Today I had a great chat with Dr Jayson Oates, ENT Surgeon, where he shared some insight into blepharoplasty surgery, who it’s for, a bit about the process, upper and lower blepharoplasty, how common they are, and a whole lot more. It’s a very common procedure here in Australia, check out this podcast.
Trish: Hey podcasters, it’s Trish here again, and today I’m talking with the lovely Dr. Jayson Oates, who is from Academy Face Body in Subiaco in Perth. Dr. Oates is an EMT, and he does lots of surgery on the face, so today we’re going to have a chat about one of the most popular surgeries in Australia, which is the blepharoplasty, which is getting rid of excess skin and sort of fatty tissue around the eyes. Well, I think we’ll find out for sure if that’s exactly what it is, so welcome, Dr. Oates.
Dr. Jayson Oates: Hi, Trish, good to be speaking with you again.
Trish: Yeah, thanks so much for joining us today. Tell us about a blepharoplasty, is that upper and lower, or like what does blepharoplasty mean?
Dr. Jayson Oates: Yeah, so it’s improving the appearance of the eyelids, and it can either be upper or lower, or both. A lot of people think of the upper eyelids especially, and think of excess skin there, and in the lower eyelids, they’re usually thinking about excess fat there, although there are caveats to both of those ideas.
Trish: Okay, and so I know all surgery is a big deal, but I know that blepharoplasties are actually really quite common. I don’t know if this statistic that I heard is true, but they reckon one in four people in Australia have it done. Does that sound true, or is that just a rumour that I heard?
Dr. Jayson Oates: I don’t know, I certainly haven’t heard that exact statistic myself. It’d be great if it was true, but maybe over their entire lifetime, yeah, certainly it’s a very common surgery, and perhaps it’s one of the commonest cosmetic surgeries. It can also be a functional surgery as well, and it’s certainly one of the least invasive surgeries, as far as cosmetic surgeries go.
Trish: Do they have to be done in a hospital? Like, because I’ve heard of lots of situations where they’re not done in hospitals, is that the case?
Dr. Jayson Oates: Well, we do all of ours in hospital, but of course my practise is a bit different in that we have our own registered twilight sedation hospital on-site, so I would do 99% of my blepharoplasty surgery under twilight sedation in our own facility here. People come in and go home the same day.
Trish: Okay, so it sounds like it’s a really easy procedure to do.
Dr. Jayson Oates: Well, it’s a very technical, hard procedure, and an area that doesn’t allow a lot of tolerance for mistakes or variation. Technically it’s still a very demanding procedure, but for the patient to go through, yes, it’s-
Trish: That’s what I meant, sorry, I meant the patient. I know it’s not easy for you, but I meant was it easy for the patient. Sorry about that.
Dr. Jayson Oates: Well, it’s easy for me, but yeah, we don’t want to ever really give patients the idea that coming in for any kind of surgery is an easy thing, or something that should be taken in a flippant or light way, because it’s still a procedure. When it’s a cosmetic procedure, it’s an unnecessary procedure medically that you’re doing to improve your confidence in your ability in your appearance, but there’s still potential complications, and some of these potential complications are very serious, so we do take it just as seriously as any other procedure that we do.
Trish: Yeah, and so tell me, I heard, and I don’t know if this is true, so at the moment there is a Medicare rebate, or there’s a Medicare item number for, you know because I know that it can affect people’s vision and that, but I heard today, and tell me if this is true, that that’s actually about to change.
Dr. Jayson Oates: It certainly can be, the Medicare rebate is only if you can justify that there’s a medical reason for having the surgery, and Medicare is getting much stricter on picking up on these things. I’ve been doing this operation for almost 20 years, and in the first 18 years, we never really heard from Medicare, we never had them asking for you to justify why this person is having it as a medical procedure, as opposed to a cosmetic procedure. More and more commonly, Medicare is now asking for that justification, so we need to be very careful on who we do give access to the item number.
In fact, in the end it’s a relatively small amount, so in relation to the total cost of the procedure, it isn’t a huge amount.
Trish: Yeah, okay, and fair enough, you know like I mean if it’s not for medical reasons, so Medicare shouldn’t cover it, there’s no problem with that really.
Dr. Jayson Oates: No, not at all. There are a lot of ophthalmologists who, under local anaesthetic, and in fact there was a time we used to hear about the ophthalmologists doing it one eyelid at a time, under local anaesthetic, and potentially for no sort of out-of-pocket costs at all. I do a very simple, skin-only removal, and it’s not meant to be a cosmetic, aesthetic procedure, it’s just to stop the skin from hanging over your eyes so much that you can’t see.
Trish: Right, okay. Who can it help, like because I know for a fact that my partner gets those heavy eyes, and some people just naturally have that really quite loose skin above their eyes and below their eyes, and some don’t.
Dr. Jayson Oates: Yeah, absolutely. In fact, it’s one of the earliest places to show ageing changes. Some people, it is a familial sort of issue, and they have heavy upper eyelids or bags in their lower eyelids from a very young age, even virtually teenagers when it’s a strongly familial or racial characteristic. The most common by far is somebody maybe from their 40s, but very commonly 50s and 60s who are just noticing that extra skin hanging over their eyelashes, and it may be just very thin skin and deflated. For a heavier sort of person, it may be very chubby, fat-filled skin, and it’s starting to crowd the eyes, make the eyes look small. It gets to that point eventually, it becomes a medical issue where it starts to shade the vision in the upper-outer quarter of their vision.
People sometimes come in and they grab their eyebrows and lift their eyebrows up, and that pulls and uses up that excess skin, and they say they want their eyelid to look like that. That’s where we then get into the whole discussion about is it an eyebrow issue, and as the eyebrows come down, the skin that’s underneath the eyebrows is stretched over a smaller amount of their face, their eye socket area, so that skin then bunches up. Or is it that their eyebrow position is fine, and they don’t necessarily want the brow elevated, but they’ve got that excess, and then we have to take some of that out.
Trish: Okay. I’ve got so many questions to ask, it’s like which one do I get out first. Is it more common in, like can you get it, like some people are obviously like maybe 30 and might need it done, and some people could be like 50 and need it done, so it can be a genetic thing?
Dr. Jayson Oates: Yeah, so definitely certain people will need it much earlier, and they might say that, yeah, their mother or father had the procedure at an early age as well, and also just people are getting more comfortable with having all kinds of cosmetic procedures, so that sort of is increasing. It is over quite a wide range, it’s also perhaps one of the more common procedures for men to have as well, because you know they see it in their eyes, and a lot of men are sort of, they’re not as comfortable necessarily wanting to have a facelift, a big procedure like that, but something they see as being small, quick, in and out the same day, much more limited recovery, yeah, men are more likely to present for that kind of procedure.
Trish: Yeah, of course. You don’t have to have both done, you can either have like an upper or a lower, or both done, is that right, depending on what you need, or could there be a person that might just need the lower and not the upper?
Dr. Jayson Oates: Yeah, yeah, certainly we have times where we just do the lower lids and not the upper lids, although upper lid is perhaps more common. Even occasionally, you get somebody who just needs one side doing, and they may have a lot more fat in the lower eyelid of one side, they may have a droopy eyelid just on the one side, and then you need to just correct the one side, but that’s a bit less common.
Trish: Okay, and so how long does someone take to get over it, like what’s the recovery period like? You go in in the morning, so you have your surgery in the morning and you go home, you obviously can’t drive yourself home.
Dr. Jayson Oates: When we do sedation, they’re not meant to drive for 24 hours, so they need somebody who can pick them up, take them home, and look after them. It’s really not a painful procedure at all, and people don’t need a lot in the way of pain relief, don’t have nausea sort of problems, but we still like somebody to be with them for the rest of the day and overnight. We used to always bring everybody in to see us the next morning, but now more commonly we’ll just ring people at home, see how they’re going. I use a suture that runs underneath the skin, and there’s a little knot at the inner corner of the eyelid and a little tail that sticks out at the outer corner, so generally we’ll just bring people back a week later, and grab that stitch and pull it out.
In that intervening week, you’re basically feeling fine. I don’t want people out digging holes in the garden and doing strong physical work, or work that involves a lot of bending over, but for a lot of people, they’re pretty well doing their normal sort of things with a day or two from surgery.
Trish: Okay, and with what you do after surgery, so you do stitches on the inside of the eye, so there’s no … Because I had a friend that got it done, she had like, it looked like black eyeliner all the way across, but that was her suture, so it doesn’t look like that, it’s just a little-
Dr. Jayson Oates: It varies a lot from person to person.
Dr. Jayson Oates: Especially for like myself, who’s doing a lot of the cosmetic procedures, you’re wanting your patients to look as good as possible as quickly as possible. If there’s somebody who’s doing a more functional-type procedure and there’s no out-of-pocket expense to the patient, then they might find that they’ve got a lot more stitches showing, and just I guess the aim of what we’re trying to achieve is a little bit different.
Trish: All right. Do you reckon someone could go back to work like the next day, apart from having, you know…
Dr. Jayson Oates: Yeah, so if you’re working on computers and in an office, if it didn’t matter if you had a little bit of swelling and potentially bruising, and most people have a pretty good idea of how much bruising they’re going to get. I usually say, “Look, if you’re a bruiser, well then chances are you’re going to end up with bruising and maybe two black eyes.” If you were just having the upper eyelids done, the bruising always seeps around and goes into the lower eyelid as well. If you’re not much of a bruiser, then you have the procedure done, and you get some ice packs to minimise the swelling, and then really there’s not that much to see for those few days.
Trish: Yeah, sure. I know it’s “not such a big deal”, but are there any risks associated with having bleph surgery, like is there any, you know because it’s pretty close to your eyes, and-
Dr. Jayson Oates: We’ve got a big information sheet that we give everybody, and I run people through little stories and say, “Look, if I take a tiny little piece of skin out of your upper eyelid, you’ll get this tiny little change, and if we do a bigger piece of skin, you’ll get a bigger change, and if I take this great, big piece of skin out, then you won’t be able to close your eye.” The biggest worry that we have is people who take too much skin out, and so I did see that last year, somebody who was done in the chair by their GP, and they just took too much skin out, and she couldn’t close her eye, and so she got a very dry eye.
Trish: I’ve seen that too, I’ve seen that too, where you could see the whites, you know like you’ve got your pupil, and then your eyelid, you could actually see the top between the top of the pupil and her eyelid, like you couldn’t, you know-
Dr. Jayson Oates: That’s a disaster, and so then we suddenly have to graft skin back in, and we don’t really want to be doing that. That can happen in both the upper and the lower eyelid, so that’s probably one of the number one things to do, is take too much skin out. As we cut through, we are cutting through the muscle that scrunches the eye up, and that muscle helps spread the tear film, so the tear film perhaps doesn’t get spread quite so well for a few weeks afterwards, and so the eye can feel a little bit dry. Part of the way the eye responds to dryness is to water, so you can also have a little bit of a watery eye in the early phases.
The biggest fear that surgeons have is bleeding from usually the fat pockets, and there are two fat pockets in the upper eyelid and three in the lower eyelid, and if you’re touching the fat pockets and you get bleeding, especially bleeding that goes behind the eyeball and inside the eye socket, that puts pressure there, it stretches the optic nerve, and it can actually lead to blindness. This is obviously something that’s incredibly rare, and in the 20 years that I’ve been doing it, I’ve never seen it as a patient, I’ve never met a surgeon that’s told me that they’ve had it as a complication.
I had this discussion with every patient, and it scares everybody, but the important thing is that it’s something that can be fixed, there’s a way of releasing the pressure, and you might end up with a big black eye that takes two months to fade away, but at least you can see. It means that if there’s a problem and it’s the middle of the night, that we have a plan to solve it in the middle of the night, and the patient knows not to ignore the problem. We have all these sort of discussions, and I hope that I can go another 10 or 15 years and never have to see it and never have it…
Trish: Of course.
Dr. Jayson Oates: In the middle of the night, but it’s an important discussion to have with a patient, so that they know what the potential is and how to react if they’ve got a problem.
Trish: Yep no, that’s fair enough. One other thing, like a lot of women on our closed forums are asking about a lower bleph to get rid of the dark circles under the eyes, like can you tell us a bit about how they could get rid of dark circles under the eyes? Because I don’t think a bleph would, especially if they’ve got wrinkly skin I guess a bleph would kind of help that, but what’s a solution for that.
Dr. Jayson Oates: It’s a complicated area, because there’s a number of things that are involved. For some people, it’s a pigmentation issue, and that can actually be one of the hardest things to solve, like go through the bleaching creams, there’s skin-lightening lasers, and they can sometimes have these wonderful results. It can be from wrinkly skin, and it’s really the sort of shadowing that’s causing the problem. Commonly when I’m doing surgery for the upper eyelids, I’ll do some laser on the lower eyelids, and you tighten skin up a lot, and that can make a big difference for dark circles for some people.
Trish: What type of laser, like that would…
Dr. Jayson Oates: CO2 laser, I’ve always sort of had CO2 lasers, and that’s usually the best as far as tithing with the skin, and you can dial up and down the intensity of the laser. Obviously we’re dealing with very thin and delicate skin, so we’re using it in a gentler setting than perhaps on the rest of the face, but you want it intense enough so that it does tighten the skin there. That can be really really successful in improving lower eyelids, and in fact I probably do less lower eyelid surgery now than what I did 10 or 15 years ago because of the success of lasers on the lower eyelids. Then the next is the tear trough deformity, or the lack of fat and volume around the edge of the lower eye socket, and there are a number of things that contribute to that.
The bone itself actually shrinks away with age, but that then doesn’t support the cheek fat, the cheek fat drops down a little bit, and this creates this bit of a hollow, and you can have the slightly bulgy fat of it, which then casts a shadow, because the light is generally coming from above you, into the hollow below. There are more technical, complicated forms of lower blepharoplasty called fat repositioning surgery, and so with that, we don’t cut away the fat of the lower eyelid, but we just tease it out a little bit, fold it over the edge of the eye socket, and then stitch it over there, and that can smooth that eye socket out, fill in that hollow and improve the shadowing and the dark circles there. That also can make a big difference there.
Trish: Okay, so yeah, there’s other solutions, you don’t need to … Yeah, there’s basically, it’s different strokes for different folks, and depending on what it’s like, that’s what you will work out with the patient when they come to see you.
Dr. Jayson Oates: Yeah, so sometimes patients will see on the internet somewhere, “Have your eyelids done for $3,000,” or something, and they’ll sort of say to me, “Well, why is your price more expensive?”, and I might say, “Well, I’ve done all this training in eyelid surgery, and you don’t know what they’ve done. I’ve got a registered hospital that we’ve got to be doing the surgery in, as opposed to perhaps having it in a chair in a GP’s office. I’m going to be available in the middle of the night if you’ve got the problem, and I don’t know what else, but also there’s all kinds of different surgeries. Even for the upper eyelid, some people I will just take out a little strip of skin and muscle, and that’s all they need.
Some people, you take out skin muscle and take out a lot of fat. Some people have a bulge of fat in the inner corner of their eye, but then have a hollow in the middle, what we call the A-frame deformity. It’s quite an ageing thing for the upper eyelid, where it gets deeper and more hollow, and in fact in that eyelid, the last thing you want to do is take out more volume. There, it’s very useful to take the fat from the inner corner and stretch it over the eyelid and stitch it in place, and that fills in the hollow. In fact, volume is really… there’s a suture known as the brassiere suture, where we fold the muscle of the upper eyelid, we fold it around it, and attach it deeper into the bone of the eye socket.
That just supports and lifts the fat pad of the eyebrow and stops it from descending down. It does have a very beautiful aesthetic curve of the upper brow, and that’s really important. Fortunately, we have all these brochures in our offices nowadays, you know especially from the filler companies, and they’ve got these beautiful young women that have got these beautiful full eyelids, and usually quite low eyebrows. A lot of people come in and say, “Oh look, I need my eyebrows to be higher and higher.” You look at all these pictures here, none of them have a really high eyebrow, but they’ve got a lot of volume, fullness in that upper lid.
We can help maintain and accentuate that with the right kind of surgery. Then as we were talking with lower eyelids, you know you can just take the fat out, or you can be repositioning the fat. There are simpler and much more complicated surgeries, and then usually the much more complicated surgery takes a lot longer to do, and it ends up being more expensive.
Trish: Okay, so there’s lots of options, so probably the biggest takeaway is make sure you go to someone who’s properly qualified, make sure they’re doing it in the right place.
Dr. Jayson Oates: Yeah, the right person, the right place, and the right experience, the right backup, because it’s your face, it’s your body, it’s your health, you really ought to be doing some research into who you’re going to be letting touch that.
Trish: Totally, totally, and I guess that’s with anywhere, hey?
Dr. Jayson Oates: Yeah, absolutely.
Trish: Awesome. Well, thank you so much, I can’t think of any other questions that anyone could possibly want to ask, but if there are, you can always just drop us an email to firstname.lastname@example.org, and we will find out for you. If you’re looking for Dr. Jayson Oates, you can look him up on Google, and it’s Academy Face Body in Perth.
Dr. Jayson Oates: Great.
Trish: Awesome. Thanks Dr. Oates, we’ll talk to you next time, thank you so much for taking the time.
Dr. Jayson Oates: Thanks, look forward to speaking to you again, bye.
Trish: No worries, bye.