Why Blepharoplasty is Everywhere Right Now, the Best No-Surgery Eye Fixes and Could Contact Lenses be Bad for Your Eyes? With Oculoplastic Surgeon Dr. Babak Maleki

24:47You're physically measuring. With like a millimeter, like some device. Yeah, so on the exam table, when we're examining you, we're looking at the position of the eyelid, and we're looking at the muscles, and so we make an estimation of how much to advance. So it's highly technical. So you get to the end result, and on the table, she looked great. And in the healing process, and this is the part where most people don't really understand, when you're doing an operation on anybody, any individual, there is a healing process. And in that healing process, there may be some variability in terms of how people heal and the outcome varies.

25:18So when I was seeing Carleen in her follow-up visits, I was looking at how the swelling was going down and things were improving. When she got to the point where the swelling had gone away completely, we got to, quote unquote, her kind of final result. That's when we did kind of some measurements again. We said, okay, Carleen, this is your measurement today. And we compared that to our measurement prior to our surgery. We have photos. and we saw that there was an improvement in the ptosis, but not a complete resolution, meaning that the eyelids came up a little bit, but there was still a little bit of asymmetry between the eyes.

25:50And then we had to have this conversation. It was like, Carlene, how do you feel about this? And so we went back and forth and she was like, well, I'm not sure. I think I'm okay with it. And I said, well, it's really your call. And I said, listen, well, let's continue to follow you. I followed you for another, I think another year probably, right? And then at one of your follow-ups, you said, you know what? I think this has kind of bothered me enough that we should look at it again. We looked at it again. I did some measurements. Again, I said, there's enough of a difference here that I felt confident to do a secondary ptosis repair, meaning going back in and finding that muscle again and tightening it one more bit.

26:26But it wasn't an easy decision. I know you were a little bit hesitant. And in full disclosure, I wanted to do what was in your best interest. So I didn't want to push you in one direction or another. but I felt that I can explain, you know, what I can do for you, but you have to ultimately make a decision. He let me come to my own decision and which I appreciated. And I can just say, I'm so glad that I had it redone. Like I'm so happy with the result now. And so I, I don't know what that, the takeaway is for people. Every situation is different, but for me, I just, I don't think I ultimately would have been completely happy had I left it.

27:07And I don't see this as like a failure in any way. I don't see this as doing any, like anything having gone wrong. I appreciate that. Again, you go back to that example of the celebrity we talked about earlier. It's like, I don't want, you know, I don't want to go. I would rather that we did it this way than take the risk of going too far. And it's funny because you and I collaborated on a post with, are the before and after and everyone can take a look at Breaking Beauty's feed to see that. And I was looking at the comments and most people were like, wow, this is amazing. This is amazing. And one person was like, I think you could have gone further.

27:44And it's like, this is, I mean, again, everybody's different, but for me, I don't want it further. I don't want to change the shape of my eyes. Like I always had puppy dog eyes. That's what I was told. And I want to maintain my character that looks like my mom and my brothers. And like, I don't want a big round eye that I never had. Yeah, absolutely. You know what I mean? It's so funny they made that comment because I get that comment all the time. So you can imagine in my field, it's a very public thing. So we're posting. So every once in a while, we'll say, oh, you could have done a little bit more here.

28:18It's like there's always a critic in the audience. But the reality is that I'm not that person's surgeon. I'm the patient's surgeon. So the patient and I have a discussion. We decide on how far we want to go. And of course, I'm going to give my professional and honest opinion. I'll say, listen, I think we can go this much because we don't want to change. But ultimately, and so I'm really happy that you came to that decision yourself. And then we did that together. And right now, I think that we were just talking about this before. I can't even tell which eyelid was the eyelid that had ptosis. I know.

28:55That's really good. But good. I think it's important because I think revisions are a big part of cosmetic surgery. It happens frequently and it doesn't mean it's bad or good. It's just like a constant dialogue with your provider, right? And here's some advice to kind of listeners. If you're going to undergo any type of cosmetic or plastic surgery, one of the questions that you should ask your surgeon is that should things not go as planned? And are you able to do your own revision surgery? And that's a really important point, right? So people will do blepharoplasty or rhinoplasty or facelifts.

29:34But if you're not comfortable doing revision work on your own patients or other people's patients, that's a really important distinction. So, yeah, so you need to be able to be comfortable with that anatomy enough that you don't just do the easy cases, but you do the difficult cases too. I think that's critical in terms of choosing. So there's some people who don't do that? Yeah. There are people who do plastic surgery and they do only primary surgery. They don't do any revisional work. Really? So if there's a problem. The one and done surgeons. If there's a problem, complication, they'll be, oh, this is out of my expertise.

30:06And they'll actually say that. This is not in my expertise area. I'm going to refer you on to. So I probably like 30 % of my practice is revisional work with other surgeons who've done surgery. So if you do your surgery, well, then if you're unable to correct the problems or potential problems that come as a result of it, then it's a little bit of a problem. Okay, I've never heard that before. That's a great piece of advice because we've often asked in the past what to ask to try to vet who you're going to ultimately go with. Do you do revisional work? Yes. You do your own visual work and also you do other people's revisional work.

30:45So if someone's not doing any revisions at all, that's a bit of a red flag. That means that, okay, you either haven't done enough surgeries to encounter problems, which is a problem, right? If you've only done surgeries for like one or two years and you haven't done enough operations, you don't know how to fix problems. Yeah, right. Well, essentially, you're not accountable for your work is what that means. You don't have enough experience or expertise to fix. Right, right. So it's not that they don't want to do it. It's just they don't have the expertise to do it. Right, okay. Okay, right. Yeah.

31:15Fair enough. Fair enough. And I mentioned before that you often do post your surgeries online on social media, so everyone can go look at this. Yeah. But what's interesting is it's local anesthesia, which you mentioned. For the most part. Yeah. So how do people deal with that? Because it's like, you know, when you get a tooth pulled or something, you're very aware of what's going on. Okay, so is there a volume? Yeah, so let me explain. So it's not just done under local anesthesia. So none of the surgeries I do are just done under local anesthesia. They're all done with local anesthesia with some degree of sedation.

31:51So every single patient gets at least an Ativan, which is an oral sedative, which calms your nerves. And 99 % of them get also IV sedation, which means that we give them intravenous. Oh, yeah, that's the good stuff. And that's the stuff that acts kind of quickly. Yeah. And it calms you down. And we have control over how much medication we give you. And so that makes people more comfortable. Yeah. But you are, but you are correct. A majority of my surgeries, we do this awake. So the patient's aware, but they're kind of in a more relaxed state. So. Yes. I can speak from experience. You're in a very, it's like, it's like, you know that because your, your eyes need to be open and you can explain that part.

32:29Yeah. For part of the surgery. For part of the surgery. But like, you, you know, it's going on, but you don't care. Yes, exactly. So it's kind of like the local anesthetic anesthesia thing where you're getting the dental, but you're also kind of getting this other medication where it's like you just don't care. We're just like kind of chatting like someone's doing my hair.

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36:56The most Googled question around blepharoplasty is how long does it last? Yeah. I didn't know that was the most Googled question. I was like, I didn't even ask that. So am I going to be back seeing you in 15 years? So yeah, so I mean, nothing is permanent in the sense that, you know, your face is aging, your skin is becoming more lax and things. But typically when a well-executed blepharoplasty typically lasts for years to decades. How many years, how many decades? It's hard to know because it depends on the patient's aging profile. So, but it's not uncommon that when we do blepharoplasty that, and I've seen some patients who I've did blepharoplasty done 15 years ago and they still look good.

37:37I'm like, okay, you still look good. Because they're seeing me for other things. They're coming to me for X, Y, Z. And I'm like, oh, let's take a look at your eyes. Your eyes still look great. So it's not that you will absolutely need to do another blood floplasty. That's not true. You may not need to do another blood. But if it does happen, it happens very gradually over a year. Typically, I'll tell patients, I probably won't have to do this, anything like that, in that nature, probably for 10, 15 years. But it could be longer. Typically, what happens is that the rest of their face starts to sag.

38:05Like their eyes start, their brows start to droop, their face starts to droop. But once you've removed eye bags, once you've done fat grafting, once you've removed excess skin, typically those things don't come back in a short period of time. It's going to be like many, many, many years to decades. So post-recovery, you mentioned within a week, usually people are wearing makeup, doing their everyday life. I think that was the case for Carlene. Yeah. Now, also I want to ask about scarring because people may be interested in that and I'm sure you've perfected it at this point. So how do you go about hiding scars?

38:36Sometimes on social media, people will be called out. So you can see this scar, that scar. So what's the most modern way of preventing that? Yeah, so most of it has to do with planning. So when you're planning surgery, most surgeons who are doing this cosmetic surgery, and they do a lot of it, try to plan to make their incisions in areas that are either completely hidden or not very visible. So for example, for an upper lip blopplasty, we hide the incision in your eyelid crease. So when you open your eyes, you really don't see it. And how big is it? Oh, well, it's the length of your crease. So it's like three centimeters in length.

39:14But in terms of width, it's very small. It's like a millimeter at most and it's in your crease. So when you are healing, once you're healed and the final healing, usually I tell patients, you know, you got to wait at least six months to get to your final healing. So some of the stuff is done internally. So when I do ptosis repair, sometimes it's done internally. So there's no scars. For lower blepharoplasty, I do most of my lower blepharoplasty internally. So there's no external scars. Brow lifts I do typically from the hairline. So it's kind of hidden in your hairline. So I think the planning is important.

39:46And then the aftercare. You know, you want to follow your surgeon's instructions to the T, which means, you know, no kind of bending over, no exercise for the first two weeks. You don't want to rub your eyes because potentially things can open up or splay. And so you want to avoid those activities. And then we have lots and lots of good treatments for scars. We have lasers and scar creams that can help improve the scars. So I'm not, I'm usually not super, super concerned with people not healing well, quote unquote, because I think that we can, we can manage them. Yeah. And you have kind of like a in office suite, I guess, that does all non-surgical stuff.

40:26Yes. And so is that designed to be in conjunction? Like, did you create that to be in conjunction to the surgeries or as an alternative? Oh, that's a great question. Does it help with the scarring? Yeah, it came out of a desire to improve outcomes more. So it all started off with the CO2 laser. So when I started my practice, I was doing blepharoplasts. I was doing a lot of them. and blepharoplasty is great for removing skin, removing fat, opening eyes. But in terms of like wrinkles and fine lines, surgery can help a little bit, but really that's not really the realm of surgery. Like if someone comes to me and says, I just want to improve my wrinkles, that's not a surgical problem.

41:13So then what I did was the very first laser that I bought was a CO2 laser. And this was like way back when. So almost all of my lower-the-bluffaroplasty I do with CO2 in a patient who's a candidate for CO2. And what it does is it helps tighten the skin around the eye. So the fine lines and wrinkles. It is a dramatic difference for people I've seen that have done that. Huge difference, yeah. So it started off like that. It started off as an effort to just improve outcomes. I wanted my patients to have the best outcomes possible. So I said, okay, let's go and figure out how we can do that. And the first thing I did was I bought a CO2.

41:47And then from that, it kind of snowballed. I was like, okay, well, what else can we do to improve outcomes? And then we got other lasers, Erbium, Diode. So we can treat veins around the eyes. We can do other kind of treatments. Then we got into radiofrequency, microneedling. We got into, we just started doing Botox and PRP. So it was all an effort to kind of serve my surgical patients. But the side benefit is that there are some patients who come to see me who are just not candidates for surgery yet, right? And they're like, okay, I want to improve X, Y, Z. and I said, well, listen, we can start with this laser.

42:24We can start with Botox. We can start with this. And then whenever they do become ready, then we have the capability of serving them in both ways. What I want to do is the PRP and microneedling under the ice. I like PRP and I use a lot of PRP as well in conjunction with, but I would say like PRP and CO2 is probably more powerful than PRP and microneedling. I just don't know if I want to get my skin blasted off, you know, because CO2, what we're not saying is very ablative. It's an ablative laser. So you're basically, the downtime is probably more than what Carlene had. You're wearing Vaseline all over your face.

42:56Yeah. So the downtime is probably about two weeks. So if you're able to kind of move your social calendar for two weeks and like, you know, not, because you'll be red, you'll be red and you'll be crusty, then it's a good, it's a good, it's a good treatment and you can tailor it to the individual. So more, more intense, if you've got more wrinkles, less intensity or less wrinkles. So I have some, because I've posted on, on social media, I have some patients who are a little bit younger who don't have as many fine lines and then their co2 recovery is like five six days they look they look amazing i'm like how is that possible well it's because it's tailored right so it's not co2 is just the the device i can tailor the co2 based on what i'm so if someone only has a mild degree of fine lines and wrinkles it could be a very short recovery whereas if somebody who's got significant wrinkles and fine lines it could be a longer recovery so So there's a range with these types of things.

43:48But if downtime is an issue with you and you can't take any downtime, then probably CO2 is not the option for you. But we have other options that can help with that. I think we also need to talk about dark circles. Number one question we get. And bags. Yes. Talk to me. What you would recommend? Okay. So dark circles is a very kind of generic term. and it's a little bit confusing because people don't know exactly what they're talking about in terms of why they have dark circles. So the way that I think about dark circles, I think about it kind of in three different ways. So you can have dark circles because of hollowing.

44:25So if you look at your under eye area, if you have an indentation, so like everyone has a tear trough, but if that tear trough continues on all the way around your eye and goes to the other side, So it's like a half circle indentation. And that's one very common cause of dark circles. And we have good treatments for that. I'll talk about that. Second cause of dark circles would be eye bags. So if you have an eye bag, the eye bag is casting a shadow below it. And that's creating some darkness. So that's the second cause. The third cause would be the actual skin itself. If the skin itself is pigmented, is darker, and that could be either genetically or because of sun damage, then that skin will be darker.

45:06and you'll look like you have quote unquote dark circles. So we actually have treatments for each one of those problems. So if you have eye bags, the solution is surgery. Hands down. There's no real, you can... Because we're talking about it's popping out, right? Or sagging. Yeah, you can see the puffiness coming out under the eye. So I have lots of patients who've had eye bags and then they'll try to look for like a quick fix and they'll do fillers to the hollow ears. Yeah, mask the eye bag. And yes, it does work temporarily. It does. And I've had, you know, and I've had experience with that too.

45:44So I've done fillers on patients who had eye bags. This is years ago, many years ago. And it does work. However, it's very short term and potentially can cause other problems. And the other problems that occurs is that you get kind of swelling effects because if you got to think about it, if you have an eye bag and you have to add filler to the top of that eye bag to mask it, that's a lot of filler. That's a lot of hyaluronic acid gel. That's a lot of swelling because the hyaluronic acid fillers in general, the way they work is that they draw water in. They're hydrophilic, so they bring water in.

46:15So if you're adding a product underneath the eye bag that's going to draw water in, eventually over time, you're just going to get pooling of that water and then it'll just sit on your cheekbone. And so that's a problem that I see very commonly. It's called malar edema. So for me, eye bags, as soon as you have eye bags, that's a surgical problem. Don't even mess with like anything else. It's surgery. There's only, there's no cooling tips. No. Oh yeah. And there's other things that are out there too. Like these like creams, like it's basically hemorrhoid creams you put under your eye. And it's like, but then it bounces back like with a vengeance.

46:50So you put it on for like, for like, you know, 30 minutes, an hour. Looks good for like an hour or two. And then you take off the hemorrhoid cream and then it like bounces back. So, so eye bags, it's surgery. If it's hollowing, then, and if you have hollowing by itself, you don't have eye bags, then yeah, maybe fillers is an option. But I think a better option is fat transfer or fat grafting. Fat grafting basically means we borrow fat from another part of your body and we put that fat into the hollows and that corrects the hollowing. The reason I like fat transfer, fat grafting better than fillers is because your fat as a substrate, as a tissue, doesn't draw water in.

47:26It's not hydrophilic. So when I add fat there and it corrects the hollowing, once you've healed from that fat transfer procedure, A, it's a permanent solution because you develop blood supply to those fat cells. And B, you don't have to worry about that in like two years or three years, you're going to get fluctuation and swelling because fillers, think about fillers as acting like a sponge. It draws water in, whereas fat does not act like a sponge. So that's probably my number one treatment for under eye hollows. It's all natural, guys. It's all natural. And it's yours, right? So it's the best type of filler.

48:00So it comes from your own body. And so I would say for hollows, use fat transfer over filler. And then for hyperpigmentation of your skin, I would say that we have some excellent lasers for hyperpigmentation. So laser treatment to lift off that sun damage and some brightening creams, combination of brightening creams. And so if you do... What's the laser? What's the laser? Because there's so many. We have different lasers. So the laser that I would... So CO2 is definitely one laser if you have wrinkles. If you don't have wrinkles and it's just pigmentation, then I would say the ND YAG or diode laser.

48:34And then Erbium laser if you're kind of slightly darker skin tones and you want to lift up. So we have different lasers for different skin tones. Yeah. And also different problems. But I would say that those are the main ones. Have you really shopped the brightening eye creams out there? or do you just have one that you went with? I have. Have you really gone the gamut? Yeah, we have and we've tried them and we've used them on our patients and we use them on ourselves. So I think the brightening creams that are out there, they kind of fall in two different categories. So you can have the hydroquinone brightening cream.

49:06So hydroquinone is a compound that actually suppresses the melanocytes, the pigment producing cells in your skin. And it's very effective at brightening the skin. However, depending on the percentage of hydroquinone in that cream, 2%, 1%, 4%, 6%, you can get further brightening of the skin, but also it can cause inflammation. So it's not a great treatment for long-term. So if I'm trying to short-term, can I get some pigmentation down? I will use one of those creams. If I'm looking for long-term... Sorry, is that by prescription only? Yeah, you need a prescription for over a certain percentage.

49:42So for 2 % or under, you can get it at a doctor's office. If it's over 2%, like 3%, then you need to get a prescription. Okay. And it has to be compounded. So that's kind of one category of brightening. And that actually works. Like it really works. Yeah. But it's not a good long-term treatment, right? You can't be on that for like years. It doesn't work that way. You'll cause problems. Okay. And then there's some non-hydroquinone brightening creams, creams that have compounds like niacinamide and other, yeah, transamic that can help. And those you can use that as more for like maintenance. And those are available over the counter and they're available at most kind of cosmetic institutions.

50:21And they do work, but it's like, I would think of it more like maintenance in terms of, in order to decrease the pigmentation, you need something a bit stronger than that. Okay, so maybe you start with hydroquinone and then go to the bright. That's what we typically do. Or we can do them at the same time. Right. You can use them at the same time, but you'll just stop the hydroquinone after like three months. Yeah. And then just carry on with the non-HQ creams to maintain the skin. And if you do that in conjunction with a laser, amazing results. You can get very, very nice results with that. What's the brand you like for the maintenance niacinamide and the…

50:57Well, we carry kind of two of them. So Vivier is one of them that has a great brightening cream. And Elastin has another one as a good brightening cream. yeah okay and vip is a canadian brand so if you want to support canadians it is a good line it's a low-key sleeper hit line great spfs as well yeah okay so we've covered a lot of ground here i know i'm gonna say is there anything that maybe is top of mind for you that's coming up more in your practice that maybe we didn't touch on today that is blowing up in the group chat of plastic surgeons oh i think right now the thing that's really blowing up is fat transfer fat Fat transfer is the thing that everyone's talking.

51:36Every meeting that I go to, I'm going in, is it in April? I got invited to speak at a facial plastics meeting in Germany, in Cologne. So I'm going there. And my whole talk is about modern techniques in blepharoplasty, how to use fat, when to use fat, and all the different techniques of using fat. Because fat transfer, people don't know, has been around for a very long time. It's probably been around for like 20, 25 years. But initially, plastic surgeons who were doing fat transfer weren't getting great results because of the technique. They were using macrofat, big fat molecules. So people were having kind of lumpy, bumpy kind of appearance.

52:12So it didn't really take off until like maybe I would say four years ago, three, four years ago when more modern techniques started becoming more and more. And now, so now what we're doing is we're doing, what I'm doing in my practice is microfat. So microfat grafting is basically fat particles less than a millimeter. and then we can further refine that fat to like smaller particles, smaller particles to get something called nanofat. So microfat, nanofat, basically we're, by using the smaller fat particles, we can get very, very delicate and get into the minutiae of correcting people's hollowing.

52:46And it's been working amazing for under eye hollows. So I can do very, very kind of elegant, subtle corrections with those things. And in terms of the nanofat, we're getting the growth factors to improve the skin quality. So that's really what a lot of people are talking about at conferences. And that's certainly what I'm talking about when I get invited to meetings to speak on this topic. Yeah. And when you're saying fat transfer, that's still a surgery or you're like, you're harvesting, like how do you do it? That's a good question. It's kind of like, so it's, it's typically done by surgeons.

53:17There are a couple of dermatologists here and there that are starting to do fat transfer. It's done by surgeons primarily because it's done typically in conjunction with surgery. So either facelifts or blepharoplasty. But it can be done on its own. So I have patients that I've seen that I've treated who just have hollowing. They'll have no eye bags, no loose skin, not a lot of wrinkles, just have hollowing and will do fat transfer on its own. So technically speaking, it's not really a surgery per se. I'm not cutting anything out. We're basically doing a mini, mini liposuction so we'll borrow fat from a part of your body that has excess fat and everybody cares a bit of extra fat either on their abdomen or their flanks or their thighs so we'll harvest that fat like a mini liposuction and then clean that fat prepare that fat and then process that fat to get those smaller fat particles and then inject that fat just like we used to do with fillers so I use a cannula, inject the fat and I can be very very granular very precise with the fat injections and it works well So it's kind of a gray zone.

54:20It's not really a surgical procedure per se, but it's mainly done by surgeons. Well, we've taken up a lot of your time today. We've learned a lot. I feel like I've gotten a consult and learned so much about Carleen's journey. So we really appreciate you taking the time. Thank you so much. Thanks for having me. And if everybody wants to follow you, if they're not as squeamish as me, you're giving lots of great advice on your social media. Where can they find you? So my handle on social media is just my name. So Dr. Babak, B-A-B-A-K, Maleki, M-A-L-E-K-I. And yeah, you can follow me on that handle.

54:53And yes, I try to be as transparent as possible online in terms of education. So show the good, the bad, the ugly, and we'll see. And so people can understand. And potential new office coming, I've heard. And potential new office. Yes, exactly. We'll keep you posted. All right. Thank you so much. Thank you so much. Thanks a lot. Thanks for listening. You can find details on every product mentioned in today's episode, along with our exclusive promo codes on our blog at breakingbeautypodcast.com. While you're there, be sure to sign up for our newsletter. Every episode will be delivered directly to your inbox so you won't miss a single thing.

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