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Interviewer: It's a pretty common question. How do you fix droopy eyelids? Dr. Eric Cerrati is the Director of Facial Plastic Surgery at University of Utah Health. Dr. Cerrati, first of all, what usually brings patients to you looking for an eyelid procedure? What are some of the common themes?

Dr. Cerrati: I would say the most common thing across the board is that patients say that they feel or look tired, especially when they look at themselves in the mirror.

Interviewer: Got you. And you have a procedure that can do that. Now, is it something that you can do without surgery, or is surgery always involved?

Dr. Cerrati: So there are actually a lot of different options. There are nonsurgical options, in which case you put filler underneath the eye, you can do laser procedures to tighten the skin under the lid, and then there's a whole arsenal of surgical procedures, where we tighten the muscle underneath, we remove some of the skin, and we lift the brows, all giving a more rejuvenated or rested appearance.

Interviewer: How would you decide what is best for a particular patient?

Dr. Cerrati: It starts with the patient's concerns and what their question is. This is actually more common in males than you would think. It's very common that patients come in and just say they look tired and their colleagues are commenting, both male and female.

Another common complaint that patients will say is that it's affecting their vision, in which case the droopy eyelids can actually block some of their peripheral vision. If that's the case, we could actually send them for an objective visual field test is what we call it. They have the test. Depending on how they perform, there are certain insurance criteria and if they meet that criteria, insurance will actually cover the procedure.

Interviewer: So you can get rid of the tired look and also improve your vision, which is fantastic. It's a safety thing, really.

Dr. Cerrati: Exactly.

Interviewer: You know? And just a quality of life thing as well. So you have a conversation with them. You try to find out what their needs are as far as then determining which one of these procedures you're going to go with. How often is it possible that somebody could do nonsurgical?

Dr. Cerrati: It's difficult to say. I would say people that have more on the mild side of findings we can treat it nonsurgically. Botox Botox, which is actually common medication that we use, that you think of smoothing wrinkles on the face, but you can actually use the push/pull of muscles on the face to actually create a brow lift to give a more rested appearance to the brow. Some other nonsurgical options include, for the brow, using Botox to elevate the brow. Fillers Really not much you can do for the upper eyelid skin, but the lower eyelid you can place filler in the tear trough to help provide some volume to the under eye, which gives them more of a rested appearance, and also doing a laser procedure to tighten the skin underneath the eyelid.

As far as topical creams and those sorts of things, they do help slightly. I wouldn't say it would give the patients a long-lasting result that they're really looking for when they come to my office.

Interviewer: And when you talk about long-lasting results, how long could somebody expect this to continue to be what they want it to be?

Dr. Cerrati: So obviously, we can't stop the aging process, so it continues. But I would say for eyelid and brow revisions, usually you're talking several, several years down the road, 10-plus years.

Interviewer: And then where, if it is a surgical option . . . I'd imagine the nonsurgical happens in your clinic. What about the surgical options? Tell me more about that.

Dr. Cerrati: So the surgical options are performed either up at the main hospital, the University Hospital, or out at one of the satellite offices. When I consider eyelid rejuvenation, you have to consider the brow and the eyelids kind of as one unit. And so, if the brows are ptotic or have fallen down some, addressing the brow can create a very significant improvement in the appearance.

So if the brow is being done, usually I perform that under general anesthesia, and then the upper lids, if we're coupling that with the brow, again under general anesthesia. If it's just the upper eyelids, we can actually do that in the clinic setting just under local anesthesia. It takes maybe 45 minutes to an hour. And then the lower lids are a little bit more involved. I tend to do those back in the operating room.

Interviewer: Got you. And what kind of recovery time are we talking about? I'd imagine it varies because it sounds like the approaches vary.

Dr. Cerrati: So I tell everyone it's about a one-week recovery. At one week, all the stitches come out. Most of the bruising has resolved. Still taking it easy as far as activity-wise, but one week you're pretty much recovered and back to your normal day-to-day activities.

Interviewer: Do people generally choose not to go to work for that one-week period while they're healing?

Dr. Cerrati: Depending on what their job is, yes.

Interviewer: See if they can work remotely and maybe do that?

Dr. Cerrati: Exactly.

Interviewer: Got you. And you mentioned insurance covered it if it was a sight thing, so that's pretty good.

Dr. Cerrati: If insurance feels that the findings affect your peripheral vision, they will actually cover both the brow lift and the upper blepharoplasty or upper eye lift.

Interviewer: Tell me about how the skill and experience of the surgeon can make a difference in the outcome when it comes to this type of procedure. I mean, you do it. You also have some very talented colleagues that do it. How would somebody choose the person that they want?

Dr. Cerrati: So there's a team of surgeons, and with every surgeon, there's a team that works around them to help provide the best care here at the University. For brows, I tend to use an endoscopic approach, which is incisions hidden way back in the hairline, so that way, really minimizing the amount of scarring or any incisions on the face.

The eyelid incisions are hidden right in the natural creases of the eye. And again, all of this is tailored to the specific patient's needs and the skill the patient takes, in both aesthetics and shorten the recovery time.

Interviewer: And how could a patient make sure they're picking the surgeon that's right for them?

Dr. Cerrati: So the most important thing is the in-person consultation. It's important to come meet your surgeon, discuss with them kind of what you're hoping to achieve. You can look at some before and after pictures. And if you feel comfortable with the surgeon, that's the most important thing.

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Dr. Miller: Two approaches to have your hip replaced, which one's best for you? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: I'm Dr. Tom Miller and I'm here with Jeremy Gililland. He's a professor of orthopedics here at the University of Utah in the department of orthopedics. What's the best way to have your hip replaced, from the back or from the front?

Dr. Gililand: The honest to goodness truth is you should have your hip replaced by a surgeon who knows what they're doing from what approach they're using.

Dr. Miller: That's pretty good basic advice. Know your approach and know it well.

Dr. Gililand: Exactly.

Dr. Miller: So talk to me about the differences because patients do assume that maybe one approach is better for them, maybe it's less invasive, requires less time in the O.R. I just don't know.

Dr. Gililand: Sure. So I think there are two major approaches in hip replacement today and that is either the direct anterior approach or the posterior approach. Both have been around for a long time. The anterior approach is not a new approach. It's been around since the 1950s, It's just taken a hold, I would say, in the last decade as a . . .

Dr. Miller: Mainstream procedure.

Dr. Gililand: Mainstream procedure. Exactly.

Dr. Miller: Why would one do an anterior approach or why did the posterior approach become ascendant?

Dr. Gililand: So the posterior approach has always been a very nice approach with very good visualization, good access to the pelvis and to the femur and it's quite extensile. Meaning if there's any troubles during surgery, you can get access to everything you need and fix any troubles there. However, with the posterior approach, we've had issues with dislocation and dislocation is a big problem for patients if you have a dislocation.

Dr. Miller: So once the hip's replaced then the patient post-operatively has a higher risk of dislocation than in a patient who's had an anterior approach.

Dr. Gililand: Well, we like to think that. We like to think that the anterior approach has mitigated some of the dislocation risks. So that's really where the surge and popularity of the anterior approach came in as well as it being a little bit less invasive, smaller incisions and patients like to think that's it's muscle sparing as compared to the posterior approach. So that's really what's driven a lot of the popularity of this approach.

Dr. Miller: Now, you do the anterior approach in your practice?

Dr. Gililand: Correct, I do.

Dr. Miller: Do you do primarily an anterior approach?

Dr. Gililand: I would say it's about 90 to 95% of my patients that I do hip replacement on get anterior approach and a small percentage will get posterior approach based on certain factors.

Dr. Miller: But other surgeons in your practice will utilize primarily the posterior approach.

Dr. Gililand: Absolutely.

Dr. Miller: So how does a patient choose?

Dr. Gililand: There's a lot of stuff on hype on the Internet, a lot of information that I would be careful of reading. I think that patients need to talk with their surgeon. They need to feel comfortable with their surgeon and they need to really listen to what their surgeon has to say in terms of their expertise and their feelings of the surgery.

I think for approach one versus the other, there are benefits potentially the anterior approach. Patients sometimes feel like in the first six weeks they're up on it quicker. It's a little easier and less painful for recovery. There's definitely less concerns for positions of the hip in terms of dislocation.

With the posterior approach we give you certain precautions or positions to avoid for dislocation. With the anterior approach there's less of those precautions. However nowadays with a well done posterior approach or a well done anterior approach, dislocation risk is very, very low and patients can do well with both.

Dr. Miller: So it comes back to what you were saying earlier which revolves around the surgeon's expertise in that particular approach, their ability to perform that particular procedure over and over again and do it really well. So I think for the patient who's looking to have a particular approach, they should listen to what the surgeon does mostly or what the surgeon recommends and not try to push him in a direction that the surgeon is not comfortable with or less comfortable with.

Dr. Gililand: Absolutely. One of the problems we've see with the anterior approach is that it has become a marketing tool for surgeons. So surgeons will use that to bring patients into their practice and start saying, "I do the anterior approach, please come and get your hip done with me."

The problem being is they may have a very low number of hips in their experience there. It's got a significant learning curve, probably around 100 hip replacements before you really are competent with the approach, and so patients may not know that their surgeon has had very little experience on the approach yet says that they do the approach and the surgeon may say that they prefer that. So I think it's wise for patients to always ask their surgeon what's your experience with this approach, why are you saying that I need this approach and be educated on that.

Dr. Miller: What's nice in your practice or your group practice is that you have surgeons doing both. Have you had a patient request a posterior approach that you've then referred to your colleague or vice versa?

Dr. Gililand: Absolutely. I think that . . . and I'll have patients come to me that request an anterior approach and I'll tell them I don't think they're a good candidate for it for x, y or z reasons. If they are not comfortable with it, they can find somebody else who may be comfortable to do that approach but we offer all approaches here at our practice. I think we all have very very good success with our hip patients regardless of approach. Again I think it boils down to surgeon's comfort and patient's comfort with their surgeon.

Dr. Miller: On the redo prosthetics of patients will come back and they'll need a new hip after a number of years. Either approach or one in particular?

Dr. Gililand: I think the posterior approach is generally the workhorse for us when it comes to going for revision surgery. They are certain cases when I will do revision surgery through an anterior approach but that really is somewhat select. Most of the time we're using the posterior approach, again, because of the nature of it being a more extensile approach that gives us better visualization of both the pelvis and the femur.

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