Taking Out Mountains & Filling in Valleys: Eyelid Surgery with Fat Transfer

Announcer (00:04):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:13):
Hey. Dr. Koehler.

Dr. Koehler (00:15):
Hey, Kirstin.

Kirstin (00:17):
We're going to talk about fat again.

Dr. Koehler (00:21):
What fat? Your fat?

Kirstin (00:25):
What fat.? Just kidding. Okay. We normally don't talk about celebrities or pop culture, but as we know,

Dr. Koehler (00:35):
Why are we going to start? Why are we going to start? Why would we start if we haven't done it?

Kirstin (00:40):
Because this week everyone is talking about Kris Jenner and Kris Jenner's facelift. Have you seen it?

Dr. Koehler (00:47):
We're talking about who?

Kirstin (00:49):
Kris Jenner.

Dr. Koehler (00:51):
The athlete?

Kirstin (00:53):
No, no, no. The athlete's wife, Kris.

Dr. Koehler (00:55):
Oh yeah.

Kirstin (00:56):
Kris Kardashian Jenner.

Dr. Koehler (00:58):
Oh yeah, Kardashian. Yeah. I don't really know. I haven't really been paying attention to that. I've seen some people talking about that. I sort of flipped through the Instagram and I saw people talking about her

Kirstin (01:09):
In between the hockey games. You saw that?

Dr. Koehler (01:12):
Yes.

Kirstin (01:12):
A little bit of info.

Dr. Koehler (01:13):
Yes, I heard. She looks really good. I haven't sit and examined pictures of before and after of her, but yes. I heard she looks really good.

Kirstin (01:20):
I'm going to show you a picture.

Dr. Koehler (01:22):
Okay, show me.

Kirstin (01:24):
Okay, so today we're talking about eyelids and eyelid fat, and we want to know if Kris Jenner has had something done to her eyelids along with her facelift.

Dr. Koehler (01:37):
Well, the picture's kind of small, but definitely, I mean, obviously she had her lower face and neck done and that looks really well done. You can see some of the bands in her neck are gone and she's got a nice jaw contour, not over pulled. It looks really good. It looks like she might have had a brow lift there. Her lateral brow is raised up a little bit. I don't know if they did a little upper eyelid skin as well, but yeah, her skin looks really good too. So maybe some resurfacing of some sort as well. No, she looks good. She just doesn't look over done.

Kirstin (02:10):
She looks great.

Dr. Koehler (02:13):
She's got a nice taper to her jaw and neckline. It looks good. Which we've talked about before. The key is not to pull it as tight as you can. And I will say one other thing, results vary and they vary for a number of reasons. So a facelift doesn't correct sun damaged skin, fine lines and wrinkles of the face. And if you look at Kris Jenner, her skin overall is really good even in the before. And so when all that gets repositioned and tightened and good overall, she's got good skin before it's just you can see the platysmal bands in her neck and the skin laxity there. So when that's, I mean, let's just face it. Don't look at her face, look at her shoulders and her chest. I mean, she doesn't have sun damaged skin with horizontal ribbons across her neck and all sorts of photo damaged skin.

(03:12):
I mean, so she's in a really good starting place, although I think a lot of people have already, she's had previous work done, but she had a good surgeon and they did the right things. They didn't overdo it and she looks great. So good for her. I mean, that's what we're going for. That's the goal. But I guess the thing I would just like to say is that just like when patients come in and they might go, oh, I saw it doesn't matter what the procedure is, breast augmentation or something. Oh, I like for 47 on your website. I'm like, well, unless you look like number 47 in the before, I can't give you 47. It's not like a take it off the shelf and install it. It's like for facelift, it's your existing bone structure, the soft tissues, the fat, the skin, the muscle, all of those things. And we are just repositioning, reshaping and doing all that. And so selecting the proper combination of procedures and executing those procedures in the best possible fashion. And then yeah, again, starting with a good subject end up with a really nice result. So that's nice to see.

Kirstin (04:21):
Yes. Okay. So we think that she had a little, some sort of skin tightening or blepph or something like that, maybe upper lids at least. So what can we do us here as normal humans in Alabama to help with our eyes?

Dr. Koehler (04:41):
It just sort of depends on what the needs are. So when we're talking about the eyes, we really also need to talk about the brows because sometimes, so for instance, male patients or somebody like myself, I have low set brows. My brows are low, they've always been low. If you look at a picture of me from when I was 18, I mean my brows were low, my dad's brows are low. It's just the way I'm built. And that's why Kenny Rogers, in my opinion, talking about celebrities people said, oh, Kenny Rogers had a bad face left. I'm like, well, his lower face and neck looked pretty good to me, it didn't look bad. But what probably didn't look good was the fact that he had his brows elevated pretty significantly when they've been low his entire life. And men don't typically have a well-defined upper lid eyelid platform.

(05:27):
Women want that because they want to be able to see their makeup when they put their makeup on. Men often don't show hardly any upper eyelid platform. And Kenny Rogers went from no upper eyelid visible at all to a significant portion of his upper eyelid visible and it feminized his look. So anyhow, but when we're talking about eyelids, we're talking about brow position. Does the brow need to be repositioned? Because sometimes if the distance between the brow and the upper eyelid or the lash margin is small, you can take out a gob of skin here and you'll still see zero cosmetic change because the distance is so short and we still can't recreate that crease. And the only way we can do that is by elevating this and then taking some skin out. So sometimes it takes a combination of two procedures to do that for upper eyelids.

(06:19):
And yeah, I mean it just depends. And there's different types of brow lifts. So when we're talking about eyelids, there's a tricylic brow lift where the incision is right along the hairline, and that's a useful procedure for people who have maybe kind of a high forehead because we're going to take out some skin and we can actually shorten their forehead in addition to lifting up their brow. And so that's kind of a neat way to do it. If we really don't need to change forehead at all, then the incisions can be in the hairline, we can do it endoscopic. And those would be kind of the two most common ways of doing brow lifting. But then, yeah, the upper eyelids, that's a pretty straightforward one. But again, sometimes people get an upper eyelid done and they don't see a whole lot of change. And what they really needed was both the eyelids and the brow done.

Kirstin (07:04):
When people say you look tired, is that somebody who would be a candidate for both brows in lids or what's going on with their eyes that makes people look tired?

Dr. Koehler (07:14):
Well, it can be both, but typically the one that really makes people look tired is the bags on the lower eyelids. I have a before and after picture that I use pretty commonly to show patients, and it's this male patient that I treated years ago, and he's a farmer. And the guy came in and he's like, I don't even care what I look like. He says, I'm just sick and tired of people telling me I look tired, cuz I'm not. And so he was concerned with his looks only so much that people just didn't ask him if he was tired. And so what we see sometimes several things occur with aging. In the lower eyelids, we see the fat pad that overlies the bony orbital rim. You take your hand and you can feel where the bone is, but there's fat that kind of overlies that. And as we age, that fat descends and also the fat that's surrounding the eyeball itself, there's a little septum that separates that fat from the outside world or from the skin and our face.

(08:15):
And as we age or can be hereditary as well, that septum is weak. And so it allows the fat to bulge forward. And so what you see is these persistent bags under the eyes. And so you see fullness here. And now this is all descended, and now there's hollowness here. And what you typically, you'll hear people say, well, I've got these dark circles under my eyes. Can you give me some cream to fix that? And I'm like, there's no pigment there. This is not something a cream can fix. The reason it looks like a dark circle is because the light from above is coming down and a shadow is created in the hollow area because of the bulging of the upper eyelid or the lower eyelid fat. And so you can use bleaching creams or whatever you want all day long. Those dark circles are not going away.

(09:05):
It's a surgical treatment. And so that's what makes people, I think definitely look quote tired. And then I guess the other component to lower eyelid aging is the actual skin itself. So you've got the fat that's bulging around the eye. You've got the fat that's descending in the cheek, and then it's the skin quality itself. And sometimes people will be like, I don't like how I have bunching or wrinkling up under my eyelids. And that can be caused also from a couple of things, like there's a condition called orbicularis hypertrophy where the lower eyelid or the muscle of the lower eyelid is sometimes really strong in people. And when they smile, the skin all up under here bunches up and they look like they have this ridge. And sometimes that can also be wrinkled, but it looks like they've got a lot of fullness there or bulging. And really it's just the muscle that's contracted down. And so for those people, you can put Botox in there and that can work with no surgery, and it'll make it look smoother and better. But other people will have just lots of wrinkles under their lower eyelids when they smile. And a lower eyelid surgery can improve that, but we have to address the skin. So either laser resurfacing or sometimes we're taking some skin out as well. So it just depends on the circumstances.

Kirstin (10:25):
So when we're talking about fat with an upper bleph or lower bleph, you do something different with each of those, right? You remove fat?

Dr. Koehler (10:33):
So with upper bleph we're typically the only fat we're maybe removing is sometimes the medial fat right here in the corner. Sometimes people have some fullness there, and we'll take a little bit of fat out. Many years ago, it used to be common practice to try to take all the fat. Well, there's really just two fat pads in the upper eyelid. There's the medial in the middle, because out here laterally is our little gland that creates tears. So we don't want to take that out. So there's just two little fat pads. But what we found, what was kind of like what we were talking about on another podcast about taking out buccal fat, they used to take out eyelid fat all the time, and then as people aged, they looked hollow in their eyes and it made them look older. And so that's not what we're going for. So a lot of times we remove no fat on the upper eyelids, but if we do remove fat, a lot of times it's conservatively and it's usually just the medial fat that's on upper eyelids. Lower eyelids is a different story. I mean, we are routinely either removing or repositioning the fat on lower eyelids.

Kirstin (11:39):
So take it out, put it back in.

Dr. Koehler (11:44):
Yeah. So there's two kind of primary ways that I do lower eyelids. If the skin overall is good, they don't have a of extra skin and they've just got the bulging fat and maybe they've got some fine lines and wrinkles to the skin, but they don't have extra skin that needs to be removed, then we'll do it, called a transconjunctival. So the incision is on the inside of the eyelid, and from that inside incision, we can take out the bulging fat, and then usually I'll take some fat from their abdomen. It's not a lot. We don't need a lot of fat. We need like five ccs or six ccs of fat. And then we take that fat and through just a little needle, we'll inject that fat in the hollow area. We take out the mountain, take down the mountain and fill in the valley.

(12:33):
So we fill in the valley here, and so we're removing fat and putting fat in, and then we're not taking any skin out. And then after we're done, we'll take a CO2 laser and we'll resurface the skin because we have to address the skin component as well. So there'll be a little pink or red under the eye for maybe a week, 10 days. That's the one method for a lower eyelid. The other method is it what's called a subciliary, in which I make the incision underneath the lashes of the, so it's on the outside of the eye, so it's external incision, and then we elevate all the skin and muscle down. And then in a lot of these patients, instead of taking this fat out, I just take it and then I reposition it into the hollow area here. So instead of suctioning fat and putting other fat in there, I'm just going to use that fat and reposition it, and then I elevate the skin, I trim off the excess skin, and then everything gets sewn back together.

(13:34):
And sometimes people are like, well, why do you inject fat with the other one? Why don't you just reposition fat when you do it from the inside of the eyelid? And you can, it's just a lot harder because when we do this open approach, we have much better access and we can really get down to that area. And it's a lot easier to put the fat in predictably, but pros and cons to both of those approaches. But if I need to take out skin, then I'm doing it with an incision on the outside. If I don't need to take out skin, then incisions on the inside.

Kirstin (14:04):
So if you weren't repositioning fat or transferring fat, is that something that you could just use filler for instead?

Dr. Koehler (14:13):
Yeah. No, not really. When we're doing surgery, we're definitely going to use fat because what we put in there is going to be longer lasting. I mean permanent, I don't like to ever use the word, but it's going to be much more long lasting. The only thing about fat is if you're suctioning it from one area and injecting it into another that it's a little less predictable because it's transplanting cells from one area to another. What percent is going to stay as an argument? And you don't want to overcorrect because what if you overcorrect and then there's too much, so you have to kind of put it in and you may not get enough correction, but when you transposition the fat, that's going to be much more predictable and it will stay. So the fat is better. It's long lasting. You wouldn't do filler at the time of a lower eyelid surgery.

(14:59):
I mean, I've never heard of anybody doing that. And filler for, sometimes people come in and they've got these tired looking eyes and they're like, can you just put filler in there? And I'm like, yeah. See, the problem is, although we are filling in the valley, like I mentioned with fat, if we're doing a lower eyelid surgery, if you just try to fill that in with filler without taking down the mountain, the bulging fat, it oftentimes will make their eyelids look even more bulgy. They look even more tired because it's hard to put that filler just perfectly strategically in the hollow area. Sometimes that filler will migrate up or get into that eyelid and it absorbs water because it's hydrophilic and it'll make the eyelid look puffier. So if there's just a little mild hollowness, yes, you can use filler on lower lids or to give more youthful look.

(15:53):
Got to be careful. But yes, you can. When it gets a little more significant, you really ought to consider doing something surgically. And if you've had filler in your lower eyelids, it's a really good thing to make sure you tell your doctor if you've been regularly doing filler in that area and now you want to get an eyelid surgery, that you have that filler there, or you get that filler because they're going to want to dissolve that before they do a lower eyelid surgery so that we can correct with the adequate amount of more long lasting fat and get the look we're going for versus getting in there and finding out you got a bunch of filler in there, and I mean, the surgery can still be done, but you're going to get a better result if you let your doctor know these things.

Kirstin (16:36):
Are these surgical procedures, you touched on this a little bit, but this is something that you do for both men and women typically, right?

Dr. Koehler (16:43):
Eyelids? Yeah. It's actually a really common thing. Some men will come in and they don't like their neckline or their jawline, but I'd say way more men just don't like their eyelids and particular their lower eyelids. Men just don't like to be told they look tired. So women, they want their makeup to look good and they want their eyelids to look good. It's a different thing, guys. We don't want to hear, we look tired. That's it. Don't tell me I look tired. I'm not tired.

Kirstin (17:14):
So we're upper lids and men are lower lids.

Dr. Koehler (17:16):
No, women are upper and lower. They still need everything. But guys are less concerned. They're concerned about the look, but they're really just only concerned about people giving 'em a bad comment.

Kirstin (17:31):
All right. How long before people can be photo ready after eyelid surgery?

Dr. Koehler (17:39):
I don't know. It varies, but in a few weeks, three, four weeks, people look really good, but just depends. Swelling and bruising, those vary. Some people look fantastic after even just a week or two, but anytime anybody has something really important to do, I'm like, don't leave it till the last minute. Don't do it three weeks before. Give yourself, I think anything, most things are looking pretty decent in four to six weeks, so I would give yourself always at least four weeks, but preferably longer than that if you can. If you've got something where you're going to be having photos, because I hate to say it, sometimes there's little hiccups in these things, little complications, no big deal. We're going to get through it. And it may be a minor thing, but when you're fighting a timeline, you go like, I got to look good in three more weeks. I'm like, we can only do what we can do. We can't rush the process. If there's an issue, we got to address it properly.

Kirstin (18:36):
All right. What advice would you give someone who's noticing aging around the eyes? Maybe they're not quite ready for surgery yet. Is there anything they can do proactively?

Dr. Koehler (18:47):
I mean, like we mentioned, sometimes Botox can be useful for treating crow's feet and sometimes some of the wrinkling near the under eye, so that can be helpful. Filler in certain circumstances. But again, if we're getting really close to that surgery, then I turn down a lot of lower eyelid filler because I just know that it's not going to give 'em what they want, or it could potentially look worse. I've had patients come into me, they've been injected other places, and they had hoped it was going to look better and it ended up looking worse in their opinion. And honestly, sometimes I don't think that's an injector issue. The only issue is you shouldn't have been injected. I don't think it's a technique thing. Sometimes it just doesn't work well in some people.

Kirstin (19:30):
Okay. Anything else to add about eyelid surgery?

Dr. Koehler (19:33):
Yeah, I will say that is one surgery that can be very powerful and people look so much better and nobody will ever know you had anything done. That's the one where it's not that dramatic because it truly is the difference between somebody who might just go, God, you look great, you look rested. Whereas you chronically looked tired before and now you look rested. So they just think you got a good night's sleep and you went on vacation. It's like I did. I was vacationing at home, recovering from my eyelid surgery. But anyhow, and that's the goal, really. Again, natural results, that's what we're going for. Want to look good. And if you don't get a compliment, that's okay too. You just look good. You don't want to go, Hey, did you get your eyelids done? If it's that obvious, like, Hey, I noticed you the average person, really, I mean, some people are pretty insightful and maybe notice certain things, but sometimes not. I sometimes laugh, you we're talking about people or their celebrities or other thing when they post stuff that they've had done, and sometimes I'm like, maybe they have, maybe they haven't. I mean, you can take one person and in two different lighting scenarios, make them look completely different to where they look like they've had surgery done when really it was just the lighting and the photograph.

Kirstin (20:59):
Well, talking about Kris Jenner, one of the other Jenners, Kylie maybe, I'm not sure, posted her implant stats somewhere this week as well. And it's like moderate profile, 445 or whatever. Anyways, that's the big trending thing on TikTok right now too. And now that

Dr. Koehler (21:19):
What you post your size?

Kirstin (21:20):
Well, that she posted her size. Now. That's what everybody wants. Her breasts look beautiful and perfect.

Dr. Koehler (21:25):
Oh, right. Yeah. So we're back to number 44. You want number 44? Yeah.

Kirstin (21:30):
Right. It may not look the same on everyone, but now

Dr. Koehler (21:32):
It doesn't.

Kirstin (21:33):
All these people are like, okay, well, I'm going to go to my surgeon and be like, I want moderate profile 445. So anyways.

Dr. Koehler (21:39):
Oh God. All right. Well,

Kirstin (21:41):
Yeah,

Dr. Koehler (21:41):
Whatever.

Kirstin (21:42):
That's it. Okay.

Dr. Koehler (21:44):
More explaining. More explaining.

Kirstin (21:45):
Yeah, more talking for you. Okay. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (21:59):
Thanks, Kirstin.

Kirstin (22:00):
Go back to making Alabama beautiful.

Dr. Koehler (22:02):
I'm on it.

Announcer (22:05):
Got a question for Dr. Koehler? Leave us a voicemail at Alabamathebeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery.Alabama the Beautiful is a production of The Axis, theaxis.io.