Chirurgie des paupières

Chirurgie du visage - Dr Patrice Hilligot Paris

La chirurgie des paupières ou blépharoplastie va consister à corriger un excès de peau et/ou de graisse (“poches”) au niveau des paupières supérieures et/ou inférieures. Cette intervention peut-être associée à d’autre gestes de rajeunissement au niveau du visage : lifting du visage, lipofilling du visage, injection de comblement des rides.

La blépharoplastie corrige de façon durable les imperfections en supprimant l’excès cutané et graisseux au niveau de la paupière

La chirurgie des paupières ou blépharoplastie par le DR Patrice Hilligote

Sommaire :

• Quelles sont les nouvelles techniques de blépharoplastie ?

• Vieillissement et conséquences thérapeutiques

• Technique opératoire classique et raffinements personnels

• Photos avant / après de blépharoplastie.

What are nasolabial folds?

techniques

Les nouveautés sont nombreuses et nécessitent une expérience redoublée tant techniquement que dans leurs indications relatives, adaptées à chaque cas, souvent très différent l’un de l’autre, et au désir voire à l’exigence de chaque patient(e).

Aussi, dans la restauration de la beauté du regard ou son embellissement, il faut :

1. considérer et analyser précisément l’ensemble de la région orbito palpébral et non plus seulement l’état des paupières et en particulier :

• les sourcils : leur symétrie, leur position, leur forme et leur hauteur, notamment dans leur tiers externe ou « queue »du sourcil ;

• les cernes et la « vallée des larmes »;

• les rebords orbitaires supérieur et inférieur et le tissu cutanéo-graisseux qui les matelasse;

• les pommettes et leur volume proportionnel par rapport au reste du visage ;

• l’état cutané des « pattes d’ oie », de la glabelle (surface cutanée médiane située entre les 2 sourcils) et de la racine du nez.

2. connaître parfaitement les nouvelles techniques médico- chirurgicales adaptées l’embellissement du regard, leurs avantages, leurs inconvénients, et leurs indications respectives :

• modification de la forme des yeux, ou domine le regard « slave », les yeux « en amande » ou encore le « cat eye » où il ne s’agit plus de restaurer l'aspect de paupières senescentes mais de modifier le regard en utilisant une technique à la base ancienne, la canthopexie externe mais récemment remaniée et devenant dynamique;

• le comblement par des injections d’acide hyaluronique, par de la graisse (lipofilling), plus rarement par d’autres produits ;

• le « resurfacing » ou polissage de la peau par le laser CO2 pulsé, le laser CO2 fractionné, le laser erbium, l’arc électrique du plasma pen, ou encore l’injection de cellules souches;

3. savoir affiner et préciser les anciennes techniques chirurgicales de blépharoplastie notamment :

• le transfert des poches graisseuse sous-cutanée et non pas leur exérèse systématique comme cela était le cas il y a encore quelques années ;

• l’exérèse musculaire de l’orbiculaire, non systématique, de façon minimale et non plus complète, notamment sur les paupières supérieures afin d’ éviter de creuser une paupière qui ne l’était pas initialement ;

• l’ exérèse cutanée a minima sur les paupières inférieures et, à chaque fois que cela est possible, en évitant la cicatrice sur la peau grâce à une incision muqueuse interne.

4. Savoir associer ces différentes techniques médico-chirurgicales afin d’assurer à son ou sa patiente un résultat aussi proche que possible de ses désirs tout en restant naturel et en harmonie avec le reste du visage.

Il va sans dire l’importance de prendre conseil auprès d’un chirurgien, si possible chevronné, plutôt qu’ auprès d’un médecin esthétique dont les compétences sont très variables, voire d’une esthéticienne, ce qui est malheureusement de plus en plus souvent le cas.

What are nasolabial folds?

vieillissement

3/ know how to refine and specify the old surgical techniques of blepharoplasty, in particular:

- the transfer of subcutaneous fat pockets and not their systematic excision as was the case a few years ago;

- muscular exeresis of the orbicularis, not systematic, minimally and no longer completely, in particular on the upper eyelids in order to avoid hollowing out an eyelid which was not initially hollow;

- cutaneous excision on the lower eyelids at a minimum and, whenever possible, avoiding the scar on the skin thanks to an internal mucosal incision.

4/ Knowing how to combine these different medico-surgical techniques in order to ensure his or her patient a result as close as possible to his or her desires while remaining natural and in harmony with the rest of the face.

It goes without saying the importance of taking advice from a surgeon, if possible experienced, rather than from an aesthetic doctor whose skills are very variable, or even from an aesthetician, which is unfortunately more and more more often the case.

AGING RESULTS AND THERAPEUTIC CONSEQUENCES

Several morphological elements are involved in the beauty of the gaze: the eyebrows; wrinkles of the "crow's feet", the glabella and the root of the nose; the padding of the upper and lower orbital rims; dark circles and “valleys of tears”; and finally, the condition of the upper and lower eyelids.

These elements are intimately linked in the aspect of aging of this middle stage of the face.

1/ The results of aging of the orbito-palpebral region or middle level of the face:

- eyebrows

Vieillissement et conséquences thérapeutiques par le DR Patrice Hilligot

Note the importance of their symmetry, shape, thickness and direction in relation to the lateral line of the nose. In my opinion, the lateral line of the nose (A) must extend according to a harmonious curvature (B) with the eyebrow, whose tail is at the top (C) .

Under the effect of gravity, the outer third of the eyebrow, harmoniously rising, tends to horizontalize then to sag. It must always be specified, in the presence of excess skin on the upper eyelid, whether this excess comes from the eyelid itself or from the sagging of the eyebrow and particularly its outer third. The resulting treatments are very different, either simple blepharoplasty, or lifting and suspension of the eyebrow, or a combination of the two interventions.

- wrinkles and folds in the crow's feet area just outside the outer corner of the eye.

They translate the effects of an exaggerated mimicry in the squinting of the eyes or a lowering of the outer third of the eyebrow, which also accentuates the thickness of the upper eyelid.

- the lower eyelids

Between the eyeball and the bony orbit, the motor muscles of the eye and the fatty elements are lodged. Over time and under the effect of gravity, this periocular fat is gradually drawn outwards and downwards. It protrudes under the deep face of the lower eyelids, distends them, and creates real pockets.

It also seems to me that the first phase of this eyelid aging is the consequence of a modification of the zone which borders the lower eyelid downwards, that is to say, the cheekbone and the cheek. The fat and muscles in this area sag, ptose, dragging the eyelid and the periocular fat which quickly leads to a skeletonization of the middle third of the face: dark circles and "valley of tears". The bony contours of the orbit appear with, consequently, the frequent impression of a deepening of the eye and a hollowing of the eyelids. Ultimately, the contours of the eyelids widen and their center swells in a variable way.

- the upper eyelids

The deepening is, unlike the lower eyelids, often more pronounced than the swelling except in the inner corner of the eye. The excess skin is often significant. Always refer to old photographs of each patient, which become a model for reflection and work.

Despite great individual variability, skin and fat excision must always be perfectly dosed, and often more moderate than it initially appears.

2/ Therapeutic consequences

The ideal etiological treatment should result in an upward and outward repositioning of the cheekbone, the cheek, the outer third of the eyebrow and the "crow's feet", combined with excision of the periorbital fat pads and excess palpebral skin as shown in the following diagram.

But, this is a real lifting of the middle floor of the face which often corresponds to an intervention that is much, too important compared to the wish for a simple intervention formulated by my patients. Therefore, the usual treatment is summarized by blepharoplasty, which consists of removing the fat pads and the excess skin and muscle. Elsewhere, it is useful to attenuate the skeletonization, no longer by excision, but by an injection of fat called lipofilling, or even an injection of hyaluronic acid, or even by a pedicled transfer of fat pockets.

As we can see, blepharoplasty corresponds to a treatment of the effects and not a treatment of the causes of aging, the inconsistency and all the subtlety of which we sense. Ultimately, it is the meticulous analysis of the morphological abnormalities of the eyelids noted on photos compared to older photos that make it possible to define the intensity of the degradation and to identify the therapeutic consequences adapted to each case.

What are nasolabial folds?

operatoire

CLASSIC OPERATIVE TECHNIQUES AND TECHNICAL REFINEMENTS TO IMPROVE RESULTS

The treatment of aging eyelids is always summarized by classic surgical blepharoplasty. Nevertheless, recent techniques can be associated with it or even, in some cases, replace it.

This shows the importance of a fine analysis of the degradation of the eyelids and the areas surrounding them (orbital palpebral regions) which, depending on the desired goal and the desire of each patient, will result in a truly personalized treatment.

Classic blepharoplasty

On the upper eyelid:

– the skin incision straddles the upper palpebral fold;

blepharoplastie superieure avec exerese cutanées par le Dr Patrice Hilligot

– the excision removes a strip of skin and usually does not include the orbicularis muscle. This excision is meticulously adapted to the excess skin and must often be asymmetrical because each upper eyelid is usually different from the other. On the other hand, this point is fundamental and undoubtedly the most difficult to achieve in order to obtain perfect postoperative symmetry of the two eyelids. This excision, which is mainly cutaneous, must be more moderate than what many authors suggest in order to prevent the scar from being visible to others on the upper eyelid when the eyes are closed. I also insist on the very frequent uselessness in lifting the orbicularis muscle, a gesture often still too often performed. The consequence is a deepening of the upper eyelid sometimes giving a hollow eye which is not synonymous with rejuvenation, quite the contrary, especially if the person has always had, even in his youth, thick upper eyelids, which is extremely frequent especially in humans;

– septal incision (fibrous tissue) and excision of excess retro septal fat carefully adapted to each case. Indeed, if the fat excision is too moderate, recurrence is inevitable. Conversely, a hollow eye can be the consequence of too pronounced a fat excision. In the inner angle of the eye, excess fat is often predominant. In some cases, I limit upper blepharoplasty to excision of this internal excess;

– meticulous and very careful haemostasis;

– cutaneous suture by intradermal overcasting (prevents secondary epidermal cysts) of Prolène 5/0, without excessive tension.

On the lower eyelid:

– incision flush with the eyelashes without traumatizing them;

blepharoplastie inférieure avec exerese cutanées par le Dr Patrice Hilligot

– Subcutaneous-muscular detachment of the eyelid downwards;

– incision of the septum (fibrous element which ensures the rigidity of the eyelid) and fatty excision following the rules identical to those imposed on the upper eyelid;

– meticulous and careful haemostasis;

– cutaneous excision, the most delicate time, very precise, to the nearest quarter of a millimeter, and adapted to each case.

The goal is to tighten the skin and remove excess but without trying to improve its texture. Let me explain. There are two skin anomalies: excess and texture anomalies (wrinkles, pigmentation, etc.). The mistake would be to want to treat excess and fine lines at the same time. The risk is to resect too much skin and create a permanent deformation of the upper edge of the eyelid which takes a concave shape upwards (round eye) or even detaches from the cornea: this is scar ectropion secondary treatment always delicate.

Ultimately and schematically, if the excess is treated by skin excision, the wrinkles are treated by resurfacing, in particular with laser, we will see it again.

– lastly, fine suture with separate points of Prolène 6/0, without traumatizing the eyelashes. The incisions often extend beyond the level of the external angle of the eye by a few millimeters in order to equalize the suture, but without seeking to “lift” the skin outwards as certain authors recommend. This tendency to lift the skin of the eyelid outwards leads, in my opinion, to a "rounding" of the outer corner of the eye which becomes less acute. This deformation, even minimal, gives the impression of “operated” eyelids which lacks naturalness and signs, for an experienced eye, an imperfect blepharoplasty.

Fat filling or lipofilling

– This is the filling of hollow eyelids by injecting fat, previously taken by syringe in the lumbar regions, on the abdomen or thighs, then treated by filtration or even by centrifugation.

– the technique must be meticulous, in particular the injection, practiced milliliter by milliliter, in all the superficial but especially deep subcutaneous planes, and in particular in the pre-periosteal plane, in contact with the bone in order to avoid superficial skin irregularities .

– in the case of a transplant, the taking of which is always uncertain, the results are variable but often well appreciated.

More and more often, we can also use hyaluronic acid or shreds of pedunculated fat pads.

blepharoplastie avant après par le Dr Patrice Hilligot

Cutaneous lasers

– This is the smoothing of superficial wrinkles best achieved by lasers (pulsed CO2, triphasic, Erbium, etc.) which vaporize the superficial layers of the epidermis to a depth of extreme precision. Fine lines are vaporized and the epidermis, by regenerating itself, gives firmer, clearer and more velvety skin.

– A local skin preparation is compulsory, and, in the event of a history of herpes, appropriate prevention.

– The procedure is painful and requires local anesthesia.

– Too pronounced pigmentation of the skin theoretically contraindicates the application of the laser: only stages 1 or 2 of Fitz-patrick do not cause secondary scarring problems. In other cases, I prefer to use a laser test behind the ear before any application on the face.

– The postoperative edema lasts 7 days and the pink appearance of the skin about 1 month.

– If the fine lines are deep, the laser is intense and the postoperative inflammation is all the more persistent.

– When the indications are well placed, the result of the laser can be remarkable, especially when using a new handpiece.

– When the skin excess is moderate, the laser can even replace conventional blepharoplasty.

blepharoplastie laser par le Dr Patrice Hilligot

The mucosal laser

More rarely used, it is reserved for particular treatments of the lower eyelids which combine moderate puffiness and very little excess skin. The subciliary skin incision is avoided by removing the fatty pockets through the internal mucous surface of the eyelid.

Lifting of the outer third of the eyebrow

Excess skin on the upper eyelid is secondary:

– either to the progressive aging of the palpebral skin itself;

– either by lowering the outer third of the eyebrow.

– The diagnosis is supported by the comparison of current and old photos.

– The treatments are different and often give opposite effects:

repositioning of the outer third of the eyebrow upwards and outwards, in the event of ptosis, or vice versa, in the event of pure eyelid aging, classic blepharoplasty often tending to lower the eyebrow very slightly.

– The precise lifting technique of the outer third of the eyebrow is covered in the chapter corresponding to the eyebrows.

Bluish or pigmented eye

This aspect is quite common and typical of the lower eyelid. It is sometimes associated with a sunken or sunken eye.

– Blepharoplasty alone does little to improve inner dark circles and never pigmentation. The treatment is often disappointing. Some authors insist on pulsed light which could give a satisfactory result. Others rely on vitamin K creams which sometimes give good results on pigmentation.

The external angle of the eye or external canthus

In fashion, we change the look. This is the “cat eye”. The look must nevertheless must retain all its personality, and the classic external canthopexy (refixation of the external canthus of the eye to the bony orbit), for aesthetic purposes, gives in my opinion unnatural results. It is preferable to use dynamic canthopexy, a more recent technique, where a fragment of orbicularis muscle of the lower eyelid is fixed to the superior external zone of the orbit.

Before / after

BREAST SURGERY

photos

avant après blepharoplastie par le Dr Patrice Hilligot

Blépharoplastie uniquement des paupières supérieures chez une jeune femme au magnifique regard mais qui était alourdi par un « couvercle » supérieur épaissi. Le piège, dans ce cas que j’aime beaucoup, était d’enlever trop de peau et de « creuser » des paupières supérieures qui avaient toujours été un peu épaisses et lourdes. Il faut rarement modifier le regard chez les jeunes…

Dans ce cas :

• exérèse de peau sur les paupières supérieures surtout en dehors;

• pas d’exérèse du muscle orbiculaire ;

• pas d’exérèse de graisse sous musculaire, sauf un tout petit

• peleton graisseux en dedans, du côté nasal.

Le regard est magnifié.

Blépharoplastie des 4 paupières avec remise en tension musculaire des paupières inférieures et des sourcils par lifting temporal.

Le magnifique regard de ma patiente était assombri par, du haut vers le bas :

• des sourcils tombants;

• des paupières supérieures lourdes,

aspect encore accentué par la chute des sourcils ;

• le rebord ciliaire ou bord supérieur des paupières inférieures arciforme et concave vers le haut, surtout à droite, à la limite de l’ectropion (qui aurait encore été aggravée par une blépharoplastie classique) : c’est insister sur l’ importance d’obtenir un rebord ciliaire bien horizontal, rectiligne, afin d’aboutir à un aspect d’yeux en amande et imposant une remise en tension externe des muscles orbiculaires;

• des poches inférieures associées vers le bas à un sillon marquant la jonction entre paupières inférieures et joues.

Dans ce cas :

• sourcils : rehaussement par lifting temporal avec une incision invisible, située dans le cuir chevelu ;

• paupières supérieures: exérèse de peau et de graisse, sans toucher aux muscles : l’exérèse musculaire aurait eu pour conséquence de « creuser » les paupières supérieures et modifier complètement le beau regard de cette patiente. Cette faute est encore couramment commise par des chirurgiens non entraînés.

• paupières inférieures : lifting externe de la paupière inférieure et de son bord ciliaire ;_ablation des poches graisseuses par voie interne, conjonctivale, donc sans incision sur la peau de la paupière;_comblement du sillon situé entre paupière inférieure et joue par injection de graisse ou lipofilling.

Le regard est magnifié par une intervention complexe et énigmatique car sans incision visible et qui est très éloignée de l’ intervention classique de blépharoplastie.

Blépharoplastie supérieure et inférieure chez une jeune patiente présentant un regard assombri par :

• sur les paupières inférieures : un léger excès de peau en dehors et, en dedans, près de la racine du nez, une petite masse graisseuse arrondie qui bombe sous la peau. En revanche, les sourcils sont bien placés et leur forme harmonieuse;

• sur les paupières inférieures : une peau marquée par des ridules superficielles et un manque de tonicité. Vers le bas, on note un sillon marquant la limite entre paupière et joue. En revanche, le bord ciliaire supérieur est relativement tendu et rectiligne.

Le traitement est personnalisé:

• paupières supérieures: exérèse d’une fine languette de peau sans toucher, ni au muscle, ni à la graisse sous musculaire (sauf au niveau d’une petite zone arrondie en regard de la racine du nez) afin d’ éviter de trop « creuser » les paupières supérieures, à l’origine d’un regard triste et vieilli, ce qui est encore trop souvent constaté entre les mains de chirurgiens non entraînés;

• paupières inférieures : injection de graisse ou lipofilling de type nanofat qui a double effet : _ comblement des ridules superficielles et du sillon inférieur ;_ tonifiant et lissant de la peau par son apport en cellules souches.

Pour la petite histoire, j’ai opéré cette patiente il y a plus de 20 ans, juste après avoir participé au congrès de Boston où le Dr Sydney Coleman présenta pour la première fois sa technique révolutionnaire d’injection de graisse.

Trouvant cette technique séduisante, je l’ai immédiatement intégré à mon arsenal thérapeutique, alors qu’il a fallu de nombreuses années avant que l’on commence à en parler en France.

Être à l’écoute, précurseur, et toujours vouloir progresser…

Voir toutes les résultats avant / après de blépharoplastie

CABINET A PARIS

Dr Patrice Hilligot Chirurgie et médecine esthétiques

10 rue Quentin Bauchart

75008 Paris (Champs Elysées)

Tel : 01 47 20 54 52

Doctolib

cabinethilligot@gmail.com

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