Online Health Chat with Julian Perry, MD

Wednesday: May 13, 2015


Cosmetic surgery procedures have increased significantly in the past decade. The American Society for Aesthetic Plastic Surgery (ASAPS) statistical data indicates a 12 percent overall increase in cosmetic procedures performed in the United States in 2013 alone.

Take advantage of this opportunity to chat with a board-certified ophthalmologist who specializes in cosmetic eye surgery and procedures. Topics will include everything from BOTOX ®, fillers and peels to eyelid and brow lifts, as well as cheek and forehead lifts.

When considering cosmetic treatments or plastic surgery to refresh your appearance, you should address many questions and discuss recent trends with a board-certified specialist. Cosmetic eye surgery and procedures can help reawaken your natural beauty and improve your confidence and overall outlook. But when deciding if this is right for you, there are many things to consider.

About the Speaker

Julian Perry, MD, joined Cleveland Clinic’s Cole Eye Institute in 1999 after completing an ophthalmic plastic and reconstructive surgery fellowship at Jules Stein Eye Institute, University of California Los Angeles, where he was a Heed Foundation AOS-Knapp Fellow and recipient of the Institute’s fellow clinical research award.

His specialty interests involve aesthetic oculofacial surgery, including cosmetic eyelid surgery (blepharoplasty), cosmetic forehead and cheek lifting, cosmetic BOTOX injections, cosmetic facial filler injections, cosmetic oculofacial surgery and all aspects of ophthalmic plastic surgery. He also specializes in lacrimal and orbital surgery. His clinical interests include all types of eyelid, eyebrow, forehead and cheek surgeries, including surgeries for skin cancers, tumors, trauma and other conditions within these regions. Dr. Perry also specializes in reconstructive surgery.

His research interests include new techniques, materials and devices in oculofacial surgery, novel surgeries for eyelid reconstruction and droopy eyelids, and new surgical techniques for orbital decompression. He has studied cosmetic upper facial surgery (blepharoplasty, midface lifts, endoscopic forehead lifts, laser surgery of the eyelids and face, face-lifting, fat transfer, fat injections, BOTOX and facial filler injections) in Beverly Hills, California.

Let’s Chat About Cosmetic Eye Surgery

Moderator: Welcome to our chat about Cosmetic Eye Surgery with Cleveland Clinic specialist Julian Perry, MD. Thank you, Dr. Perry, for taking the time to be with us to share your expertise and answer our questions.

Let’s get started with our questions.

Basic Bags and Sags

Koala: Generally, what causes eyelid bags and sags? What are the risk factors? Can my spending long hours in front of computer worsen formations of bags and sags? How can I reduce the likelihood of formation? Thank you so much.

Julian_Perry,_MD: The distribution of the fatty tissues, other soft tissues and fluid compartments around the eye create eyelid bags. Sags are created from tissue laxity from time and gravity. Risk factors include family tendency, skin type, sun damage, allergies and other inflammations around the eyes that can stretch the tissues, and just age. Reducing inflammation around the eyes, protecting the skin from ever-present sun damage and getting some sleep can help.

xdwl: Hi doctor. I am a 57-year-old female. I have had obvious hallow/sunken eyes since I was 50, particularly in my eye socket superior (my father and mother had the same problem.). I heard the treatments include: fat injection, fillers and implants. I would like to know how long the benefit can last with each method and which way you would recommend most? Thank you very much.

Julian_Perry,_MD: You are correct about some of the treatment options available to you. Decades ago, surgeries actually produced some of the hollowness that you noticed. We now know that hollowing can be a sign of age in some patients, and recurrent surgeries are designed to preserve, sculpt and reposition rather than completely remove fatty tissues around the eyes. Treatment of hollow eyelids still represents a challenge. Fat injections can produce lumps and bumps, as can fillers. Implants can lead to an unnatural appearance. I don’t perform fat injections around the eyelids after seeing many patients who developed problems after fat injections from well-intentioned surgeons. I perform very few implants nowadays, as I have not been happy with the somewhat unnatural appearance of them. Fillers such as hyaluronic acid fillers offer a good option in some patients. These are not perfect, however, and they can result in some discoloration and overcorrection in some patients. Free fat grafting represents another option, but this can also result in lumps and bumps. The amount of tissue that remains after free fat grafting is somewhat unpredictable. The patient still may be a candidate for fat repositioning if there are some areas of redundant fat that can be moved into the hollow areas. Cheek lifting can also recruit fatty tissues to the hollow areas in some patients. So, there are many options, but that is because none of them are perfect and each current option has drawbacks.

CCF: Are there any daytime or nighttime creams that can assist with the diminishing of eyelids and sags? Thanks, Darlene

Julian_Perry,_MD: So many of my patients ask this vital question. Unfortunately, I don't think there are any over-the-counter creams that truly provide long-lasting and/or cost-effective improvement. Prescription creams, such as Retin-A, can help with the crêpe papery wrinkles that develop around the eyes.

Battling Under Eye Bags

ahmc: What is the best solution for bags under the eyes? Please describe the advantages and disadvantages of the options for treatment. Thank you.

Julian_Perry,_MD: Thanks for the question. The answer to this question will likely occupy most of our time during our upcoming webchat. Different types of bags around the eyes require different treatments. Fat bags, hollows and fluid bags all require different types of treatment.

savvylady: If my under eye bags are darker in color, will the procedure help with the coloring as well as excessive skin?

Julian_Perry,_MD: Dark circles! Dark circles can arise from a variety of anatomic issues. The cause is not always obvious. Lower blepharoplasty can sometimes improve dark circles by repositioning fatty tissues into the hollow areas beneath the lower eyelid. However, sometimes pigmentation issues or other factors causing dark circles will persist after surgery. In terms of excessive skin on the lower eyelids, great care has to be taken in removing this redundant skin. Removing too much skin or removing skin in the setting of loose lower eyelids can cause the lower eyelids to be pulled down. I see at least one patient every week who has had such surgery from a well-intentioned surgeon. This condition, called post-blepharoplasty eyelid retraction, can be very challenging to treat, and very frustrating to live with.

Katie D: You discussed treatment for dark circles, but are there any "home" or "over-the-counter" treatment options other than make-up? Thanks.

Julian_Perry,_MD: Many of my patients described home remedies including cucumbers, teabags and other treatments. However, I'm not aware of any home remedies that offer predictable results. Medicated creams, such as hydroquinone, may be appropriate for some patients. But even with hydroquinone cream and/or surgery, dark circles remain difficult to treat.

Walknstyle: I am 63, female. I've always had bags under my eyes. Is surgery the most effective treatment?

Julian_Perry,_MD: Bags are typically caused by structural problems, and surgery is often the most effective treatment. However, some bags may be improved with fillers or other nonsurgical means. A thorough evaluation can often distinguish which bags are more amenable to surgery versus nonsurgical treatments.

Asking About Eyelids

Carolee888: I understand why I have eyelid bags, but why are mine red in color? I asked my dermatologist and she has no clue.

Julian_Perry,_MD: Some patients with very fair skin can have a reddish hue over the fat bags. This may be due to transmission of the red color of the blood vessels and muscle directly beneath the skin. The underlying fat bag may accentuate this tendency. In other cases, patients have rosacea or other inflammatory conditions around the eyelids producing some red color.

CB222: I feel like I’ve had droopy eyelids my whole lift. I feel like they affect my vision as well as my confidence. Are there other options for this besides surgery (BOTOX, fillers)?

Julian_Perry,_MD: It depends. If you've have had droopy upper eyelids your whole life, this may be a condition called congenital ptosis. There really are no good nonsurgical treatments for this condition. If the droopiness, on the other hand, is from heavy eyebrows, then there are good nonsurgical treatments. Even when patients visit me in the office, it often requires a great deal of discussion to determine whether a particular patient is bothered by a droopy eyelid, droopy eyebrows or both.

Eyelid Drooping and Vision

Ed95: My 86-year-old mother is having difficulty with her left eyelid "staying out of the way" of her vision. The problem is most noticeable when she's lying down watching TV in bed. She's on warfarin and willing to have the cosmetic surgery to correct it. My question is: is there anything she might be able to do (home remedy) to help alleviate the problem and spare her from going off her blood thinner and going through the cosmetic surgery?

Julian_Perry,_MD: Great question. It sounds like your mom has eyelid ptosis (drooping). This is different than extra skin accumulating around the eyelids. I wouldn’t call this cosmetic, however, because it may be affecting her vision. If patients meet certain specific criteria, insurance sometimes covers such surgery, as it may improve vision and quality of life. The surgeries are quite straightforward, although not entirely predictable. The issue of stopping warfarin is an important one and would require input from the prescribing doctor and a discussion of the exact risks and benefits of discontinuing the anticoagulant. Regarding nonsurgical alternatives for eyelid drooping, one very old technique is the use of a “ptosis crutch” that is placed on the backside of glasses in order to mechanically elevate the eyelid. Every once in a while I encounter a patient who has such an old-fashioned device. If the risks of surgery outweigh the benefits, this could be an alternative.

Miriam: Is blepharoplasty covered by insurance?

Julian_Perry,_MD: Good question. Upper blepharoplasty is occasionally covered if the heavy eyelid tissues are interfering with the upper field of vision and are causing significant quality of life issues. Different payors (insurance companies) have different criteria, but all involve evaluation of photographs and evaluating visual field tests. If the visual field tests demonstrate significant improvement in vision with the eyelids lifted, and if photographs meet criteria of skin resting on the lashes, some insurance companies may cover the procedure. While the upper eyelids are sometimes covered by insurance if patient's meet strict criteria, the lower eyelids are never covered by insurance, as lower blepharoplasty does not improve vision.

Sherri1062: Both of my eyelids are what I call "fat eyelids" and hang over the eye slightly, obstructing my vision. Is this something that could be taken care of with eyelid surgery?

Julian_Perry,_MD: Your condition sounds exactly like what upper blepharoplasty can address. Upper blepharoplasty addresses excess skin and fatty tissues on the upper eyelids. This tissue often rests on the eyelashes and can obstruct the upper part of the patient's vision. The surgery involves removing a strip of skin and sometimes the fatty tissue beneath the skin in order to improve the contours and, sometimes, the vision. The incision is typically concealed within the crease of the eyelid.

Summing-up Surgery

nutzy: I wanted to ask if there are some contraindications to undergoing this procedure, and also some explanation about the kind and time of the anesthesia.

Julian_Perry,_MD: There are some contraindications to surgery:

  • Patients who cannot stop blood thinners risk bleeding, and bleeding could even affect vision after eyelid surgery.
  • Patients with Graves' disease or other inflammatory conditions around the eyes have a higher risk of complications, although this is not a true contraindication.

Most cosmetic eyelid surgeries are performed under monitored anesthesia care. This typically involves some light sedation while we numb up the areas. Patients then are often somewhat awake during the procedure, but they are very comfortable as the eyelid is numb. Occasionally, if patients are very nervous or if we are performing more invasive procedures, we can do the surgery with the patient asleep.

Jamie: Do you do the endoscopic brow lift? Who is a candidate for this procedure?

Julian_Perry,_MD: Yes I do perform endoscopic brow lifts. Interestingly, it seems that I performed more of this exact type of procedure 10 years ago than I do today. That is probably because there are more options for brow lifting. These include BOTOX fillers and other less invasive surgical brow lifting techniques. The endoscopic technique is excellent for patients with mild to moderate brow heaviness. However, the patient's hairline must be intact enough and dense enough in order to conceal the incisions. Patients with thinning hair, very high hairlines and/or male pattern baldness are less optimal candidates for an endoscopic brow lift. We offer a variety of brow lifting techniques, including other less invasive techniques that involve incisions only along the lateral hairline within forehead furrows or a combination of techniques.

FR822: If I need both my upper and lower eyelids done, do you do them at the same time? If so, what is that recovery like?

Julian_Perry,_MD: The upper and lower eyelids are typically performed simultaneously if desired. The upper eyelid surgical time is typically around 30 minutes. The lower eyelid surgical time can vary significantly depending on an individual patient's anatomy. The lower eyelid surgical time can vary from 30 minutes to approximately two hours. Thus, the recovery will depend on the exact type of lower eyelid surgery needed. Typically, the swelling and bruising resolves in around one or two weeks. Most patients feel comfortable returning to work and in the public eye approximately one week following surgery.

Sara: What problems can happen during a blepharoplasty?

Julian_Perry,_MD: I'm glad you asked this question. While blepharoplasty surgery represents a fantastic option for most patients to improve their cosmesis and even their vision with a straightforward surgery with relatively predictable and straightforward healing, it certainly has risks. When patients have complications, it often affects their vision and their comfort as well as how they look. This is sometimes when patients find an expert oculoplastic surgeon to help them. Upper blepharoplasty risks removal of too much skin. This can cause the eyes not to close. The eyes can then become dry, red and irritated. Fortunately, in expert hands this is rare. However, I do see patients routinely who have had well intentioned or aggressive surgery who developed this complication. This can be challenging to treat, as it may require replacement of the removed skin, i.e., a skin graft. Skin grafts along the upper eyelid are typically visible.

Lower eyelid blepharoplasty entails more risks, and I see patients on a regular basis who have developed problems after such surgery, even from experienced regional and national practitioners. Aggressive lower blepharoplasty or blepharoplasty in the setting of loose lower eyelids can cause the lower eyelids to become saggy and pulled down. Not only does this result in a "sad" appearance, it also causes pain, irritation, redness and discomfort. Patients are often very troubled by this all-too-common and all-too-avoidable complication of lower blepharoplasty. I perform surgery on referred patients to improve this condition routinely.

It is important to remember that surgery around the eyelids can result in bleeding that could even affect vision permanently. Even small amounts of bleeding in the confined space around the eyes can cause pressure that causes blindness. Fortunately, this type of bleeding is very rare and may occur as rarely as one in every several thousand cases. But it is not zero, and patients need to understand this prior to undergoing eyelid surgery. It is important for patients to consider risks to vision when considering eyelid surgery. Oculoplastic surgeons are specialists in both vision and plastic surgery around the eyes.

E-man: I am interested in this type of cosmetic surgery, but I really do not know what type of physician to seek out – plastic surgeon, eye/oculoplastic surgeon. Where do I begin?

Julian_Perry,_MD: Many surgeons trained in a variety of disciplines perform blepharoplasty. Blepharoplasty represents a straightforward option for many patients to cost-effectively improve their appearance with less downtime than some other more invasive facial cosmetic procedures. However, the surgeries involve the delicate tissues and structures around the eyes, and complications from surgery can affect vision. It is important to find a surgeon who has a great deal of experience in eyelid surgery. Many surgeons trained in a variety of disciplines have such experience. Oculoplastic surgeons undergo training in ophthalmology and are familiar with the delicate and vital tissues around the eyes. They also train in microscopic surgery and are thus very detail-oriented. Oculoplastic surgeons then receive training in cosmetic and reconstructive surgeries around the eyes, often for at least two years. This training centers on plastic surgeries in the eye region. Oculoplastic surgeons also routinely treat patients who have complications from cosmetic eyelid surgery.

Face Facts

pharmerb: What is the typical age range for blepharoplasty with brow lift? Can the procedure be repeated in 20 to 30 years, if needed, and is BOTOX still needed for forehead wrinkles after brow lift?

Julian_Perry,_MD: The age range for upper blepharoplasty and/or brow lifting is quite broad. I have operated on patients with very heavy eyelids and brows as young as upper 20s. Some patients who are in good health and bothered by their cosmesis and or vision seek such surgery well into their 70s or even 80s. Many patients visit me for an initial cosmetic consultation are in their mid to late 30s.

Squeeky: Do you offer fillers for eyebrows? Should that be used before surgery or do you recommend just going straight to surgery?

Julian_Perry,_MD: Fillers can be used in order to replace volume to the eyebrows. Some practitioners feel that fillers can actually lift the eyebrows as well. BOTOX can lift the brows, and I agree with you that it makes sense to consider nonsurgical treatments prior to more invasive treatments. However, in some cases, surgery may represent the best initial option. This is especially true if patients have very severe brow heaviness that would be unlikely to be improved with BOTOX or fillers.

Susan: Will the wrinkles around my eyes (crow’s feet) go away after eyelid surgery?

Julian_Perry,_MD: Good question. Lower blepharoplasty can certainly address excess eyelid skin and fat, as well as improve the contours of the lower eyelid. However, crow's feet wrinkles are often due to dynamic forces from the muscles to close the eyes. This is often best treated with BOTOX and not usually improved with surgery. Some crow's feet wrinkles may be due to skin texture issues that occur with age and sun damage. Surgery also does not treat this type of skin texture abnormality. Lasers or chemical peels can often improve skin texture.

General Information

LucyintheSkies: Would you briefly describe what a typical appointment would entail, for instance, if I was coming in for an evaluation of possible cosmetic eye and brow procedures.

Julian_Perry,_MD: Patients typically scheduled their appointments through our convenient centralized appointment desk. We do offer same-day appointments as well. The typical appointment lasts approximately 45 minutes to an hour. Patients are initially worked-up by our comprehensive Cole Institute Eye technicians. This involves evaluating the ocular (eye) surface as well as the vision. It is important to remember that eyelid surgery, even when cosmetic, can have significant effects on this vital organ. Patient's then meet with me and we look together in a hand mirror to understand the individual patient's concerns. After examination, we then revisit the hand mirror and I educate the patient regarding their anatomy and function. We discuss options for improvement. And then photographs are taken.

LucyintheSkies: Do you offer virtual consults?

Julian_Perry,_MD: Not yet, but we are getting there. Cleveland Clinic has an outstanding and innovative technical team that is working with a variety of our services to provide such a service. I think this service would be particularly well-suited to cosmetic consultations. Hopefully will hear more about this soon.


Moderator: That is all the time we have for questions today. Thank you, Dr. Perry, for taking time to discuss cosmetic eye rejuvenation with us.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

Julian_Perry,_MD: Thank you for your questions.

For Appointments

To schedule an appointment with Dr. Perry at our Cole Eye Institute, please call 216.444.2020 or 1.800.223.2273 ext.42020. You can also visit us online at

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