Question 1

What common misconceptions do patients have before eyelid surgery?

Accepted Answer

Dr. Massry notes that most people ask the wrong questions before eyelid surgery, emphasizing the importance of comprehensive patient education to ensure informed decisions. For example, a low brow can mechanically hood the eyelids, mimicking excess lid skin, and if the brow is low, it may be advisable to address this before or in conjunction with eyelid surgery.

Question 2

What are the risks of excessive skin or fat removal during eyelid surgery?

Accepted Answer

Removing too much skin during eyelid surgery risks incomplete eyelid closure, which can be a lifelong problem. Similarly, removing too much fat can lead to hollowing, which can make a patient look older. Unrecognized ptosis (drooping eyelid) can also become more apparent after eyelid surgery.

Question 3

Can lower eyelid surgery (blepharoplasty) make upper eyelids look hollow?

Accepted Answer

While it may sound unlikely, the theory that lower eyelid surgery could make upper eyelids look hollow is anatomically plausible, especially if surgery changes the fat or supporting tissues around the eye. During lower blepharoplasty, some fat may be removed, or surgical techniques might affect supporting ligaments, potentially causing the eye to shift slightly. However, Dr. Massry notes there are no strong clinical studies proving this causation, and for now, upper eyelid hollowing after lower blepharoplasty remains a theoretical possibility, not a confirmed complication.

Question 4

What temporary effects can patients expect during brow lift recovery?

Accepted Answer

After a brow lift, several effects can look or feel concerning but are almost always temporary. These include the brows appearing too high (often intentionally positioned higher as they are expected to settle), scalp numbness (sensation gradually returns over weeks to months), lumps and bumps behind the hairline at incision sites (due to swelling and sutures, which smooth out with healing), early asymmetry where one brow moves more than the other (due to swelling and temporary nerve effects, improving with healing), and a temporary 'Botox effect' (unusually smooth forehead related to swelling and reduced movement). Dr. Massry emphasizes that what is seen in the first few days or weeks is NOT the final result, and understanding the healing process can significantly reduce fear and anxiety.

Question 5

What should patients know about eyelid skin grafts for lower eyelid retraction?

Accepted Answer

Eyelid skin grafts are an important tool for repairing a pulled-down or retracted lower eyelid, especially in severe cases or after complicated/unfavorable lower blepharoplasty. While most cases can be corrected without a graft, adding skin via a graft may be necessary when retraction is severe, less invasive approaches have failed, or the eye is naturally prominent/bulgy. Dr. Massry emphasizes that skin grafts must be used for the right reasons and their indications respected. Patients should not fear them, but understand they require patience during healing. Early on, grafts may show color mismatch, visible edges, or noticeable scars, and at one week post-surgery, they are expected to look different. However, with proper technique and healing, these initial differences can soften dramatically, and over several months, a well-healed graft should continue to smooth, soften, and blend remarkably well. For the right patient, a skin graft can be life-changing, restoring the eyelid and addressing the significant emotional toll severe retraction can take.

Question 6

What is the difference between festoons and malar bags, and how are they treated?

Accepted Answer

Festoons and malar bags are distinct problems that should not be treated identically, making accurate diagnosis crucial. Festoons are hammock-like folds of skin and tissue where the lower eyelid meets the cheek, categorized as 'dry' (primarily loose, overhanging skin, often effectively treated with direct excision, with incisions healing very well in properly selected patients) or 'wet' (associated with fluid accumulation and swelling, requiring a different or combined approach). Malar bags appear as prominences over the upper cheek, often accentuated by hollows and volume changes above and below them, and are not simply excess skin. Energy-based treatments such as laser or radiofrequency may help improve their appearance, but malar bags are generally much less amenable to direct surgical excision compared to dry festoons. Dr. Massry advises extreme caution when treating either condition with filler, as adding volume to an area already prone to prominence or fluid retention can worsen the problem's appearance.

Question 7

What combination of procedures does Dr. Massry use for natural eyelid rejuvenation?

Accepted Answer

Dr. Massry often combines several subtle procedures to achieve a natural, balanced, and refreshed outcome. This can include a small upper eyelid blepharoplasty to improve the upper lid near the nose, a lower eyelid blepharoplasty to reduce lower lid bags, and fat used to smooth hollow areas beneath the lower lid bags. Laser resurfacing can also be added if wrinkles are a concern.

Question 8

What are the differences between fat repositioning and fat grafting for lower eyelid hollows, and which does Dr. Massry prefer?

Accepted Answer

Both fat repositioning and fat grafting can be effective for lower eyelid hollows, but they are very different approaches. Fat repositioning involves moving the native eyelid fat (that creates the 'bag') into the hollow below, simultaneously reducing the bag and filling the hollow. This technique is anatomically sound, well-supported in literature, and reliable due to maintaining vascular connection, though it has a significant learning curve and is technically demanding, requiring surgeon experience. Fat grafting, conversely, harvests fat from another body area via liposuction, processes it, and injects it into the hollow. It provides an additional fat source for precise augmentation but requires a separate donor site, and the graft must establish a new blood supply, leading to variable fat retention. Fat grafting fills the hollow but doesn't directly eliminate the eyelid bag, so the protruding fat may need separate addressing if used alone. Dr. Massry often combines both techniques, using existing fat with repositioning and adding volume with grafting where needed, believing 'sometimes the best answer isn’t either/or—it’s both.'

Question 9

How does Dr. Massry treat an A-frame hollow in the upper eyelid?

Accepted Answer

An A-frame hollow is a specific and common hollow of the upper eyelid that peaks closer to the nose, often a classic sign of over-resected fat after upper blepharoplasty or age-related changes. This can be corrected by either fat grafting or fillers. Dr. Massry prefers fillers for A-frame hollows in the upper eyelid because he does not commonly see the swelling and color changes associated with fillers in the lower lid. His technique involves perforating the skin with a sharp needle to create a small opening, then filling with a blunt cannula for reduced risk, injecting small amounts of filler deeply with multiple passes. He emphasizes that subtleties are important in achieving desired surgical outcomes.

Question 10

Are the before and after photos on Dr. Massry's profile provided by patients?

Accepted Answer

Yes, Dr. Massry sometimes shares before and after photos that were provided directly by the patient to him, ensuring an authentic representation of their results.

Question 11

What does Dr. Massry say about their approach?

Accepted Answer

My job isn’t just to operate it’s to make sure you know what to expect so you can make informed decisions. I'm trying to keep you safe and this is what I've learned over the years. Number one, tell me about my eyebrow position. Is it low? Remember, if the brow comes down, it mechanically hoods the lids. And if you do only eyelid surgery, you can pull the brow down further and create more hooding. So if the brow needs to be adjusted, adjust it.

Question 12

What does Dr. Massry say about what they specialize in?

Accepted Answer

Dr. Guy Massry specializes in using fillers for filling the upper lid hollow. Dr. Massry's 'brow re-contour' is his specific approach to a brow lift.

Question 13

What does Dr. Massry say about their techniques?

Accepted Answer

Dr. Guy Massry typically fixes this condition by raising the cheek from below to add skin to the lower lids and uses other adjunctive procedures. Dr. Guy Massry believes that leaving the arcubate expansion (Clifford's ligament) intact during lower blepharoplasty can prevent upper eyelid hollows.

Question 14

What does Dr. Massry say about consultations?

Accepted Answer

But in his case, he's failed two revisions, it's very severe and we discussed the options of skin grafting and I showed him patients, pictures of that and we've decided to go that way.

Question 15

What does Dr. Massry say about safety?

Accepted Answer

And I don't get the blue color change and swelling like I do in the lower lids so much. Never treat these with fillers to hide the festoon. Fillers make this worse, especially if they're wet.

Question 16

What does Dr. Massry say about results?

Accepted Answer

We kill two birds with one shot. We reduce the fat and fill the hollow.

Question 17

What does Dr. Massry say about recovery?

Accepted Answer

It's okay if the brow looks high at first. It's going to drop 20 to 30%.

Dr. Guy Massry, MD

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