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Eyelid Surgery Upper



Overview

Before & After

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.

 

In the attractive, youthful eye lid, the lateral canthus should be higher than the medial canthus. With age the brow and lateral canthus sag.

Aging affects the entire face. Aging around the eyes, however, is usually the first area that is noticed. 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 do not think of aging as involving the latter two structures but, in reality, these are probably the most important ones. 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 eye region. As we age, the fat will either descend downward 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.

 

Youthful Upper Eye. Notice well defined eye lid crease
Aged Upper Eye. Notice descent of eye brow and lateral canthus

 

 

 

 

 

The following pictures show anatomically what happens to the muscles around the eye with aging.

 

Aged Eyes. Notice the drooping of the eye brow and lateral canthus
Youthful Eyes. Muscles around the eyes are circular in shape.

 

 

 

 

 

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 why it is so important to correct the problem itself and not just the effects of the problem.

When evaluating the upper eyelid there are three important components of the upper eye region that must be considered. The eyebrow, the upper lid itself, and the lateral canthus. Typically, these three areas sag at different rates and, therefore, each patient must be assessed individually.

Most patients need removal of fat and skin to create an elegant upper eyelid crease.

Reconstructive Surgery Eyelid Surgery
Example of 43 year-old female who only needs skin and fat removal
Reconstructive Surgery Eyelid Surgery
Lateral view of same woman. Notice defined upper lid crease.

 

 

 

 

 

Other patients need elevation of the lateral canthus in addition to removal of fat and skin.

 

Example of 48 year-old female who needs left lateral canthus elevated in addition to skin and fat removal
Latheral view of same patient. Notice how elevating the lateral canthus gives almond shape appearance to eye.

 

 

 

 

Descent and laxity of the lateral canthus is a major contributing factor to the appearance of old age within the eye region. This sagging gives a depressed, tired appearance. The upper eyelid of youth has a bright, open appearance. Of particular note is the fact that the lateral canthus should be higher than the medial canthus. Often, he will elevate the lateral canthus in conjunction with the upper blepharoplasty to re-create that youthful, almond-shape appearance. See above.

Others need correction of all three elements comprising the upper eye: The eyebrow, the eyelid, and the lateral canthus.

 

Example of 38 year-old female who complains of persistent tired appearance. She required a browlift and lateral canthoplasty in addition to removal of excess skin an fat to achieve desired result.
Lateral view of same woman. Notice how the eye has become youthful and elegant.

 

 

 

 

 

 

Sometimes plastic surgeons will perform a Temporal Brow Lift instead of a conventional brow lift when he does upper blepharoplasty. This is much less invasive, yet, still effective. The Temporal Brow Lift only addresses the temporal area but this is usually what needs elevation the most. The decision as to what is best for you can only be determined during consulation.

There is a forth potential problem area when addressing the upper eyelid that is not talked about much and often goes unaddressed. This is eyelid ptosis, also know as, descent of the upper eyelid. See example below.

 

Example of 26 year-old female six weeks before her wedding. She complains that her left eye(right side of picture) was lower than her left. Notice in the BEFOR how the left upper eyelid touches the pupil, whereas, the left eye is wide open and bright. Also notice difference in eyelid height. After shows both lids at the same level and similar eyelid height.

Eyelid ptosis becomes quite common as we age. The muscle that elevates the upper lid simply breaks off and the lid lowers. It may be one side or both. It gives the appearance of a chronic tired eye. Correction opens the eye and gives a brighter, more awake appearance.

The take home point to all this information is that there are several elements of the upper eyelid region that must be evaluated during and upper blepharoplasty exam.

It is important to understand the limitations of upper blepharoplasty. An upper blepharoplasty alone will not correct crow's feet. It will help but often a concurrent brow lift or temperal brow lift is necessary. Often, Botox®&reg may also be helpful.

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 the plastic surgeon to address all the components associated with aging around the eye. 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.

Upper eyelid surgery benefits.

  • Removes excess fat and skin of the upper eyelid.
  • Creates a sculpted, 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 temporal browlift or formal brow lift can can be performed at the same time.

Are you a good candidate?

Most people as they age can obtain improvement from upper eyelid surgery. Specifically, good candidates include people with the following problems around the eyes:

  • Excess skin and fat within the upper eyelid
  • Sagging of lateral eye brow if temporal brow lift is also done.
  • Sad or tired appearance of upper eyes.
  • People who desire an elegant, well defined upper eyelid crease.
  • Asians who desire a double eyelid.
  • Crow's feet within the lateral eye area.
  • Sagging of lateral canthus giving hound dog appearance.
  • Ptotic eyelid that make the upper lid appears tired.

Possible complications

The most common complication is inadequate correction of the problem or asymmetry. If this is the case, correction can usually be made with a minor additional procedure. One must understand that complete symmetry is not possible. Nobody is completely symmetrical. Sometimes, the underlying bony structure is so different from one side to the other that symmetry can not be achieved.

Complications that can occur with any surgery include infection, blood or fluid collection, and unfavorable scarring.

Do's and Don'ts prior to surgery

  • Medications. Certain medications thin your blood and should not be taken within three 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 yoru 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. Remove all jewelry including wedding rings and body piercings.

  • Arrival. It is best to arrive on time so things go smoothly. Please be sure to have someone else drive you.

  • State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned.

Anesthesia

ICRS uses only board certified anesthesiologists to make sure you have the best anesthesia possible. The anesthesiologist will discuss with you what type of anesthesia is best for you. 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 1 - 1 1/2 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 1 or 2 hours and encouraged to walk around. 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. Eyelid surgery is usually not painful. Still, 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. If oral steroids are prescribed be sure to take them as they help decrease swelling significantly.

  • 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. You can gently wash with soap but do not rub. Mild oozing will continue for about 2 to 3 days. Dressings are not necessary after the first day. Your first post operative appointment with your plastic surgeon will usually be one week after surgery.

  • First week. At about day 2, the swelling will be at its maximum. The majority of the bruising and swelling will go away in about 2 to 3 weeks.

  • 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 Upper 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

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.

  • Past Surgical History

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.


  • Medications

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.

  • Allergies to Medications

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.

  • Smoking, Drinking and Drug Use

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.

There are 4 things that you should look at regarding your upper eye lid that may need to be treated.

1) Sagging eye brow.

2) Excess skin and/or fat of upper eye lid.

3) Sagging lateral canthus.

4) Droopy upper eyelid.

Physical Exam

1) Eyebrow Position

The upper eyelid exam starts with evaluating eyebrow position. There are two main characteristics to look at. These are demonstrated in the picture below. The first one is the most important; the relationship of the medial brow to the lateral brow. The lateral brow should be at the level of or higher than the medial brow.

Two, the brow should be at the level of the orbital rim in men and 1/4 inch above the orbital rim in woman.

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Notice that the lateral portion of the eyebrow is well above the level of the medial eyebrow.

Notice the dramatic effect of elevating the lateral brow.
Eyebrow position has a dramatic effect on the appearance of the eye region. Elevating the lateral brow creates an elegant, youthful look. During your consultation, your doctor will most likely elevate your lateral brow with his fingers to get an idea how much laxity is present and, or course, to see what you would look like with it elevated. You can do this yourself. Simply elevate the temple region gently.

Usually, a formal brow lift is not necessary. A plastic surgeon can often obtain lateral brow elevation by combining the upper blepharoplasty with a temperal brow lift. This requires a small incision right at the hairline of the temple.

2) Excess Skin and/or Fat of the Upper Eyelid

  • Skin

This is what most patients complain about because it is the most obvious. With age, excess fat/skin 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 excess occurs in just about everyone with age.

  • Fat

There are two types of fat that are routinely removed by plastic surgeons during an upper blepharoplasty. The most obvious fat is the fat that you can pinch between two fingers. This fat descends from the brow area with age. Usually it is quite thick and located just below the lateral eyebrow.

The second fat is deeper. It normally lies along side the eyeball itself. With age, it tends to bulge outward. It is very common in Asians.

Both types of excess fat are present in this 47 year-old female.
Here one can clearly see the thick fat just below the lateral eyebrow. This fat once lived at or above the eyebrow level.

 

 

 

 

 

 

Proper evaluation can determine the two different types of fat. Regardless, it is often necessary to remove both types in order to clean up the upper eyelid. 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 especially toward the nose. If you look at an adolescent, you will see plenty of fat. Fat is youthful and must be removed only as needed.

Asians typically require a more aggressive fat removal. With them, almost all the fat is removed to achieve the desired result.

 

3) Sagging Lateral Canthus

This is one problem that many plastic surgeons fail to recognize and treat. In youth, the lateral canthus is 2-3mm higher than the medial canthus. This is exemplified in the picture of the ideal eyelid above. As we age, this elevation is lost resulting in what many call a hound dog appearance.

Below is an anatomic depiction of the descent of the lateral canthus.

 

Youthful Eye Muscles
Aged Eyes. Notice the drooping of the lateral canthus

 

 

 

 

 

 

Below is a excellent clinical example and treatment of a patient with descended lateral canthus creating hound dog appearance. Notice how this is usually also associated with a descended lateral eyebrow.

 

38 year-old female with descended lateral canthus and lateral eyebrow.

4) Eyelid Ptosis

This is another upper eyelid problem that many plastic surgeons fail to diagnose and treat. Eyelid ptosis simply means that the upper eyelid sags. In cosmetic patients the most likely causes is 1) The upper eyelid fat is pushing it down. Here fat removal will take care of the problem or 2) The muscle attaching to the upper eyelid has torn. This is more complicated to treat but still can easily be done at the same time as an upper blepharoplasty.

 

Normally, the upper eyelid well above the pupil.

With eyelid ptosis, the upper eyelid falls to the level of the pupil. This gives a tired appearance and increases the vertical height of the eyelid on that side. People notice the asymmetry. Sometimes both sides have ptosis and, therefore, the asymmetry is not as noticable but the eyes appear almost shut.

26 year-old female complains that her left eye(right side of picture) was lower than her left. Notice how the left upper eyelid touches the pupil, whereas, the left eye is wide open and bright. Also notice difference in eyelid height. AFTER shows both lids at the same level and similar eyelid height.

 

  • Typical Incisions

 

The amount of skin removal depends on the amount of excess skin present. Here is a typical upper blepharoplasty excision. The end result is a straight line the becomes almost impossible to see after 3-4 months.