Cosmetic Procedures

Dr. Walrath performs cosmetic surgical and nonsurgical procedures of the eyelids, forehead, and midface.

Oculoplastic surgery can be very satisfying for patients, because the eyes and periocular region are focal points in our daily interactions. As we age, the fat can deflate (in some), expand (in some), and free itself from the retaining wall that holds it back during our youth. It falls forward, out of the eye socket, and becomes visible through the lids. As our skin becomes more lax and our ligamentous attachments relax, our eyebrows tend to descend. The tendons of our eyelid muscles may relax too, leading to droop. Our cheeks descend, and sometimes that pulls our eyelids down so that we start to see the white under the eye (the sclera).

In general, these problems are largely surgical. However, in some patients who are reluctant to undergo surgery, there are nonsurgical therapies that can provide some benefit, although usually the problems that can be corrected with nonsurgical means are generally milder in nature.

Upper Eyelid Blepharoplasty

Upper eyelid blepharoplasty involves removal of excess skin and soft tissue in the upper eyelid, symmetrization of the eyelid creases and upper eyelid skin fold, and simultaneous protection of the ocular surface and preservation of normal eyelid position and mechanics. Upper eyelid blepharoplasty is often combined with forehead lifting and temporal brow lifting because of the interrelationship between eyebrow position and upper eyelid skin. As an ophthalmologist, Dr. Walrath pays particular attention to the health and safety of the ocular surface during this, and any, procedure.

Upper eyelid blepharoplasty is individually tailored. In general, Dr. Walrath adopts a “tissue-sparing” approach for some younger patients and for men, as most men find that excessive removal of tissue from the upper eyelid leads to a feminine appearance. In fact, some patients have come to our practice, after having surgery elsewhere, with the desire to regain the youthful fullness in their upper eyelids. Dr. Walrath also performs upper eyelid blepharoplasty on Asian patients, after careful discussions about the exact nature of the crease and skin fold that they desire. For a recent discussion of the eyelid crease, please look here. If you would like to see a panel of images that demonstrates the typical healing process, please look here.

Dr. Walrath has recently been invited to lecture on the topic of blepharoplasty.

If you would like to learn about the difference between ptosis repair and blepharoplasty, read here.

Many patients have questions about the “down time” required for upper blepharoplasty. A rather extensive upper eyelid and eye socket procedure was performed on a patient who was kind enough to supply photos of his healing process through the first postoperative week here.

If you would like to learn about the surgery for upper eyelid droop that can be covered by insurance, look here.

In my experience, the eyelid crease is something that most non-oculoplastic surgeons simply ignore, or at best take for granted.  I take care to establish a crease in the proper location and with proper symmetry, by careful measurements intraoperatively;  more importantly, this requires careful discussions with the patient preoperatively, particularly if the patient is Asian.  Loss of eyelid crease fixation can occur after blepharoplasty, leading to the appearance of excess skin on one side: this is a trap.  The real treatment is reformation of the crease, and not simply re-excision of the skin.  Removing too much skin creates the REAL problems that we occasionally see in upper eyelid surgery.

Lower Eyelid Blepharoplasty

Lower eyelid blepharoplasty involves the removal or repositioning of lower eyelid fat pads, support of the middle portion of the eyelid, and tightening or removal of the outer portion (skin and muscle). Dr. Walrath develops a customized plan for each patient, taking into account these distinct anatomical structures.

In younger patients, the personalized approach to the lower eyelids may involve a surgical incision on the inside of the eyelid to remove and redistribute the fat pads (“lowering the mountain”), or it may involve the nonsurgical placement of injectable filler in the region adjacent to the fat pads (“raising the valley”), both with the goal of smoothing out the transition zone from the lid to the cheek and the transition zone from the inner aspect of the lower eyelid to the nasal side wall (the “nasojugal fold” or “tear trough”). The skin may be pinched and a small segment removed, or a gentle chemical peel may be utilized to remove fine wrinkles and create mild tightening. The eyelid itself is usually anchored to the eye socket rim for additional support if surgery is performed.In patients with skin excess and eyelid laxity, the usual approach is to perform an incision beneath the eyelashes. This incision preserves the eyelash follicles. Lower eyelid fat pads can then be removed or repositioned, tailored to the patient’s cosmetic needs. Customized treatment of the middle anatomic layers of the eyelid is critical. This layer is often released surgically, and spacer materials, usually composed of processed collagen, are often used to provide vertical support to the eyelid within this middle layer, to ensure proper eyelid position and function. Excess skin is then redraped and conservatively removed, so as to avoid a “skin shortage” and the attendant problems with eyelid closure and protection of the ocular surface.

A detailed discussion of the decision making process in lower lid cosmetic surgery can be found here.
Dr. Walrath has recently been invited to lecture on the topic of blepharoplasty.

If you would like to learn about lower eyelid surgeries that are occasionally covered by insurance, look here.


Dr Walrath reshapes brows with direct incisional techniques when appropriate.  The typical settings when this is appropriate include:

  1. Prior history of unsatisfactory brow lift
  2. Very heavy brows
  3. Receding hairlines
  4. Desire for exquisite control of brow contour

Dr. Walrath offers cosmetic botulinum toxin A (Botox) for dynamic wrinkles in the forehead, between the eyebrows, and in the “crow’s feet”. He also has a great deal of experience treating patients with Botox for neurological disorders of the eyelids, tear glands, and face.

During your consultation, Dr. Walrath and his staff typically use a combination of techniques to keep you comfortable during the injections. The needle is very small, and though it does cause some discomfort without anesthetic technique, nevertheless it is bearable. Topical anesthetic cream is applied for 20-30 minutes liberally prior to the injection. A combination of ice or vibratory distraction techniques are utilized to lessen any discomfort, which is typically mild at this point.

The injection pattern for the face is developed together with the patient, using various techniques to simulate the effect of the injected botulinum toxin. The effect of the injections will start to become apparent after several days. In general, if the region treated does not respond completely, patients are entitled to return for complimentary Botox to attain full correction.

Botox injections are very satisfying for me as a clinician, and very satisfying for the patient as well. The most satisfying situation is when the clinician and the patient are the same person! Every now and again I plop down in front of the mirror and silence a few wrinkles in my forehead. I don’t use any anesthetic, not because I have a tremendous pain tolerance, but because the discomfort is not that bad. It takes about 5 minutes and leaves me with a little redness in my forehead for a half-hour, but I just sit in my office until it subsides. I will caution you though — the whole thing is a little addictive!

Fillers: Juvederm Family of Hyaluronic Acid Fillers

Dr. Walrath offers injectable fillers (Juvederm) in the region around the eyes and midface and in the lips. Often times these products can be used instead of surgery, though often they are part of a combination of techniques, including botulinum toxin and possible surgery.

Juvederm is a so-called NASHA (non-animal stabilized hyaluronic acid) filler. Hyaluronic acid is present in all animals — it’s the matrix that is present in our tissues. Translated: our bodies can tolerate it pretty well, so it’s unlikely to cause a bad reaction. The NASHA material is grown in the lab and treated chemically so that it lasts longer in the body.

These fillers can be used in several different places on the face:

The “tear trough” – the hollow that develops at the junction between the lower eyelid and the cheek
Wrinkles between the eyebrows that don’t go away with Botox
The nasolabial fold — which runs from the edge of the nostril to the outer corner of the mouth
The “marionette line”, which runs from the corner of the mouth down to the jaw on each side
The fine “smokers lines” on the top of the upper lip

The fillers can also be used to fill in:
Deflated lips
Deflated space (hollow) above the upper eyelid

They can also be used to improve the definition of the lips and to augment the “cupid’s bow”, or philtrum, of the upper lip.

Dr. Walrath uses Juvederm products: Juvederm Voluma for the midface, Juvederm Ultra for the eyelids, and Volbella for the lips. Some recent clients are seen below:

Video 1. Injecting the lips with hyaluronic acid-based fillers.

Figure 1. After lip filler, with philtrum and lip line definition.

Figure 2. After lip filler, with philtrum and lip line definition. The philtrum has been vertically elongated with filler.

Figure 3. A few days after lip filler: philtrum and lip line definition. The philtrum has been augmented with filler.

Figure 4. After lower lid filler. Post-injection photo was taken in the evening on the day that the filler was injected.
Fillers can also be quite gratifying, because: there is very little down-time, the procedure is subtle, and it is generally reversible, at least with the NASHA class of fillers. Using topical anesthetic creams for most of the injection sites can make the procedure comfortable. Lip injections require a local lip block, which is well-tolerated.
Fractionated CO2 LASER Resurfacing

Dr. Walrath offers fractionated CO2 LASER skin resurfacing of the eyelids and other facial subunits, as a surgical adjunct or as a stand-alone procedure.

Fractionated CO2 LASER is a powerful method for treating deep facial wrinkles and pigment variability. Limited facial regions can be treated in the office setting, but more extensive facial LASER procedures are typically done in the operating room.

Not everyone is a candidate for this procedure, and an in-person consultation is necessary for an in-depth discussion of this therapy.