Online Health Chat with Julian Perry, MD

April 27, 2016


The eyes are often the most expressive feature of our face. They quickly show our expression and overall mood. Unfortunately, they are often the first area to show signs of aging with lower lid "bags" and hooding across the upper lids.

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 around the eyes 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 Speakers

Julian Perry, MD, joined Cleveland Clinic’s Cole Eye Institute in 1999 after completing an ophthalmic plastic and reconstructive surgery fellowship in Beverly Hills 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 and all aspects of ophthalmic plastic surgery.

Dr. Perry has published extensively on cosmetic eyelid, cheek and forehead surgery, BOTOX and fillers. He serves as an executive editor of the American Journal of Ophthalmology and is on the editorial boards of Ophthalmic Plastic and Reconstructive Surgery and Ophthalmology Times. He has published more than 100 peer-reviewed research articles, two-dozen book chapters and a textbook. He lectures internationally on innovative surgical techniques, and he precepts a fellowship in ophthalmic plastic and reconstructive surgery.

Let’s Chat About Eyelid and Eyebrow Surgery

Secondary Conditions

mayita: Hello. I had Bell’s palsy 35 years ago, developed after an infectious mono. Neurologists have told me that I also suffered a subsequent disease due to movement of the nerves of the face. They were growing too fast, and it distorted some movements. I think it is called synkinesis. My question is regarding my eyes. Due to aging, now the paralyzed side of the face is holding, while the good side is falling if you could describe it that way. I have tried BOTOX with a neurosurgeon, but developed another palsy from it. That resolved, but it took a long time, so I am afraid to try it again. I wonder if something else can help, such as plastic or nerve surgery to lift my good eyebrow without opening my eye so much it would be unable to close.

JD_Perry,_MD: I'm sorry you have suffered with Bell's palsy. Bell's palsy can cause drooping of the affected side, and it can also cause the synkinesis that you described. BOTOX can help with the synkinesis, and it can also help with the normal side as well. Although you had an unexpected outcome with BOTOX, it might be worth another try. Neurosurgeons are certainly very capable of giving BOTOX. However, the eyelid area requires nuanced approaches that can often lead to very acceptable outcomes. If BOTOX does not achieve the desired outcome, surgical management can certainly be considered on the normal side and/or the side affected with the Bell's palsy.

ldsuz: I have a lump and bad scar on my lower lip from a previous injury with stitches that did not heal well. It is quite noticeable. Can droopy eyelid surgery be done at the same time and by the same doctor as fixing the scar on my lip?

JD_Perry,_MD: Yes. This is a possibility. Combining cosmetic eyelid surgery with other functional facial surgery is quite common. However, it depends on the nature of the functional/scar problem being addressed.

Mara02: I was accidentally hit by a ball three years ago and my ocular bone was fractured. I feel like it’s quite noticeable that my face had trauma because there is a dip on the top of my cheekbone. Are there revision options available?

JD_Perry,_MD: Yes. Surgical options exist to treat old fractures. However, results are often sub-optimal and some sinking in of the eye, droopy eyelid or other asymmetries often exist even after revision surgery.

yless1: Is it safe for patients with previous heart problems to have surgery performed outside of the traditional hospital setting? How do cosmetic surgery centers handle cardiac emergencies?

JD_Perry,_MD: A patient's underlying medical health directly impacts the decision for surgery and the type of surgery that is performed. Patients undergoing any type of sedation for eyelid surgery at the Cole Eye Institute undergo a thorough preoperative evaluation of their underlying systemic health to ensure the safest possible surgery and best outcome. Our surgery center at the Cole Eye Institute is staffed with a team of nurses, anesthesiologists, surgeons and other caregivers to handle any type of situation, no matter how uncommon.

nzimmer: Is it possible to have upper lid surgery if you have issues with dry eyes? Would the surgery have any effect on that? Also, does surgery have any effect on crêpey eyelids? Are there any options to take care of crêpey skin?

JD_Perry,_MD: This is a great question and underscores the importance of having a surgeon skilled in understanding eye issues perform eyelid surgery. Certain types of upper eyelid surgery are safer than others in patients with a history of dry eye syndrome. The exact type of surgery can and should be nuanced depending on a patient’s underlying eye problems. Regarding crêpey eyelid skin, both surgical and nonsurgical treatments exist. Medical therapies such as Retin-A can offer improvement in skin texture. Laser and chemical peels can also help. Redundant and severely crêpey skin can be addressed by careful skin removal.

Bruce: I take warfarin. Is there a less invasive option than surgery to treat drooped eyelids?

JD_Perry,_MD: Blood thinners seem to be prescribed with more and more frequency nowadays. We do have options for treatment of droopy eyelids while continuing blood thinners. For blepharoplasty, this might include removing only skin. For lifting the eyelids, it could include performing the surgery from the inside of the eyelid. Performing surgery on blood thinners does increase the risk of bleeding. However, the chances of vision loss or other catastrophic problems, even on blood thinners, are still quite low.

Determining Treatment Direction

CaraMarie: My eyelids are drooping over my eye to the point that sometimes I can see them, in addition to it looking bad. Would this require a brow lift or eye lid lift? When do you know if it’s time to have the surgery done?

JD_Perry,_MD: Great question. It is very difficult for patients to know whether it is the eyelids, brows or both that are causing the drooping. This can often be teased out during an examination with discussion by looking in the mirror together with the surgeon. Brow lift options generally require either more surgery or visible scars and, sometimes, even if the brows are part of the problem, it makes sense to improve the eyelids as a first stage.

GrannyG: Can BOTOX help for heavy brows or is surgery the only option for that?

JD_Perry,_MD: Yes. Neurotoxin injections can lift the brows, and I was one of the first to describe this in a paper more than a dozen years ago. BOTOX injections typically provide a modest brow lift, but with techniques that I have recently developed, we can often achieve a nice improvement in brow position and contour.

Seeing Scars

Mico43: What are the new surgical techniques for eye lifts? I had a friend who had a lift, and you can see her scars.

JD_Perry,_MD: Techniques for eyelid lifts continue to evolve. At the Cole Eye Institute, we have described several new techniques over the past few years. Any surgery that involves a skin incision will leave a visible scar. However, the scar can be managed by making the incision smaller, placing it in a concealed location or by using postoperative injections of medicines. The surgery to lift the eyelids can also be performed from the inside of the eyelid, in which case there is no visible scar. We have also described new techniques for brow lifting that involve smaller incisions and thus smaller scars.

Fit4Me: What has been your experience with African American skin and this procedure (upper lids) in terms of keloids, scarring, etc.

JD_Perry,_MD: Great question. Skin with more pigment can heal with raised (hypertrophic) or even keloid scarring. However, in the area of the upper eyelids, keloids are extremely uncommon. Even hypertrophic scarring of the upper eyelids is quite rare and in the uncommon cases where it occurs, it can often be improved with medical treatments. African Americans and other patients with higher levels of skin pigment represent a significant portion of my practice and typically do very well with eyelid surgery.

Insurance Issues

GWilson52: I feel like my lower eyelids are so puffy that they touch the bottom of my glasses. Would this be considered cosmetic or medical?

JD_Perry,_MD: I see several patients each month who have extreme puffiness of the lower eyelids and notice symptoms such as yours. Unfortunately, insurance does not cover lower blepharoplasty in the vast majority of cases, and it is considered cosmetic even if patients do have some functional problems.

lej1990: I am an insurance agent, and MOST health insurance no longer covers eyelid surgery even when medically necessary. If you can't afford the surgery 100 percent out-of-pocket, what other non-surgical or less expensive alternatives are available that could help? I know Medicare used to pay for it, but I'm not sure if they still do. I'm 58 and still years away from Medicare, and by then I won't be able to see where I am going. I've experienced a lot of financial hardships in my life (including just losing my job as we speak) and won't be able to utilize Care Credit to pay for it. Do you have any suggestions?

JD_Perry,_MD: Medicare and other payers publish their criteria for insurance coverage. Most of our patients who meet published criteria are able to obtain preauthorization from private payers. If patients appear to meet criteria and are declined, we can go through an appeal process with the payer. Unfortunately, for upper blepharoplasty, no non-surgical therapies really exist to achieve similar results.

SusQ: Could you elaborate on criteria for vision obstruction by drooping eyelids that would typically lead to insurance coverage of the surgery? (I am presuming that it is viewed as cosmetic until some coverage of the field of visions evolves.)

JD_Perry,_MD: We perform tests in the office to determine whether a patient may see better with their eyelids lifted. This is called a visual field test. Different insurance companies have different criteria for the amount of improvement in vision after lifting the eyelids to determine medical necessity. Insurers also evaluate photographs to determine the amount of eyelid drooping.

ldsuz: Is there any way that drooping eyelid surgery would be covered by insurance?

JD_Perry,_MD: Yes. Patients who suffer from severe upper eyelid drooping that is interfering with vision can sometimes obtain insurance coverage. Most insurance companies publish their criteria, and we submit our office examination findings when patients appear to meet criteria for preauthorization. Because lower eyelid puffiness, even when severe, does not interfere with vision, in almost any case insurance companies do not cover lower blepharoplasty.

Fit4Me: You mentioned that unfortunately, insurance does not cover lower blepharoplasty. Are there some instances where it covers upper blepharoplasty?

JD_Perry,_MD: Yes. Insurance covers upper blepharoplasty when specific criteria are met regarding symptoms, photographs and visual fields. This can be determined in the office, and the information is sent for insurance review.

Surgical Selection

indoMia: Do you do lower eyelid lifts? My skin is puffy and dark below my eye, and I don’t know if surgery is the best option or if there are other procedures to correct this.

JD_Perry,_MD: Lower eyelid surgery involves several considerations. The bags that many people notice under the lower eyelids are often caused from a combination of extra fatty tissue and descent of the cheek. This produces the bulge in the lower eyelid as well as the hollow area beneath it. This hollow area can often manifest as a "dark circle." Surgical options exist to improve the bulging fat, the hollow area beneath it and extra skin. Some of these techniques require more involved surgery, while others address just the fatty bulge and involve less surgery. Ultimately, the choice of surgery depends on the patient's commitment to more invasive or less invasive surgery in relationship to their goals for cosmetic improvement. It is very important to maintain the function of the lower eyelid during lower eyelid cosmetic surgery. Regarding your question of "lifting" the lower eyelids, most of the cosmetic concerns of the lower eyelids for primary surgery involve contours and extra skin, and lifting is typically not required. In cases of significant aging changes or previously operated lower eyelids, lifting may need to be considered and is a more involved surgery.

BSD: My eyelids sag terribly, but beyond that, my problem is sagging skin on the forehead. That actually needs lifting, therefore, lifting my eyebrows. How extensive is this surgery?

JD_Perry,_MD: Most patients who visit my office with the complaint of droopy eyelids actually have some degree of droopy forehead and brows associated with the droopy eyelids. Blepharoplasty involves removing redundant skin. It is very important for patients to understand that removing skin does not lift the brows. If the brows are significantly droopy, removing the skin will not result in a significant improvement in appearance or vision. For cases of significant brow and forehead drooping, we have several options available. BOTOX can provide a brow lift and works very well for mild to moderate brow drooping. BOTOX injection can be performed in a few minutes in the office, and the effects last for approximately three months. Other options include a variety of surgeries. Surgical therapies to treat droopy brows include small incision, direct brow lifts in which the incisions are located close to the eyebrow on the forehead. Of course these are visible, but if they are made small, they can be cosmetically acceptable. The incisions can be placed within the hairline for endoscopic brow lifting surgery. This is more time intensive, requires more sedation and healing, but offers the opportunity for hidden incisions. Other methods also exist that involve larger incisions at or behind the hairline in order to lift the forehead and brows. The type of surgery to lift the brows depends on the patient commitment to expense and healing and fair tolerance for visible scars.

Results and Recovery

BEACHBABIES: I am thinking about having my upper lids lifted, but after seeing what Kenny Rogers turned out like, I'm very apprehensive. How does one avoid that?

JD_Perry,_MD: Many of my patients share your concern. While I cannot speak of the details of other patients and other surgeons’ outcomes, in my hands, it is EXTREMELY unlikely for patient to have such an appearance after upper eyelid surgery. A major issue for every patient is to maintain their facial characteristics after eyelid surgery. If too much tissue is removed, this can lead to an appearance that is not characteristic for a given patient and a very unhappy patient! Outcomes such as this can almost always be avoided with thorough discussion and surgery that is designed to maintain ethnic/racial, gender and facial characteristics.

JadaMom: What is the recovery like for eye lid lifts? How long is it until swelling goes down and you appear “normal”?

JD_Perry,_MD: The recovery for eyelid surgery depends on patient factors and on the extent of the surgery being performed. In most cases, the bruising and swelling resolves by about seven days after surgery. Other postoperative effects can linger for a few more weeks, but most patients undergoing typical eyelid surgery feel confident in public about seven to 10 days after surgery.

bsims: What are the side effects of removing skin?

JD_Perry,_MD: Great question. The skin of the eyelids is obviously present in order to allow the eyelids to move to protect the eye. Some redundancy of the skin is necessary in order to allow the eyelids to perform this vital task. Unfortunately, it is all too common in my practice to see patients who have had surgery who lack the necessary amount of skin in the eyelids after eyelid surgery. A thorough examination and proper surgical technique and judgment should avoid this complication in the vast majority of cases. This complication is much better to avoid than treat, and in my hands represents an extremely uncommon problem.


Moderator: That is all the time we have for questions today. Thank you, Dr. Perry, for taking time to educate us about eyelid and eyebrow surgery.

JD_Perry,_MD: Thank you for your interest in eyelid surgery. Some important take-home points: Eyelid surgery should be performed in the context of the individual patient. This includes understanding the patient's underlying medical health and eye health in order to allow for the safest possible result. The evaluation should also include a thorough discussion of patient expectations. There are many different surgeries of the upper and lower eyelid to treat each of the specific aging changes around the eyes. Some patients want or need more aggressive surgery that may lead to a longer healing, and that entails more risk. Some patients may want or need less aggressive and less invasive surgery, understanding that the results may be more modest but that better fits into their lifestyle. The exact type of surgery can only be determined from a thorough evaluation and a discussion. Eyelid surgery has many nuances and is very different from other surgeries of the face and body. It is important to consider the training and expertise of the surgeon prior to committing to eyelid surgery. The surgeon must have thorough training in the specific anatomy and physiology of the eyelids and an understanding of their relationship to the eye.

Moderator: 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

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