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Eyelid Surgery- A Plastic Surgeon’s Approach


I often consult with patients who have concerns about aging, heavy, tired-appearing eyes. After a review of their general and specifically eye-health history, we always discuss their principle areas of dissatisfaction. We can then apply today’s current technology to the problem. What I find most often is that patients want an "eye-job", but don’t understand what this entails. When we look at the youthful eye – What is it that is different from the middle-aged eye? First and foremost, we need to look outside the eyelid itself to eyebrow position. As we age, the brow begins a descent. This produces a tired, heavy, and perhaps more masculine appearance. This is particularly manifested at the corners of the upper eyelids where the crow’s foot fold can become significant. I often demonstrate to patients that their eyelashes are becoming close to their eyebrows with a full open eye. Many patients have begun to contend with this problem by chronically holding their brows in an elevated, corrected position. This activity alone can worsen the perception of eye fatigue by the end of the day. Next, the forehead itself should be considered. This is important because as we consider a correction to the brow problem, we don’t want to create another aesthetic deformity - the "too high forehead". So, if there is already a good distance from the eyebrows to the hairline, special consideration should be taken before performing a procedure which can increase this distance.

A word about the difference in evaluation between women and men. Whereas, I believe that some sort of brow procedure should usually be considered for women, it should rarely be considered in men. Brow position in men is naturally lower than in women. If this relationship is artificially altered to a substantial degree, it can look very unnatural or even odd. Some of our formally-best-looking male film stars have fallen into this trap. Suffice it to say that browlift surgery produces a more feminine look.

All this and we haven’t even begun to discuss the eyelid itself. As we age, the eyelid skin thins and sags. Additionally, the support structures surrounding the eye weaken and fatty bags can become more pronounced. This is particularly notable in the transition between the lower eyelid and the cheek. Many patients are candidates for removal of some of the skin, muscle and fat from the upper eyelid. Again, careful planning in terms of browlift is crucial. Consider this. If the need for browlift is unrecognized and an aggressive upper eyelid surgery is performed; then this may preclude a corrective browlift in the future. The eyelashes will be fixed near the eyebrows and a follow up browlift could have the catastrophic complication of limiting eyelid closure which leads to excess drying and direct damage to the cornea.

Lower eyelids are currently managed with muscular suspension type surgeries which have been very effective in facelift surgery for years. This modern approach preserves more eyelid fat and moves it to where it has been lost by the aging process. This produces a natural lasting result from a safer surgery. A good bargain.

The process of evaluation of the eyelid in terms of facial aesthetic surgery has many facets and pitfalls. Preoperative computer imaging is frequently helpful in demonstrating the surgeon’s vision and creating a mutually satisfying plan for intervention.