Dr. Natalie Higgins joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. She talked about eyelid lift, blepharoplasty.
Read the transcript of Dr. Higgins' talk on eyelid lifts on Health Matters radio or listen here
Health Matters: Welcome back to Integrated Rehabilitation Group Health Matters, Maury Eskenazi, Shannon O'Kelley. Joining us, we met her at the Smokey Point Everett Clinic, at the brand-new grand opening is Dr. Natalie Higgins. She is a cosmetic surgery and ear, nose and throat specialist.
Health Matters: How is it going there at the new location.
Dr. Higgins: It's wonderful. We are seeing a lot of new patients. We have a lot of new patients to keep our new providers busy, which is great. The feedback from the patients is wonderful. They love it. You know, it's a new building. All of the specialties are in one building so they don't have to keep going across the street or drive to different places, which they really, really like. The services are centered around the patient exam room. So, for instance, if you need a blood draw, the lab comes to you, so you don't have to go to another place and wait 30, 45 minutes sometimes to get your blood drawn. You can get your appointment set up in the room so you don’t have to go back to the desk and wait in the line to make another appointment. It is wonderful. Most everything can be done in the exam room.
Health Matters: I noticed that it was really designed for patient flow and convenience. It's a great facility, and I'm glad to hear that it is going well. I'm sure you guys are going to do wonderful up there. So, you're an ear, nose and throat doctor with an interest in plastic surgery. Can you describe what you do and how you kind of got to where you are today?
Dr. Higgins: Sure. I did a residency in head and neck surgery, which is also known as otolaryngology or ear, nose and throat. ENT, people call it. It is a 5-year residency. After medical school you do residency for your training, whatever specialty you decide to do. I did 5 years in head and neck surgery in New York City and then after that you can do fellowship. A fellowship is sort of like an extra specialty within whatever sort of field of training you choose. I did a fellowship in facioplastic and reconstructive surgery and that was at the University of Illinois in Chicago. There are about 40 spots for those fellowships in the country now. It’s an extra year of training that you can apply for and do, which gives you a little more in-depth exposure to the facioplastic and reconstructive portion. Some of them are heavily weighted toward cosmetics. Some of them are weighted toward reconstructive. I had a great opportunity where I really got to do both and see both.
Health Matters: Are there situations or conditions, particularly being ENT and then a plastics physician that people need eyelid lifts?
Dr. Higgins: Yes. Usually when they come to us for a functional issue, it's a peripheral vision problem. They have problem with either their superior and/or lateral, so sort of outside peripheral vision. A lot of times it's due to excess skin that is hanging down. Sometimes they refer from the ophthalmology department. Sometimes the ophthalmology doctors will do the blepharoplasty themselves. Otherwise, they come in for cosmetic issues. They just don’t like the way the extra skin looks or they have some fat pads that are sort of pooching out or protruding that they want fixed.
Health Matters: Is there is any disease component that someone would have like a droopy eyelid, I mean, sometimes like I guess a stroke or CVA.
Dr. Higgins: Yes. The droopy eyelid is a little bit different. It is either a separation or a lengthening of the muscle that actually keeps your eye open without you having to think about it. That's why we have a crease in our eyelid. That’s the attachment of the muscle. As you get older, sometimes it stretches out to the point where it is really not able to keep your eye open. So, one eye will look smaller. It sort of comes down to cover almost your pupil in some cases instead of just to the top of the color part of your eye. That’s called ptosis. Sometimes the muscle actually completely detaches and they don’t have a lid crease. You can have a congenital ptosis where children are actually born with that. Those children typically need a more integrated approach at a children's hospital because they sometimes require muscle grafts and a little more complex surgery. But, for the older people whose muscle is just stretched out, you can actually go in through a blepharoplasty and get down to that muscle and tighten or reattach that muscle if you need to.
Health Matters: How does it stretch out? Just through age?
Dr. Higgins: It kind of loosens with age. Health Matters: It's amazing because the eye is very sophisticated and complex, and you don’t really realize that what keeps your eyelid up is a muscle. So, you are going in there and just shortening that? Or what is the procedure?
Dr. Higgins: It really depends on what the problem is. Sometimes you don't know until you go in. There are medical conditions, like people who have strokes, some people with neuromuscular disorders, some people with nerve disorders where they get a droopy eyelid and sometimes surgery won't fix it because even if you tighten the muscle, their nerve is not signaling the muscle, it does not really matter how tight that muscle is. That is part of the evaluation process when a patient comes in. We go over all of these issues to try to figure it out. But, again, it is a little bit of a separate issue, the ptosis problem. Most people just come in either for cosmetic reasons or because they have a peripheral vision issue with their upper lids.
Health Matters: Does that just happen with age?
Dr. Higgins: As you get older, everything relaxes. Your eyebrows also come down as you get older. That contributes to extra skin on your eyelid. Again, that is part of the exam when somebody comes in. You look to see is the brow ptosis it's called or a drooping of the eyebrow actually contributing to the extra skin. In those cases you know, you need to be careful. You don’t want to just remove the extra skin on their eyelid because their eyelashes are going to end up over their eyebrows because you are pulling the eyebrow down at the same time. Health Matters: That's pretty important.
Dr. Higgins: It looks a little bit funny. Usually you evaluate them ahead of time to determine if they actually need their brow set back to the correct position first and then you remove the extra skin. It is usually sort of an overtime thing. I have done brow lifts on women as young as 40 who just have the anatomy where everybody in their family has a low-set brow. It doesn't really take very much aging to make a difference for them. I've also had 60, 70-year-old people that tell me when they are driving, they have to hold their eyelid up with their finger or when they are watching television they hold their eyelids up.
Health Matters: Wow.
Dr. Higgins: I have actually had people tell me they tape their eyelids up when they get home because it's just so much effort to keep their eyes open.
Dr. Higgins: I usually tell people, time keeps marching on. You will look better than if you had done nothing, but you are still going to get progression of laxity, relaxation of the muscles and the ligaments. You may need a touch up. How long that's going to take is very variable. It depends a lot on your genetics, your skin type, your other medical issues and health problems. There is a lot to take into account.
Health Matters: Is this surgery we're talking about the blepharoplasty?
Dr. Higgins: It's a blepharoplasty.
Health Matters: Is that like an in-office deal or do you have to go to the hospital for that?
Dr. Higgins: It can be. Blepharoplasty is sort of the generic term for an eyelid lift. It can be an upper eyelid lift or a lower eyelid lift. Most of the functional ones for peripheral vision would be an upper eyelid lift. The lower eyelids are a bit of a different problem. You can have them done either in the office or in the operating room. Probably 90% of my patients, I do the upper lid in the office, very straightforward. It takes about an hour. It is pretty quick. Most people tolerate it really well. If people are nervous, they can get a little bit of sedative ahead of time.
Health Matters: I'm all for that.
Dr. Higgins: If they have somebody drive them in. You need a chauffeur that day. But people are really comfortable. It's basically done with local anesthetic, so a Novocaine type injection and then we remove the extra skin, sometimes remove, again, some of that fat that is sort of pooching out and contributing to a full, kind of tired look in the upper lids and then put the stitches in. Each eye takes about 30 minutes. If you need the correction for the droopy eyelid, that can be done at the same time. It is a little trickier because you have to make sure that you don't over tighten the muscle and then people can't close their eye, which is obviously a problem you don’t want to give them.
Health Matters: You just said something, over tighten the eye. How do you calculate that. As a surgeon in determining how much to remove. Is it based on just feel or look?
Dr. Higgins: No, it's actually measuring. Before you do the procedure, we do what is called marking. We have the patient sit upright and mark out where their lid crease is. In case of ptosis it can be tricky because sometimes the crease is not there, but most people it is sort of within 8 to 10 mm of where your eyelashes are. You mark that crease out. It is usually sort of a curvilinear crease on the eyelid and then you actually just use like a sort of pair of medical tweezers and you pinch the extra skin on the eyelid. You are pinching it just enough so that they can still close their eye, obviously, and then sort of mark out, you know, where the top of that line would be. So, you end up with parallel lines in a curvilinear fashion. For women, you extend that out into sort of one of the crow's feet creases because they have a lot of what is called hooding. They kind of get that overhang. For men, you don't want to do it because it sort of feminizes the eye. It looks a little bit funny. You have to tailor it still.
Dr. Higgins: Then we gently lie them down, give them the numbing injection. Set up everything sterilely and then do the procedure. It involves giving them the Novocaine type injection so that they are numb, they are comfortable. You pinch up the extra skin, remove it and then sometimes again you have to go through the muscle to get to the fat and you kind of tease that fat out. Again, being careful. You don't want to make them look really hallow afterward because that actually ages people more, and then you stitch the skin back together. It takes about 30 minutes for a standard one side upper lid blepharoplasty, which is really very tolerable.
Health Matters: How long is the recovery? Do they leave with bandages over their eyes?
Dr. Higgins: No, they don’t have bandages. They have a stitch that sort of zigzags underneath the skin in the eyelid and so it's taped at either end, you know, sort of over the crow's feet and then between the eyebrows. When they leave, most people look pretty good. You know, they are a little bit swollen. Sometimes you have a little bit of bruising that happens during the procedure, but they look good. You can see the results immediately.
Health Matters: Oh, right away?
Dr. Higgins: Absolutely, because the extra skin is not there anymore. I have plenty of people that leave and they say, wow, I can you know see more peripherally already. It's a big difference. Or, my eyes feel lighter already. I feel like I can open them more. Then, it is about a week recovery. You really need to take it easy the first few days because of the swelling. The less you do when you are recovering, the faster the swelling is going to go away because you are going to develop less swelling. I tell them, go home, take it easy, ice on and off as much as you can for the next two or three days.
Health Matters: Don't look at anything?
Dr. Higgins: Well, you can watch television. You can watch sports....
Health Matters: You just don't want to do a lot of lifting and pushing, pulling....
Dr. Higgins: Right. It's not the time to catch up on your housework, your garage cleaning and yard work. Health Matters: What about seven days later, is the suture coming out then?
Dr. Higgins: Seven days later, the stitches come out. Plenty of people go back to work straight from their postop appointment. You still, have to be careful about wearing makeup because you don’t want to rub the skin to take the makeup off.
Dr. Higgins: Usually within, two weeks most of the swelling is gone. The thing that takes the longest is the scarring. All scars start off pink and fairly noticeable, but over time they fade. Sometimes it can take up to three months. But, again, the vast majority of people, by a month, they are doing whatever they want and looking good. That is for the upper lids. The lower lids are a bit more complicated.
Health Matters: Well, I would imagine if it is a functional thing and you are trying to correct vision, I would think insurance would pay for this.
Dr. Higgins: Insurance companies do sometimes pay for it because it is a functional deficit if you cannot see peripherally. Usually you go for what is called a visual field test, where you put your head in that circle and look straight and they flash the lights and you hit a button. After you have done that, they actually take the extra skin up out of the way and retest you. If you can see a significant improvement in your peripheral vision, you're seeing more of the dots that are flashing then your insurance company will often times pay for it. But, we have to submit it to them for preauthorization. You need your pictures taken. You need the visual field test sent in. But, that is, just for the upper lids. The lower lids are always cosmetic.
Health Matters: You know, while we have you on the air, I just want to ask you, as a plastic surgeon and understanding scar development and scar tissue, as a parent, you know your kids sometimes get cut and they might cut their face or cut their chin. When do you know when they need to have sutures to close that or to decrease the scarring?
Dr. Higgins: It's a question we get asked a lot, and I do see a lot of children in the office who get sent from the emergency room or the Walk-In Clinics whose parents are specifically requesting a facioplastic surgeon, which is appropriate. It's hard to tell when you are the parent and you always wonder what should you do. If it is an abrasion, meaning that the skin has been removed but you can't actually pull the skin apart, there are no stitches. If you can actually pull the skin apart and see people describe it sort of as the meat underneath then you should have the child evaluated to see if they need stitches. All wounds heal on their own whether you intervene or not, the difference is how are they going to scar. Any time you have anything that goes through the skin, you are going to have a scar. Some people assume that plastic surgery means no scars, and a lot of times, we are able to get a scar to where it is really not noticeable unless you are looking for it, but you always end up with a scar. If you can pull the skin apart and you can see the meat, they should have sutures. There are plenty of Walk-In Clinic, urgent care people are able to do that, but certainly parents can request to see if there is a plastic surgeon on call. I get a lot of calls from pediatricians and primary care doctors who say can you see this person.
Health Matters: Dr. Natalie Higgins, cosmetic surgery, ear, nose and throat from The Everett Clinic. Fantastic. She was great.