Welcome to our May Newsline.

I recently returned from Hilton Head, South Carolina, where I had been invited to serve on the faculty of a Facial Plastic Surgery Conference put on yearly by the University of Tennessee Medical Center’s Department of Continuing Education. It was an outstanding meeting with an excellent faculty and I enjoyed the opportunity of being a part of it. I had also planned on participating in a conference on abdominoplasty in Tulsa, Okalahoma. This meeting, put on by one of my former Fellows, Dr, Angelo Cuzalina, also afforded me a great opportunity to ride my motorcycle. Unfortunately, the weather turned uncooperative and after getting as far as Wichita Falls, Texas, I was faced with solid heavy rain in front of me. After spending the night, and having attended a very pleasant, albeit unusual, party at the home of an acquaintance, I had no choice the next day but to turn around and return to Abilene.

Taos, NM

Right now, Gail and I are enjoying a long weekend at one of our favorite retreats, Casa de las Chimineas in Taos, New Mexico. This lovely Bed and Breakfast combines great accommodations, a beautiful location along with hearty Southwestern cuisine. We find ourselves coming back again and again. We have been so busy at the Clinic that I really haven’t had time to write a Newsline, so this has given me the opportunity to do so.

Wild River

During our visit, we drove up to Wild Rivers Recreation Area, where the Red River and the Rio Grande meet. It’s been described as the Grand Canyon of New Mexico, and it did afford some beautiful views. This National Recreation Area is about 30 miles north of Taos west of the Carson National Forest and near the town of Questa. It is well worth the visit.


At the end of January, our youngest daughter, Jill, and her husband Rob, had their first child. A beautiful baby girl, Hannah Rivkah Rosson is our sixth grandchild, and of course the most beautiful baby ever!



Eyelid surgery, or blepharoplasty, as we call it, is one of the most commonly requested cosmetic procedures. It’s not surprising since the eyes are what most people first see when looking at you. Drooping, heavy or baggy eyelids can give the face a dull or tired appearance. This heaviness can be the result of ageing, but not necessarily so. Some individuals seem to be born with this predisposition. Of course, there are also medical conditions that can contribute to this condition, and they have to be considered when thinking about surgery. Two that immediately come to mind are allergies and thyroid conditions. The importance here lies in the fact that while surgery will initially appear successful in these conditions, recurrence is common unless the underlying condition is properly addressed.

In my opinion, there have been two major milestones in the technique of blepharoplasty in the past twenty years. These are the use of lasers and the avoidance of incisions on the outside of the lower eyelid.

Laser to the rescue

Precision is certainly of paramount importance in eyelid surgery. Nowhere else can such a small change make so great a difference. Eyelid surgery has justifiably been called surgery of millimeters. The laser allows us to best capitalize on this need for precision. The eyelid tissues are so soft, that even the sharpest blades may find difficulty tracking a precise cutting path. The laser is not at all subject to this limitation. Both path and depth are under precise control. Of equal importance is the fact that laser surgery is essentially bloodless surgery. This not only contributes further to precision, but also significantly reduces post operative swellings and bruising.

By almost entirely eliminating surgical bleeding, the laser also significantly contributes to safety. Visual loss is certainly the most feared complication of eyelid surgery. While uncommon, it can occur, and if it does, it is almost always the result of massive swelling related to hemorrhage. By reducing surgical bleeding to an almost negligible level, the use of the laser has also significantly reduced the risk of postoperative bleeding. Fortunately, we have never had a patient who experienced any visual loss following blepharoplasty. In fact, to my best recollection, only two of our patients who underwent blepharoplasty with laser technique have experienced postoperative bleeding, and both of these were discovered to be bleeding in the recovery room where we were able to immediately address the problem and avoid any significant complication.

Lower lid transconjunctival surgery

Why do I feel it is so important to avoid an incision on the lower eyelid? We all know that scars on the eyelid trend to be very fine and rarely visible. The problem lies in the fact that sometimes scar tissue can form that can bind the skin down to the deeper structures of the eye. This can result in a very unattractive downward pull on the lower lid that is called ectropion. While in its milder form, it may only result in a slight lowering of the lids revealing the white sclera below the pupil, in more severe forms, it can pull the lid away from the globe revealing the conjunctiva and interfering with the normal tearing mechanism.

The only way to completely avoid this problem is to keep from making external incisions on the lower lid. Happily there is a way to accomplish our goal of rejuvenating the lower lid without an external incision. We do this by making our incision on the inside of the lower lid, again using the laser. This allows us to effectively remove any bulging fat that is responsible for the unsightly puffiness of the lower lid. It does not however, permit skin removal as can be accomplished when approaching the lower lid through an external incision. Fortunately, there is an effective alternative.

Lower lid laser resurfacing

To accomplish the goal of tightening the skin of the lower lid, we again utilize the laser, but this time in a different mode. Here we are using it in a resurfacing mode. By creating a precise burn injury to the dermal layer of the lower eyelid skin, we produce a reorganization of the collagen that produces, in turn, a tightening of the skin along

with the added by-product of reducing fine lines of the lower eyelid skin. While this adds a few days to the healing process, it is usually a well worth-while trade off.

Raising the brow

Brow Raising

Sometimes patients (and surgeons as well) are confused by whether the appropriate treatment for “tired eyes” is a blepharoplasty or a brow lift. Of course the two are inter-related since elevation of the brow has the effect of increasing the hollow space in the upper eyelid. This issue is frequently debated at surgical seminars. I personally think the answer is quite simple and represents a matter of individual choice- and whose choice should that be? Of course the answer is the patient’s choice. We have a number of techniques for elevating the brow and all of them can be combined with eyelid surgery. In fact brow lifting is a topic for a whole subsequent Newsline. The important point to emphasize here is that brow elevation is generally not a substitute for eyelid surgery. It is also not an appropriate choice for everyone with a low positioned brow. Heavy brows can be most attractive on the right individual – the actress Brooke Shields being an excellent example.

As always, success in Cosmetic Surgery begins with proper consultation and discussion. Remember, the successful operation is the one that pleases the patient rather than the one that only pleases the surgeon.

That’s it for this edition. As always your comments and suggestions are always welcome. We will try to address all responses in future Newsline editions.


Howard A. Tobin, M.D., F. A. C. S.

For general information: askdena@newlook.org or n41gt@newlook.org