the morning may be less obvious later in the day. The tissue here is very thin and fluid collection is obvious

Like all facial tissues eyelids age and become looser with time, supporting the orbital fat around the eye ball less effectively so this bulges out like a hernia  as it  does anywhere else in the body where supporting tissue has weakened, allowing orbital fat to prolapse into the weakened lower eyelid causing bags

The SOLUTION  to this is to smooth out these bulges by redistributing the fat or removing it.

In the past we removed too much fat giving the eye a  hollow look as the eyelid aged.

So we began pushing the fat back into the orbit trying to strengthen the lower eyelid at the same time to prevent it prolapsing again. This was not always successful so the current trend is to remove some fat  and push some back.

RESTORING facial structure and thus rejuvenating the face is all about adding volume now so it seemed a pity to throw away this unwanted fat.

Instead we began redistributing it over the orbital margin to fill in the circles under the eyes. This sometimes worked well especially in conjunction with a smas lift  (superficial musculo-aponeurotic system)  which lifts prolapsed tissues up to meet the redistributed orbital fat, but too often all it did was to reposition the bulge further down the cheek.

Therefore my PREFERRED TECHNIQUE  today is to remove a modest amount  of fat and then fill in the deep circles with fat transfer from somewhere else in the body. It  has to be done with a very precise technique placing aliquots of washed fat across the hollows with avery  fine cannula.  The present concept is that this fat contains stem cells which are primordial cells capable of turning into different tissue such as collagen. Undoubtedly putting this fat in very thin layers under the skin during a face lift does refresh the skin itself. so there is some prospect that this will reduce the dark circles.

The DARK CIRCLES  are due to a number of features. Firstly the skin here is very thin and lies on muscle with very little tissue between. Thus the darker muscle shows through. Here the nose tends to cast a shadow in unfavourable lights  emphasising any darkness. Also any blood pigments accumulating  here will show through  as does any increase in melanin, the dark pigment  in skin cells in the dark circles.

Hydroquinone creams and lasers have little effect.

This is not a good place to put hyaluronic acid fillers because they easily give the thin skin a translucent  bluish look called the Tyndall effect, a sure give away that you have had something injected here.

Fat is much better but not all that is put in may survive  and it may need to be topped up once or twice to get a more lasting look.

The excess fat in the lower eyelid causing the BAGS can be removed  and even redistributed through the conjunctiva lining the back of the eyelid without disturbing the orbicular muscle which supports and helps close the lids thus avoiding a common complication of approaching the fat through the front of the eyelid. This complication is RETRACTION in which the eyelid pulls down slightly exposing too much sclera (white of the eye).

This tendency can be avoided usually by not removing too much skin and then pushing the eyelid up with a finger for ten seconds ten times a day for ten days (ten,ten,ten)  At the same time it is helpful to hitch the muscle up with a stitch to the edge of the orbit and in addition tighten the free border of the lid to lateral edge of the orbit with what is called a canthoplasty stitch.

You can see from the above that a LOWER blepharoplasty is much more complex than an UPPER one which can be done under local anaestheic whereas  the former requires a general anaestheic or at least intravenous sedation for it to be comfortable for the patient and provide optimal conditions for the surgeon to get the best result.

A  TRANSCONJUNCTIVAL blepharoplasty  does not take care of skin excess causing  the wrinkles. The skin excess can be reduced (shrunk with a CO2 or erbium laser but this runs the risk of over shrinkage and scleral show,even pallor of the lid which is ageing in itself, so it is safer to just take a pinch of the  excess skin off along the lash line. The skin is the smoothed up without tension and trimmed off exactly under the lashes so that it heals with an almost invisible scar.

Dynamic wrinkles around the age give character and  a pleasant expression to the face and dont really give it a tired or aged appearance.

Regretfully it is common to see celebrities  and others  looking expressionless and somewhat stunned from  the injection of too  much neuro-muscular modifier into the orbicularis muscle.      But early judicious use of the injections can  slow down the onset of permanent wrinkles  appearing around the eyes  when one’s face is relaxed.

In some older patients the orbciularis muscle is hypertrophied, hanging in festoons and has to be trimmed too. You may recall  there was once  a fashion popularised by dermatologists for cutting the skin  and fat off with a LASER claiming that there was less bleeding and swelling.  We found that the scar was always thicker whiter and more obvious if the skin was cut with a laser. Careful expert surgery with a scalpel and pinpoint diathermy, which will shrink the fat just as easily as the laser, gave a better and more predictable result.

DOWN TIME is always dependent on the quality of the tissues, the expertise of the surgeon  and the ability of the patient not to ooze or bleed excessively. Thus all drugs that may increase bleeding should be  avoided for at least a week before surgery.  Most importantly anti coagulants such as warfarin and all anti inflammatory  drugs including most vitamins and health supliments ; although the latter may only have a marginal effect.

Down time is also dependent on the patient following post operative instructions closely. these include keeping the head elevated for the first week and not exercising so as to raise the blood pressure which would obviously increase the risk of bleeding but you can walk round normally wearing sun glasses to disguise  the inevitable evidence of surgery in the first ten days.  Cold compresses are helpful for a few days.

Because the eyelids and brow are independent mobile asymmetrical units  it is very difficult to get them precisely symmetrical in the one operation so  you need to accept minor asymmetries while the lids are slowly continuing to improve over three months or so.. Only then can a true assessment  be made of the need for a FINESSING procedure.. Also you must realise that no one has identical  orbits , eyelids  and eyebrows. These discrepancies must be recorded and photographed beforehand.

COMPLICATIONS are thus very rare in experienced hands and always correctable with a fine-tuning procedure. In the upper lid minor asymmetries are the most common whereas in the lower lid it is not uncommon to have to adjust the tension along the free border to correct  a feeling of air getting under the lid even when it sits nicely on the globe with no scleral show or to go back and correct a persistent minor bulge.

The COST  is best found out by contacting the surgeon’s office, An accurate estimate cannot be given without first seeing the patient and establishing the most suitable teqcnique, the best venue  and whether or not local or general anaesthesia is required.

Cheap is not good. Costs to add up are the anaesthetic fee. the theatre fee and the surgeon’s fee.

The UPPER EYELIDS  can be done comfortably under local ansaesthesia  usually with oral sedation but the LOWER EYELIDS are  better done with local anaesthetic, and IV sedation or general anaesthetic.

The surgeon’s fee should relate to his  known expertise in this field, his experience, his aesthetic eye, the precision of his operating  and the care that he and his staff will give  you before and after the operation. Also you should find out if there will be further cost if finessing is required.

Some people who would benefit from  blepharoplasty are tempted to try to combine a holiday overseas with the operation.   This is known as COSMETIC TOURISM.     Whatever the  expertise of the  overseas surgeon he or she  is operating under three disadvantages.

1  There is no proper consultation before the patient and surgeon are  committed to the operation

2  The surgeon will not be able to look after delayed complications because you will be home by then.

3 The surgeon seldom sees his results so how can he know if  he has done a good job and how can he improve.

We see a steady number  unhappy patients coming to us to fix poor results or complications.

Prevention is always better than cure. Some women have better  anatomy and genes for delaying the visible onset of ageing. All can benefit from living a healthy life style, a good diet, not smoking, staying off the booze, protecting their skin from the sun and getting plenty of sleep.