There was a time when going in for what's commonly referred to as an eye-tuck required the patient to go under the knife and spend a couple of weeks afterward looking like the loser in a fistfight.

Not anymore.

"Thanks to the laser, it's now a much easier out-patient surgery," said Dr. David Pratt of Clarus Eye Centre. "It's much quicker than when we operated using scalpels and scissors - 10 to 15 minutes, compared to 40 minutes. And the bruising around the eyes is pretty much a thing of the past. Instead of going into hiding for two weeks, patients now feel comfortable going out in public within two to three days. There may still be a bit of swelling, but it's nowhere near as noticeable as two black eyes."

The reason the effects of the procedure Pratt refers to as blepharoplasty have become so much less noticeable is that the laser cauterizes the blood vessels around the eye at the same time it's removing the excess eyelid skin.

Pratt is an orbital-facial plastic surgeon for Clarus Eye Centre, which has facilities in Lacey and DuPont. He performs both cosmetic and reconstructive facial plastic surgery.  The orbital phase of his title refers to the work he does in the vicinity of his patients' eyes. The facial phase is pretty self-explanatory. He and others like him treat disorders of the eyelids and sockets, including congenital malformations, trauma, tumors and eye socket reconstruction.

All of which makes an eye-tuck seem comparatively benign, but even blepharoplasty has serious implications. Removing or repositioning skin and fat around a patient's eyes and sometimes reinforcing the muscles and tendons is often functional rather than merely cosmetic. As we age, Pratt observes, gravity gets a good firm grip on our upper eyelid and it begins to sag, sometimes to the point that it can impair vision.

 "By our late 40s and 50s," Pratt said, "the extra skin on our upper eyelids, which has been accumulating since we were in our 30s and 40s, begins to creep onto our lashes and even droop over our pupils."

The fine line between facial rejuvenation and preventative medicine is often drawn by insurance companies, said Pratt.

"For instance," the doctor said, "we charge $1,800 for both eyes for blepharoplasty. That covers the operating facility, the fees of the surgical team, the follow-up, everything." 

If blepharoplasty is a procedure a patient needs in order to see clearly - to drive down the road without crossing into oncoming traffic, for example - rather than a procedure whose sole purpose is to make the patient look years younger, insurance usually covers the lion's share of the bill.

Otherwise, it comes out of the patient's pocket.

Clarus is on the preferred provider lists of more than 40 insurance companies and has personnel trained to help patients determine in advance precisely how much of their surgery will be covered.

That frees medical personnel up to learn new approaches to old problems, such as what to do with excess fat removed during lower-lid blepharoplasty. Pratt points out that in the past, most of the fat was simply discarded. More recently, however, techniques have been developed to relocate it. In a process called fat transposition, it is now placed where it will restore the contours of the eye to provide a rounder, more youthful appearance.

But perhaps the most significant innovation, he said, is the fact that so much of the work is done with lights these days.

 "In lower-lid blepharoplasty, for instance," he added, "we used to treat unattractive puffy lower lids by removing skin. Not any more - now, we use a carbon dioxide laser to tighten the skin and eliminate wrinkles, to resurface the lid without incising it."