Podcast: You Look Tired

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Eyelid surgery (the procedure that “fancy people” call blepharoplasty) is how we help fix dark circles and eye bags. The goal isn’t to make you look different, just less tired or old.

Eyelid surgery techniques differ for men and women. Unless you’re going for a feminine look, you don’t want to show much upper eyelid as a man. Dr. Koehler restores men’s eyes without throwing their masculinity out the window.

For anyone thinking about eyelid surgery, Kirstin asks Dr. Koehler the important questions, including:

• What’s the average age to get a blepharoplasty?
• Where is the incision made?
• How do I know if I need a brow lift too?
• Can’t I just get filler to fix the hollowing under my eyes?
• When can I go back to work again?
• When can I wear makeup?
• Does insurance ever cover eyelid surgery?

Read more about eyelid surgery

See Dr. Koehler’s eyelid surgery before & after photos

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Transcript

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:11):
Hey, Dr. Koehler.

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

Kirstin (00:14):
How was your weekend?

Dr. Koehler (00:16):
It was good. I worked on a book chapter. It was very exciting.

Kirstin (00:21):
That sounds exciting.

Dr. Koehler (00:24):
Yeah. I’ll be glad when I get that off my plate. It’ll be good.

Kirstin (00:27):
Okay. You got all your Christmas shopping done?

Dr. Koehler (00:31):
Have I started my Christmas shopping? No, not yet.

Kirstin (00:33):
Oh.

Dr. Koehler (00:33):
I’m working on it.

Kirstin (00:35):
Okay. I started in August.

Dr. Koehler (00:37):
It’s on my to-do list.

Kirstin (00:40):
Okay. Well, today we’re going to talk about eyelid surgery. Was that like a suspenseful?

Dr. Koehler (00:48):
Yeah, I was waiting for the subject, so yes.

Kirstin (00:52):
Well fancy people call it blepharoplasty.

Dr. Koehler (00:55):
Can you say that again?

Kirstin (00:56):
It’s a hard word for me to say actually with. blepharo, it’s a bleph.

Dr. Koehler (01:03):
Okay. A bleph, blepharoplasty. Good job.

Kirstin (01:07):
Bleph, bleph. Oh my God. Blepharoplasty.

Dr. Koehler (01:10):
Yes.

Kirstin (01:10):
That’s my Appalachian coming out. It’s the fifth most popular procedure in the us. Did you know that?

Dr. Koehler (01:17):
I did not know that. Well, I figured it’d be up there. There’s lots of eyelids running around.

Kirstin (01:22):
Yeah, that’s what I hear. So our last episode was about the facelift. You said the curtains had to match the drapes.

Dr. Koehler (01:32):
You know, when people want to say they want to look natural, which as I totally get it, and sometimes people feel like more surgery is going to make them unnatural in appearance. Sometimes the opposite is true. If you don’t do enough to kind of get everything balanced and looking like it all belongs together, that can look unnatural. So that’s what I was referring to is just the fact that sometimes we also need to address the brow, the eyelids and other things, and not just the face and neck. I mean, I understand sometimes for financial reasons or other reasons, people want to do it in stages and that can make sense. And not every case, just because you do your lower face and neck, if you don’t do the other things, it may not look bad at all. It may just look great, but there are cases where I feel like if you don’t address some of these other issues, it can sometimes not match. So that’s what I was referring to.

Kirstin (02:23):
Perfect. When someone gets their eyes done, it’s not always the most obvious thing, but what do people look like after a good well done eyelid surgery?

Dr. Koehler (02:33):
Well, it varies, and it depends on if we’re talking about males or females, but eyelid surgery is one of those things that honestly, it shouldn’t be obvious to your friends and family. You would probably notice it because you’re putting your makeup on in the morning and you’ll notice the fact that, oh, your makeup, it sits better on your eyelids. You can see more of your eyeshadow or other things, but it’s not an obvious thing. And truthfully, for men, we have to be careful because women like to have a bigger lid platform so that they can put their makeup on and that they sort of makes their eyes pop a little bit. Men on the other hand, typically don’t show very much upper eyelid at all. And if you give them a bunch of upper eyelid, it can feminize them and it makes, unless that’s the look you’re going for, but that’s not what men typically want.

(03:23):
And so yeah, it’s a subtle thing for upper eyelids, it’s just getting rid of some of that sagging skin that may be getting onto your eyelashes, or sometimes it can be hanging over your eyelashes. And on the lower eyelids, it sometimes can be loose skin. But a lot of times we have some fat pads on the lower eyelids that can start to bulge and it makes you look like you have bags under your eyes. It makes you look tired. And so that’s another popular procedure because people, I’ll never forget, I’ve talked about this guy to many patients, but I had a patient of mine who was a farmer. He came in and he said, I really don’t even care what I look like. I’m sick of people telling me I look tired. And that was the goal. And the goal of the operation was not to give him some different look. It’s just not tired. And so by getting rid of those bags under his eyes, he was able to achieve that. And so that’s kind of the goal with lower eyelid surgery.

Kirstin (04:20):
Well, are there times when people come in thinking that they want a brow lift, but actually they’re more of a candidate for a bleph?

Dr. Koehler (04:28):
Usually it’s the opposite. Usually people come in wanting eyelid surgeries and really in order to, so the distance between your brow and your eyelashes, if it’s really short, I can take out all this excess skin. Oh, you asked me what was causes. Well, the cause is as we get older, the brow descends, the skin is sagging. But if there’s not a lot of distance between where the brow is sitting and where the eyelids are sitting, I can remove lots of skin, but I’m not going to give you that improved appearance that you want. So yeah, in some cases, in order to get that more open appearance to your eyelids, it’s removing some of the excess skin and then also elevating the brows. So yeah, the more common thing is somebody says, I want my eyelids done. But when we examine them, or it’s not just your eyelids, we need to improve the position of your brow.

Kirstin (05:16):
So is there a certain age when people start coming in for this type of surgery or like a decade?

Dr. Koehler (05:22):
No, I mean, I think you sometimes do it, like I’ve done it on younger people in their thirties and sometimes hereditary, their family just tends to have heavier eyelids or lower set brows, and they just don’t like that. And so they want to improve it. So I don’t know that there’s an age, but typically when we start doing facial rejuvenation surgery, it’s typically starting in the forties usually, and then 50’s, 60’s and onward. There’s not an age. It just sort of depends when it gets to be bothersome for you. That’s the biggest thing.

Kirstin (05:56):
Okay. I have a question that you’re going to love, your little surgeon heart just loves this question. If the problem is hollowing eyes or dark circles, could I just ask you for some filler?

Dr. Koehler (06:10):
Yeah, that’s my favorite question. I get it all the time and I tell people no all the time. Not all the time. I tell ’em no a lot. Yeah. So I’ve had, over the years, I’ve trained a number of surgeons and I get text messages from time to time like, Hey, how do you manage this problem? Or what do you do with this? And one that I’ve had from several of my past fellows is, Hey, do you have any secrets for under eye filler? And the reason that get these messages is because people have a hard time getting reproducible results, putting filler in the lower eyelids. And the skin there is very thin. And the goal when we’re doing filler is if you’ve got a hollow area here and you’ve got a puffy area where your fat’s bulging, but you’ve got this hollowness underneath, yes, if it’s mild, sometimes you can put a little bit of filler in the hollow area and kind of even that out so that it doesn’t look like you have a dark circle there.

(07:03):
But if it’s more advanced and you’ve got more bulging of the fat, then putting filler there may ultimately just end up making it look more puffy and it ends up looking worse. And then you end up having to dissolve the filler. So I’m very careful on who I say as a candidate to put filler in that area. And it’s not as predictable as putting filler in maybe other areas. So sometimes instead of putting filler, they should be really considering doing some kind of lower eyelid surgery. But yeah, I understand the desire that they’re not maybe ready to have something surgical done. So they’d like to try to buy some time with filler, but there comes a point where the filler just doesn’t work well.

Kirstin (07:45):
So how long does the actual procedure take? Like say you’re just doing an upper bleph?

Dr. Koehler (07:52):
Upper eyelids is less than an hour, but depending on the circumstance, a lot of times we do this under sedation or general anesthesia. It’s not really something you want to do awake, although it potentially could be done awake. Here we put people to sleep. It’s a short anesthetic. It’s not a painful operation. You’ll take pain medicine for a day or two probably, and that’s it. And stitches come out in a week. So you may not want to be out in public for a week, but you certainly could be if you had the kind of job where you could be working from home, I would say a day off and you’re ready to go. It’s just the being in public and how the appearance might be is the only problem.

Kirstin (08:34):
So you just make small little incisions on the upper lid?

Dr. Koehler (08:38):
Well, the incision’s hidden in the crease of the eyelid. So once the stitches come out, I mean, you really are not even going to see the incision. You can’t really put makeup on until that’s a little more fully healed. So about a week or two. And then you can maybe put makeup on, but you don’t want to get makeup in your incision.

Kirstin (08:56):
Okay. So we’ve kind of touched on sometimes you need a brow lift with a bleph. Sometimes it can be done in combination with a facelift. How would I know if I was at home and playing in the mirror just to be prepared when I came in for a consultation, what would I look for?

Dr. Koehler (09:13):
To see if you needed a brow lift versus just an eyelid?

Kirstin (09:17):
Yeah.

Dr. Koehler (09:18):
Well, that’s probably something where you have to have more interaction with your surgeon because I mean, sometimes people are pulling their brow or they move their brow and they move it just like, oh, if I could just move it to right here. Well, as much as we’d love to say it’s that exact, it’s not that exact. So repositioning the brow is a little trickier.

Kirstin (09:38):
Have you seen Upneeq? Have you used Upneeq?

Dr. Koehler (09:41):
I don’t have it in the office, but I mean, they came by with some samples and I tried it on myself. And it’s basically the same kind of drug that you use for congested nose. It will help people who have ptosis of their eyelids. So ptosis is a little different than having extra skin on the upper eyelids. So ptosis is something that you can be born with it. It can be from trauma, old age, post-surgical type stuff. Anyhow, what happens is it’s not so much that you have skin excess, but that your actual eyelid sits lower and it gets to the point where it starts to cover the pupil of the eye. Now, normally your upper eyelid should, it’ll cover a little bit of the colored part of your eye, your iris, but it’s not going to cover your pupil. But some people with mild ptosis, the eyelid starts to drop and it can happen on one side or it can happen on both sides.

(10:41):
And in mild cases, you don’t really need surgery, but using a drop like Upneeq can really open your eyes. And what it does is it stimulates a little muscle in the eyelid that kind of helps elevate the eyelid, and that using that eye drop will cause that muscle to contract, and it’ll just open your eyes just a little bit. And so it works good if you’ve got ptosis, but if you don’t have to ptosis, you may see a subtle difference. That muscle is still contract, but it may only give you minimal effect. And it’s supposed to be something that you can use once a day, but it’s not cheap. And I just don’t know that it’s something that most people will see a huge difference with. But it’s out there.

Kirstin (11:25):
I used it once at an open house, the rep put it in one of my eyes, and I was literally walking around like this all night.

Dr. Koehler (11:31):
So you had one that was more open?

Kirstin (11:33):
I had one that was more open. That was before my old age, before my eyebrows fell.

Dr. Koehler (11:41):
Well, see, there you go. I mean, so obviously, I mean, you don’t have ptosis, at least I’ve never noticed it, but it can help for some people, give them a little more open look.

Kirstin (11:51):
So for people that want a blepharoplasty, would insurance cover something like that?

Dr. Koehler (11:56):
It can, but in order to get it covered, you really need to see an ophthalmologist or an optometrist to get certain types of tests done. They have to do what’s called visual field testing where they check your peripheral vision and see if you’ve got obstruction of your peripheral vision. And there’s certain criteria that have to be met. And if you meet those criteria, then insurance will sometimes cover upper eyelids, lower eyelids, they don’t really cover that. That’s cosmetic almost all the time. And there are some conditions of the lower lids that they will sometimes pay for, but it’s not for cosmetic stuff.

Kirstin (12:32):
But here we offer lots of different financing options. And our surgery coordinators are so great about trying to figure out what is best for the patient if they would need to get outside financing, things like that. And they usually direct patients to our website and talk them through the different application processes in case you do need outside financing.

Dr. Koehler (12:52):
Good to know.

Kirstin (12:54):
You knew.

Dr. Koehler (12:56):
Yes, I knew.

Kirstin (12:58):
Can patients have a virtual consultation with you?

Dr. Koehler (13:01):
No. I mean, I do some virtuals for out-of-state people, whatever, but I know during covid, I was doing some virtual consultations during that timeframe. But truly, unless there’s unusual circumstances, an in-person consultation is so much better for so many reasons. I mean, you really need to looking at pictures or computer screen, I mean, you can get an idea a lot of times, but it’s still not the same as actually seeing somebody close up and doing an exam. So I mean, I will occasionally do some virtual consultations for certain circumstances, but for the most part, I prefer to see people.

Kirstin (13:44):
And our surgery coordinators are great about explaining to the patient ahead of time what the consultation process is going to look like, and they definitely welcome pictures. That way they can show ’em to you and hopefully be able to talk to patients about what they would potentially need so they can be prepared for surgery or the different procedures that you might recommend before they come in for consultation.

Dr. Koehler (14:05):
Yeah, absolutely. I mean, that’s something that we highly recommend before you come in for consultation, especially if you’re not sure what you might need and you’re trying to figure out, well, is this even in my budget and all that. Yes. They send pictures and my coordinators will show them to me, and I’ll be like, yeah, it looks like this. I mean, I can’t say a hundred percent until I see people in person, but based off of the pictures that they send, it can at least help me a whole lot more than somebody saying, well, I need eyelids. And then I see them in person. I’m like, oh my gosh, no, you don’t need eyelids. You need this. You need something else, or whatever the case is. But so yeah, it can help to send photos ahead of time.

Kirstin (14:42):
Yeah. If you’re listening today and have questions or need info about scheduling, financing reviews or photos, check out the show notes for links. You can also find links to before and after photos to all of our surgeons beautiful photos. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabama the Beautiful podcast.com. We’d love to hear from you.

Dr. Koehler (15:08):
If you have a burning question, I may not be the doctor that you need to call.

Kirstin (15:11):
<laugh>

Dr. Koehler (15:16):
<laugh> Just saying.

Kirstin (15:19):
I have no comment for that. I’m not sassy enough tonight. All right. Thanks, Dr. Koehler. Get back to making Alabama Beautiful.

Dr. Koehler (15:31):
Alright, thanks, Kirstin.

Announcer (15:37):
Got a question for Dr. Koehler. Leave us a voicemail at Alabama the Beautiful podcast.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 eastern shore cosmetic surgery.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.