December 2021

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By Alon Kahana, MD, PhD

We would all do well to be better listeners. In medical practice, much of the diagnostic process relies on good listening skills. In my estimation, 75-90% of a diagnosis is made by listening to the patient, and the final 10-25% comes from a physical exam and various tests to assess and confirm the clinical suspicion.

In a cosmetic plastic surgery practice, the first step of any evaluation is to listen to what the patient is aiming to accomplish, and what their priorities are. There’s so much misinformation and so many false narratives in the field of cosmetic medicine that I often find myself needing to inform and reeducate patients. In today’s column, I will share some insights regarding cosmetic procedures around the eyes.

Chemodenervation (pharmacologically paralyzing a muscle) of facial muscles with botulinum toxin to reduce dynamic wrinkles is among the most common of cosmetic procedures. Botulinum toxin comes in various formulations and brands, including Botox, Dysport, and Xeomin. Chemodenervation is minimally invasive and highly effective. Unfortunately, it’s also plagued by misinformation. 

One of the most common is the notion that one should use botulinum toxin “early and often” to “prevent” facial wrinkles. As a result, many young women with nary a wrinkle on their face initiate treatment to chemodenervate their facial muscles. The problem is that if a muscle gets denervated for a length of time, it atrophies. Atrophic facial muscles are a hallmark of facial aging, with crinkly, saggy skin and facial deflation. The goal of facial muscle chemodenervation should not be complete paralysis, especially in young people. While minimal or limited chemodenervation can smooth out the skin and give the face a certain glow, excessive chemodenervation, particularly in patients under 45, will lead to premature facial aging. If you are interested in facial chemodenervation injections, make sure that your doctor, nurse, or PA is well-versed in the biological response to treatment and understands the long-term risks.

Treatment with fillers is another approach advertised to achieve nice cosmetic results. Patients should be wary of overfilled lips and cheeks, and made aware of what they can and cannot expect from fillers. Fillers come in many types. The most common are formulations of hyaluronic acid (HA), which expands with hydration and holds water for a prolonged period of time. HA is a natural substance, and our body contains much HA in the dermis and throughout the body. With age, we lose some subcutaneous HA, which contributes to facial deflation and aging. Injecting HA intradermally can restore the lost volume while smoothing out facial skin. I like HA — it’s natural and reversible (by injection of recombinant hyaluronidase enzyme). HA breaks down over time — usually over a few months — and requires regular maintenance therapy. Other types of fillers are meant to be permanent and do not require regular maintenance therapy, but they cannot be easily reversed and have a firmer, less natural consistency. Hence, permanent fillers are better for deep filling, while HA is better for more superficial filling. The ultimate “filler” is fat transfer, which is natural and semi-permanent. But fat transfer requires much more technical skill and is much more invasive. 

In my practice, I frequently encounter patients who underwent filler injection around the eyes. Often, there are unintended consequences. For example, HA is meant to absorb water. In the eyelid, HA will cause edema, which will look terrible. The swelling will stretch the already-thin eyelid skin, leading to skin atrophy and premature aging. Furthermore, eyelid skin does not have a dermis, so you cannot get an intradermal injection of filler. This means that the filler is often placed much more superficially than is advised, and the eyelids end up looking swollen, lumpy, and artificial. Removing permanent filler is an ordeal, usually requiring surgery, so it’s never a good idea to use permanent filler as a first-line filler. In my opinion, one should avoid use of any fillers in the eyelids — more often than not, it looks unnatural and potentially disfiguring. And filler isn’t cheap — by the time you account for maintenance therapy, surgery ends up being more cost-effective, with a one-time payment and long-lasting effects. 

The lower eyelids are a common area of concern. People focus on two things: 1) the ring of discoloration, and 2) the fatty bulge. You should realize that the ring of “discoloration” is actually a result of the fact that eyelid skin is the thinnest in the body, with no dermis, and what you are seeing through the skin is the purplish orbicularis oculi muscle. The only way to reduce that is to thicken the skin (for which there are a variety of non-surgical options). Regarding the fatty “bulge,” that’s the result of both orbital fat herniation (forward movement) and descent of the midface/cheek, which creates a concavity between the eyelid and cheek – a concavity that is a major feature of the aging face. Addressing this issue requires a comprehensive approach: some patients benefit from fat excision, whereas others benefit from fat repositioning, and yet others would benefit from a cheek lift to raise and smooth out the eyelid-cheek junction. Some benefit most from a combination of the above.

Finally, the upper eyelids represent the most common target of facial surgery, and among the most common of all cosmetic surgeries. The upper eyelids can suffer from distinct yet related cosmetic issues: 1) excess skin; 2) drooping of the brows, which weighs down the lids and folds the eyelid skin onto the lashes; and 3) weakness or aging of the eyelid-opening muscle, the levator palpebrae superioris muscle. Each one of these entities should be individually assessed and addressed as needed. There are so many ways to address them that there’s much room for customizing the approach to patient needs and desires. Sometimes a part of the eyelid surgery may be covered by insurance if the eyelid position interferes with visual function.

In summary, it’s important that you share with your doctor your symptoms and cosmetic priorities in order for the two of you to formulate an optimal treatment plan. And it’s critically important that your doctor listens to you — that’s the first step in any medical encounter, cosmetic or otherwise.


Dr. Alon Kahana is a Professor of Oculoplastic Surgery at Oakland University’s William Beaumont School of Medicine and an attending surgeon with Consultants in Ophthalmic and Facial Plastic Surgery, P.C., based in Southfield, Michigan. He was born in Israel and grew up in Connecticut. He attended Brandeis University and received an MD and a PhD in Molecular Genetics and Cell Biology from the University of Chicago Pritzker School of Medicine. This was followed by residency in Ophthalmology and fellowships in Oculofacial Plastic Surgery and Facial Cosmetic Surgery at the University of Wisconsin, Madison.

In 2007, Dr. Kahana was recruited to the University of Michigan Kellogg Eye Center, where he rose up the ranks to become tenured faculty with an international reputation in orbital and complex eyelid surgery. His interests range from cancer biology and stem cells to medical education and public health. He has authored over 80 peer-reviewed publications, multiple book chapters and reviews, and has given 100+ lectures throughout the United States and internationally. In 2020, Dr. Kahana gave up his tenured position at the University of Michigan to join Beaumont and Consultants.

Dr. Kahana sees patients in Ann Arbor, Livonia, and Flint, and operates at multiple locations throughout Southeast Michigan.