Eyes are the focal point of one's face. They are the first thing
people notice and are the key to facial expression. This is
the main reason why so many people seek cosmetic eyelid surgery. We hear over and over again, My eyes always look tired
and old even when I feel wide awake. This is very profound
because often if you look old and tired you will feel the same
way. How many times have you dressed up and prepared to go out
feeling good about yourself only to look in the mirror to see
that your eyes look older than you feel. The reason for this
is that during the aging process the region around your eyes
shows the effects of aging much sooner than other areas.
Aging
affects the entire face. So why is it that we notice it around
the eyes much earlier than other areas? The explanation for
this is that the aging process can be simplified by thinking
of it in terms of the three most important components of the
face. These components are the skin, the underlying muscle,
and the fat. Most people don't think of aging as involving
the latter two structures but, in reality, these are probably
the most important. Have you ever looked at a baby's cheek?
It is full and fatty. Look at a model’s cheek. It is
not as full as a baby's cheek but still it has significant
volume due to the underlying fat. There is a substantial amount
of fat situated around the orbital region. As we age, the
fat will either descend downwards on the face or may go away
completely. When this happens, it exposes the underlying facial
skeleton resulting in the familiar gaunty appearance that
we recognize as aging. Also, the fat and underlying muscles
act as a filler creating the volume seen in the cheeks of
youth. When this filler descends or goes away we see wrinkling. This process is similar to a grape which turns into a raisin
when the water is removed.
The importance of the underlying fat and muscle has been
revolutionary in the field of plastic surgery over the last
10 years. It is no longer acceptable to think of eyelid rejuvenation
as merely a procedure to tighten the skin. This is many doctors
feel it is so important to correct the problem itself and
not just the effects of the problem. Men'sy of the old-school
plastic surgeons feel that eyelid rejuvenation requires removal
of fat and skin. Other forward thinkers in plastic surgery
advocate not removing fat but rather repositioning it back
to where it once was. In fact some of them often add fat by
fat transplantation or suture suspension during his/her eyelid
or facelift procedures.
Another contributing factor to the appearance of old age
within the eye region is the fact that the lower eyelid, especially
toward the temple region, begins to descend and give a depressed,
sad appearance. This is much different than the appearance
that one had when he/she was younger. The lower eyelid of
youth has a bright, elegant appearance with the lateral aspect
being higher than the nasal aspect. Plastic Surgeon Locator
doctors feel that it is important to address this issue to
create the best look possible. Often, they will elevate the
lateral portion of the lower eyelid to re-create that youthful,
almond-shape appearance. This is a subtle but very effective
maneuver and is well worth the additional time.
Eyelid surgery alone will not correct crow's feet. It will
help but often a concurrent brow-lift and/or face-lift is
necessary. Some of the doctors, however, are able to reduce
it significantly during their eyelid surgery by repositioning
the underlying fat and muscle into a more youthful position.
It is often very useful to perform fat transplantation, as
well as either chemical peeling
or laser skin resurfacing,
in addition to eyelid surgery. This allows plastic surgeons'
to address all the components associated with aging around
the eyes. Remember, the aging eyelid is a result of problems
within the skin, muscle, and fat.
 Benefits
There are many benefits to eyelid rejuvenation surgery. The
key is to determine exactly what the problem is.
Lower eyelid surgery benefits.
- Tightens and smoothes out bags underneath the eyes.
- Repositions lower eyelids into a more elegant, almond-shaped
appearance.
- Repositions underlying fat to get rid of the sunken, aged
appearance.
- Repositions skin and underlying muscles to smooth out
wrinkles.
- Markedly fills out the deep crease known as the "tear-trough”
between the eye and the nose.
- Eliminates circles underneath the eyes.
- Improves dark discoloration within the lower eyelid.
- Improves fine wrinkles.
Upper eyelid surgery benefits.
- Removes hooding and excess skin of the upper eyelid.
- Creates a larger, more attractive upper eyelid.
- Creates a "double lid" and removes excess eyelid
fat in Asians.
- Elevates the upper eyelid to give a more bright, and youthful
expression.
- Repositions upper eyelid fat into more youthful position.
- A moderate brow-lift can also be performed through the
upper eyelid incision.
Are
you a good candidate?
Most people as they age can obtain improvement from eyelid
surgery. Specifically, good candidates include people with
the following problems around the eyes:
- Bags and loose skin.
- Sad or tired appearance.
- A deep crease circling underneath the eyes.
- Excess skin and wrinkles.
- Dark discoloration underneath the eyes.
- Hooding or excess skin within the upper eyelid.
- Crow's feet within the lateral eye area.
- Sunken appearance to the eyes.
Possible
complications
In Plastic Surgeons Locator hands, complications are rare
but it is important that they are discussed. The most common
complication is inadequate correction of the problem. If this
is the case, correction can usually be made with a minor additional
procedure. Other complications include ectropion, or downward
pulling of the lower lid, asymmetry, and dryness of the eyes. Complications that can occur with any surgery include infection,
blood or fluid collection, and unfavorable scarring.
Do's
and Dont's prior to surgery
- Medications. Certain medications thin
your blood and should not be taken within 3 weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and
should not be used within 3 weeks of surgery. Your doctor
will go over this more thoroughly prior to the procedure.
- Sleep. It is important to get a good
night's rest prior to the procedure. If you think this may
be a problem, please, do not hesitate to ask your doctor
for something to help you sleep.
- Smoking. Do not smoke within 3 weeks
before and after surgery. Smoking has a profound effect
on reducing wound healing capabilities. It significantly
increases the likelihood for infection, wound healing problems,
and scar formation. It also affects your airway, therefore,
makes anesthesia much more difficult.
- Eating. Do not eat within 8 hours of
surgery and do not drink within 6 hours of surgery. It is
OK to take medications with a sip of water. Please discuss
all medications with your plastic surgeon and the anesthesiologist.
- Washing. It is a good idea to wash the
surgical area thoroughly the night before and the morning
of surgery. Wash your hair and comb it straight back. Do
not apply makeup.
- Arrival. It is best to arrive on time
so things go smoothly. Please be sure to have someone else
drive you.
Anesthesia
The anesthesiologist will discuss with you what type of anesthesia
is best for you prior to the procedure. He/she will take into
consideration your medical history, the procedure, and your
personal wishes.
Eyelid surgery can be performed under general anesthesia
or under local anesthesia with or without sedation. If several
procedures are being done at once then general anesthesia
is the better option. This will be discussed during your consultation
with a plastic surgeon and the anesthesia team.
After
the procedure
The procedure itself will take about 2 hours. If other procedures
are also being done then, obviously, the operative time will
be longer.
Immediately. Right after the operation you
will be watched by a nurse for 1or 2 hours and encouraged
to walk around. You will be given as much pain medication
as necessary both immediately after the operation and for
the next 4 to 5 days. You will have dressings around your
eyes as well as ice packs to reduce swelling. It is very important
that you keep your head elevated to decrease swelling. Still,
you can expect that your eyes will swell up and there will
be bruising. You will be able to eat and drink when you get
home.
That evening. It is recommended that you
take it easy. You can walk around, eat, but not much more. You should take as much pain medication as necessary and try
to go to sleep early. It is very important to keep your head
up the first 3 days. This will markedly decreased the swelling
and bruising. The eyes tend to swell and bruise quite easily,
so do not be concerned by this. It will go away.
First 48 hours. You can take a shower the
day after. Just be gentle. Do not use hot water. Allow cool
water to hit your scalp and then trickle over your eyelids. Do not wash your eyelid with anything, merely, allow water
to trickle over it. Afterward, dab dry. Mild oozing will continue
for about two to three days. Dressings are not necessary after
the first day. Your first post operative appointment with
your doctor will usually be 1 week after surgery.
First week. At about day 3, the swelling
will be at its maximum. The majority of the bruising and swelling
will go away in about 2 to 3 weeks. It is not uncommon for
the lower lid to start to pull downward the first few weeks
after eyelid surgery. Do not be concerned. This is normal. It will go back up as healing occurs.
Beyond. Swelling will not completely resolve
for about 6 months but, as mentioned above, the majority of
it will be gone by 2 weeks. The final result will not be evident
until at least 3 to 6 months when all the swelling has resolved
and skin contraction is complete. Patients who have fat transplantation
tend to swell more.
Recovery
time
Usually, people are off work for about 1 to 2 weeks depending
on how self-conscious a patient is about the swelling and
bruising. Once again, patients who have had fat transplantation
tend to take longer for the swelling to subside.
 Consultation
For Lower Eyelid Surgery
We have outlined below what you can
expect from your lower eyelid consultation. Read carefully,
as there are many suggestions that will save you time,
clear up questions, and help you convey to your plastic
surgeon what it is you want to accomplish.
Health History
All cosmetic surgery consultations
begin with a thorough health history. This is especially
true if general anesthesia is being used but also applies
to local anesthesia. Prior to meeting with the plastic
surgeon you will be given a health
history questionnaire. There are five areas of
your health you will be asked about. Be sure to answer
it with detail so that your surgery and anesthesia can
be optimized for you.
General health problems are important
to discuss so that your surgery is as safe as possible.
Be sure to mention any chronic illness. Of particular
concern are high blood pressure, diabetes, heart problems,
liver and kidney disease, stroke, cancer, bleeding problems,
and wound healing problems.
What will the plastic surgeon
do if I have medical problems?
In short, he/she will make sure
your health is optimized as much as possible to ensure
your safety. This may mean referring you to your private
physician.
If you have
a health problem or are over 50 years of age you can
often save yourself time by getting a letter from your
private physician prior to your cosmetic consultation
stating what the problem is, how it is being treated,
and whether or not you are able to tolerate general
anesthesia safely.
If you are
seeing any specialist (cardiologist, kidney doctor,
psychiatrist, etc. ) be sure to bring a letter from them
stating you are able to tolerate surgery.
If you are not able to tolerate
general anesthesia it may be possible for your procedure
to be done under local anesthesia. This must be discussed
with your plastic surgeon.
On your questionnaire you will
be asked about previous surgeries.
Be sure to identify any problems you may have had with
anesthesia. Of particular concern are previous
cosmetic surgeries especially if you do not like the
result and are interested in revision.
Be sure to list all medications
including aspirin and over-the-counter medications.
These are important as they may increase bleeding and
affect your surgery. It is extremely important to stop
taking aspirin and aspirin containing products at least
10 days before surgery. Tylenol is a good alternative.
Here is a partial list of aspirin containing products and other products
to be avoided prior to surgery.
Information about medications
that cause allergies is very important so that these
medications can be avoided. Of particular importance
is the reaction you had, especially if you had trouble
breathing. Be sure to include this information!
Nausea is not an allergy but it is important to
mention as well.
These there will certainly affect
your surgery and MUST be mentioned so that your surgery
can be optimized. Smoking causes a profound decrease
in wound healing and will lead to worse scarring and
a less favorable result. With
large procedures such as a face lift, neck lift, tummy
tuck, and breast lift smoking must be stopped at least
2-3 weeks before and after surgery. Otherwise, the
results could be disastrous leading to non-healing wounds,
poor scarring, and/or infection. With smaller
procedures such as eyelid surgery, nose surgery, breast
augmentation, and liposuction smoking will hurt the
overall result but this may or may not be noticeable.
In this case smoking cessation is strongly advised but
is not mandatory.
Specific
Eye Issues
During your consultation you must
be very accurate with your eye problems. These include
glaucoma, lazy eye, retinal problems, and cataracts.
Of particular concern is Dry Eye.
Dry eye is characterized by frequent blinking, red eye,
itching and burning. It is important because it can
made worse by eyelid surgery especially if proper measures
such as canthopexy or canthoplasty are not taken.
Patients with thyroid disease must
be particularly careful with eyelid surgery as it can
cause dry eye and/or persistent swelling if it is not
controlled. Therefore, it is important to bring
documentation of your last thyroid function test
to your consultation as this will be a requirement prior
to surgery.
What Do You Want To Change?
It is important that you have a
clear idea of what you want changed when you go for
consultation. The least favorite thing a plastic surgeon
wants to hear is "what do you think I need done. "
Look in a mirror and identify what
bothers you. Be specific. It may be helpful to look
back at younger pictures to see if that problem always
existed or if it is part of aging. Bring
the picture as it may be helpful.
Physical
Exam
The exam can be broken up into
5 anatomic parts that make up the lower eyelid. During
your consultation your plastic surgeon will examine
each part individually and determine which of them needs
to be changed to obtain the desired result.
Do you have an excess of skin?
Usually, this will result in wrinkles. If so, then
skin removal may be needed.
How is your skin texture. If you
have dark circles or age spots then some type of textural
rejuvenation will be necessary such as laser
or a chemical peel.
Often, proper skin care with Retin-A and/or glycolic
acid will help tremendously. Other types of treatment
such as IPL, and micro-dermabrasion are helpful but
often take many treatments. They will not obtain the
significant improvements that laser and chemical peeling
can but they also do not have as much, if any, down
time.
The orbicularis oculi muscle is
right under the skin. It is responsible for the wrinkles
around the eye that occur with smiling. As we age this
muscle sags and give a tired appearance often leaving
"circles under the eyes. " When this is present, resuspension
of this muscle is necessary.
There are two types of fat related
to the lower eyelid. The first is located just under
the eyelid. During aging this fat often bulges out
and causes "bags. " If "bags" are present there are
two ways to get rid of them. The most common way is
to map out exactly where they are and cut them out during
a lower blepharoplasty. If the bags are not severe
then they can be flattened by resuspension of the orbicularis
muscle.
The second fat related to the lower
eyelid is the cheek fat. This fat often descends with
aging. This leads to loss of cheek height and the characteristic
signs of cheek aging. As the fat descends it causes
the nasolabial folds to get bigger. Correction of this
problem is accomplished either by a face lift or by
a cheek lift performed through the same incision as
the lower blepharoplasty. A cheek lift is done by elevating
the orbicularis muscle and cheek fat as a unit back
up to where they once were.
A third modification of lower eyelid
fat can be performed by fat
transplantation. This is done by harvesting fat,
usually from the abdomen, and injecting it directly
where it is needed. This is described in more depth
in the section fat
transplantation
The bone is rarely modified but
it always must be taken into consideration during lower
eyelid surgery.
Note how far forward the cheek
bone is on the patient on the left compared to the patient
on the right. The patient on the right is much more
difficult to treat because she does not have much cheek
support under her lower eyelid. This patient will definitely
need lower eyelid support if she has a lower blepharoplasty.
This support is obtained by resuspending the orbicularis
oculi muscle or by resuspending the lower lid itself
by a canthoplasty, or both.
Bone modification can be performed
by implants. The most common implants are silicone.
Cheek implants are very effective in cheek augmentation.
The fifth part of the lower eyelid
exam is the position and laxity of the lower eyelid.
This is extremely important.
Normally the lower lid position
is just touching the colored portion of the eye (the
iris). If it is below this then lower lid support is
necessary by tightening it via a canthoplasty.
Another important factor is laxity
of the lower lid. If a lower blepharoplasty is performed
on a loose lower eyelid without supporting it, then
the lower eyelid will certainly droop after the procedure
leaving a "hound dog" appearance. Laxity can be determined
via the "snap back" test. This is done by pulling the
lower eyelid away from the eye ball. Without blinking
the lower eyelid should "snap back" against the eye.
If it takes a few seconds or does not occur until you
blink then you know that lower eyelid tightening is
necessary.
Putting it all together
As you can see, lower blepharoplasty
is not simple. This is why it is imperative that you
have it done by an experienced Board Certified Plastic
Surgeon. All the factors above must
be taken into consideration in order to achieve the
desired results safely.
Typical Incisions
Consultation
For Upper Eyelid Surgery
We have outlined below what
you can expect from your upper eyelid consultation.
Read carefully, as there are many suggestions that will
save you time, clear up questions, and help you convey
to your plastic surgeon what you want to accomplish.
Health History
All cosmetic surgery consultations
begin with a thorough health history. This is especially
true if general anesthesia is being used but also
applies to local anesthesia. Prior to meeting with
the plastic surgeon you will be given a health
history questionnaire. There are five areas of
your health you will be asked about. Be sure to answer
it with detail so that your surgery and anesthesia
can be optimized for you.
General health problems are important
to discuss so that your surgery is as safe as possible.
Be sure to mention any chronic illness. Of particular
concern are high blood pressure, diabetes, heart problems,
liver and kidney disease, stroke, cancer, bleeding
problems, and wound healing problems.
What will the plastic surgeon
do if I have medical problems?
In short, he/she will make sure
your health is optimized as much as possible to ensure
your safety. This may mean referring you to your
private physician.
If you
have a health problem or are over 50 years of age
you can often save yourself time by getting a letter
from your private physician prior to your cosmetic
consultation stating what the problem is, how it is
being treated, and whether or not you are able to
tolerate general anesthesia safely.
If you
are seeing any specialist (cardiologist, kidney doctor,
psychiatrist, etc. ) be sure to bring a letter from
them stating you are able to tolerate surgery.
If you are not able to tolerate
general anesthesia it may be possible for your procedure
to be done under local anesthesia. This must be discussed
with your plastic surgeon.
On your questionnaire you will
be asked about previous surgeries. Be
sure to identify any problems you may have had with
anesthesia. Of particular concern are previous
cosmetic surgeries especially if you do not like the
result and are interested in revision.
Be sure to list all medications
including aspirin and over-the-counter medications.
These are important as they may increase bleeding
and affect your surgery. It is extremely important
to stop taking aspirin and aspirin containing products
at least 10 days before surgery. Tylenol is a good
alternative. Here is a partial list of aspirin containing products and other products
to be avoided prior to surgery.
Information about medications
that cause allergies is very important so that these
medications can be avoided. Of particular importance
is the reaction you had, especially if you had trouble
breathing. Be sure to include this information!
Nausea is not an allergy but it is important to
mention as well.
These there will certainly
affect your surgery and MUST be mentioned so that
your surgery can be optimized. Smoking causes a
profound decrease in wound healing and will lead
to worse scarring and a less favorable result.
With large procedures such as a face lift, neck
lift, tummy tuck, and breast lift smoking must be
stopped at least 2-3 weeks before and after surgery.
Otherwise, the results could be disastrous leading
to non-healing wounds, poor scarring, and/or infection.
With smaller procedures such as eyelid surgery,
nose surgery, breast augmentation, and liposuction
smoking will hurt the overall result but this may
or may not be noticeable. In this case smoking
cessation is strongly advised but is not mandatory.
Specific
Eye Issues
During your consultation you must
be very accurate with your eye problems. These include
glaucoma, lazy eye, retinal problems, and cataracts.
Of particular concern is Dry Eye.
Dry eye is characterized by frequent blinking, red eye,
itching and burning. It is important because it can
made worse by eyelid surgery especially if proper measures
such as canthopexy or canthoplasty are not taken.
Patients with thyroid disease must
be particularly careful with eyelid surgery as it can
cause dry eye and/or persistent swelling if it is not
controlled. Therefore, it is important to bring
documentation of your last thyroid function test
to your consultation as this will be a requirement prior
to surgery.
What
Do You Want To Change?
It is important that you have a
clear idea of what you want changed when you go for
consultation. The least favorite thing a plastic surgeon
wants to hear is "what do you think I need done. "
Look in a mirror and identify what
bothers you. Be specific. It may be helpful to look
back at younger pictures to see if that problem always
existed or if it is part of aging.
Bring the picture as it may be helpful.
Common complaints are wrinkles,
excess skin, droopy upper eyelids, excess fat, loss
of upper eyelid height, and saggy eyebrow.
Physical
Exam
The upper eyelid exam can be broken
up into 5 anatomic parts that make up the upper eyelid.
During your consultation, your plastic surgeon will
examine each part individually and determine which needs
to be changed to obtain the desired result.
Do you have an excess of skin?
Usually, this will result in a
loss of vertical height of the upper eyelid leaving
an eyelid that is not capable of makeup application.
Sometimes, the redundancy is so pronounced that the
skin drapes over the eyelid and can impair vision especially
when looking upward. Skin excision of the upper eyelid
is almost always necessary as we age.
How is your skin texture. If you
have dark circles or age spots then some type of textural
rejuvenation will be necessary such as laser
or a chemical
peel. Often, proper skin care with Retin-A and/or
glycolic acid will help tremendously. Other types of
treatment such as IPL, and micro-dermabrasion are helpful
but often take many treatments. They will not obtain
the significant improvements that laser and chemical
peeling can but they also do not have as much, if any,
down time.
There are 2 types of fat that are
evaluated in the upper eyelid. The first is located
along the medial aspect toward the nose. This fat used
to be routinely removed but plastic surgeons learned
that this can leave the upper eye with a "hallowed-out,"
and old appearance. However, if this area is bulging
then some fat removal is necessary.
The second type of fat is located
laterally toward the temple. This fat can be either
eyelid fat (often seen in Asians) or can be eyebrow
fat that has fallen into the eyelid region. Proper
evaluation can determine the difference in origin.
Regardless, it is often necessary to remove this fat
in order to "clean up" the lateral aspect of the upper
eye. Once again, there was a time when plastic surgeons
routinely removed all this fat but this is no longer
the case. Complete removal can lead to a "hallowed
out" appearance just like it can medially. If you look
at an adolescent, you will see plenty of fat. Fat is
youthful and must be removed only as needed.
The position of the upper eyelid
must be evaluated. Typically, the upper eyelid should
overlap the colored portion of the eye (the iris) by
2mm.
People with thyroid disease (Graves
Disease) often have no overlap or may even show some
white above the iris. It is important for the plastic
surgeon to pick this up as it may significantly affect
the patient's health by early detection.
With aging, it is not uncommon
for the upper lid to droop lower. This is because the
muscle that elevates the lid weakens or tears. In youth,
this is referred to as "bedroom eyes," but as we age
it gives us a tired and aging expression.
Show ptotic eye example
Seen above is an example of unilateral
eyelid droopiness. This demonstrates that it can happen
even in young people. Correction requires repairing
the weakened muscle.
The forth part of the lower eyelid
exam is the position and laxity of the lower eyelid.
This is extremely important. In reality, it is actually
the first thing that the plastic surgeon will evaluate.
It is very common that someone will consult for an upper
blepharoplasty when what they actually need is a brow
lift.
Show Ray Rose
Shown above is an example of a
man who requested upper eyelid cosmetic surgery. He
was told that this was what he needed. In reality he
needed a brow lift in conjunction with an upper blepharoplasty.
He refused the brow lift. In the before picture, it
is clear that the patient is using his forehead muscles
to elevate the brow. This is why his forehead is wrinkled.
He has to do this so that the upper eyelid skin does
not hang over his eyes. Once the upper eyelid skin
is removed, the eyebrow relaxes allowing it to fall
farther. Notice how his eyebrows are lower and he still
has redundant upper eyelid skin. A brow lift would
have solved the problem.
See the section on Brow
Lift for more information
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