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Eyelids
The eyelids are
frequently the first facial area to show signs of
aging, resulting in a tired, sad appearance. This
causes patients concern because the eyes are usually
the first feature that we notice in a person’s face.
The problem tends to be excess skin in the upper and
lower eyelids. Or it could be an accumulation of
fat, causing "baggy" eyelids. Many times this
tendency may be hereditary and can be seen at an
early age. It can also be seen in people with
allergies and those who suffer from fluid retention.
Initially, the bags may only be noticeable when
first getting up in the morning. As the problem
becomes more severe, this puffy look may persist
throughout the day. An additional cause may be the
attachment of the skin to the upper eyelid muscle.
With aging there may be significant disruption of
this attachment, causing a lax, tired look.
A point should be
made clear here. The bags under the eyes and
fullness above the eye are not caused by excess fat.
They are caused by loss of tone of the supporting
structures of the fat that is normal and has a
function in that part of the body. If a skull is
looked at, the orbits (area where the eyes belong)
are large. That space is filled with the eyeball,
the muscles that move the eye and the substance that
our body uses as lubricant for those muscles – fat.
The retaining ligaments holding this fat back get
lax with age and certain physical conditions. They
can be likened to a dam holding back the fat. When a
dam starts to leak, there is little to be gained by
removing some water from behind; it makes more sense
to fix the dam. In the old days, a great deal of fat
was removed during blepharoplasty. This resulted in
a very hollow and more aged look to the eye area
either immediately or, certainly, as fat normally
atrophies with age, a skeletal look as the person
got older. Today, the fat is removed in smaller
quantities or it is repositioned to give a more
natural and younger look to the eye. The retaining
ligaments are also tightened to give a beautiful
sweep to the eye. This can even be exaggerated in
those so desiring it.
Eyelid surgery does not
remove the small creases around the eyes ("crows
feet"). It also will not correct the posture of the
eyebrows and any contribution that this area has to
a "tired look" should be addressed first. The reason
for this is simple. Say, for example that an
individual has some mild descent of the eyebrows. He
goes to a physician who does not recognize this and
an upper eyelid procedure is performed. The brows
then continue to descend and, when it comes to be
recognized that this is a major contribution to the
tired look, too much skin has been removed from the
upper eyelid and, when the brows are repositioned,
there is not enough skin to allow the eye to close
completely. Hopefully, this would be recognized
before the brow procedure is done.
Upper eyelid
blepharoplasty is a relatively easily performed
surgical procedure. For this reason, many different
types of doctors with different training perform it.
You must make certain that your surgeon has an
excellent knowledge of the aging of the entire face
and certainly the forehead and eye region. In many
instances an upper eyelid procedure is the wrong one
to perform first but, because of inexperience or
inability to perform the correct procedure, it is
done first. Sometimes things cannot be corrected
when done improperly or for the wrong reasons.
Procedure
Surgery on the
upper eyelids involves an incision made in the fold
of the lid. This incision is almost invisible in
almost all individuals. If there is no lid fold or
ones that are too low, the fold can be repositioned
or made at the time of surgery. The Asian "double
lid" procedure is done in this way with a
specialized technique to create or raise the lid
fold to give still an Asian appearing eye, but one
with a fold. Most Asian people have upper eyelid
folds, they tend to be lower on the upper lid
compared to Caucasians. On the lower eyelid, if skin
has to be removed, the incision is made in a natural
crease directly below the eyelashes. More recently,
where bags need to be removed, an incision is made
on the inside of the lower lid to prevent any
visible scars. If skin tightening is required, this
can be done with a laser and, again, no scar is
present on the skin. Some bruising and swelling
occur in the upper and lower eyelids. This will
persist for seven to ten days. No bandages are
needed, and vision is unaffected.
The correction of a
drooping upper eyelid is a little more difficult and
delicate. It involves the reattachment of the muscle
that has stretched from its insertion in the upper
eyelid structure of support. The muscle can be
tightened to some extent and the open posture of the
eyes made more even. There are some conditions of
droop that cannot be corrected since they are caused
by nerve or muscle problems.
Ancillary Procedures
There are
many ancillary procedures to eyelid surgery. The
most common (or the one that should be performed
most commonly) is a procedure that raises the
posture of the outer portion of the eye. This is a
highly technical procedure and is termed a
canthopexy or canthoplasty depending upon what is
performed and needed. With aging, the lateral
(outer) corner of the eye often drops giving a sad
visage. This can be raised by the procedure
mentioned. It can only be done when there is little
skin lag over the area or this may be made worse.
For this reason, this is often coupled with a brow
lift procedure.
Another ancillary
procedure mentioned previously is laser resurfacing
to help the texture of the skin as well as tighten
it markedly. In many younger patients who require a
brow lift, the skin of the upper eyelid can be
tightened solely with the laser and, when the brows
are raised, this is enough to remove any skin excess
in the area.
Another ancillary
procedure is the removal of the medial epicanthus's
that is that fold of skin on the inner side of the
eye that, in severe cases, can actually cover the
inner corner of the eye. This is an Asian trait and
the improvement of this area is often coupled with
the double eyelid procedure. My comment is only that
both should be done in moderation.
The last ancillary
procedure is a major one. In some individuals, there
is a groove between the side of the nose and the eye
along the inner side of the cheek and, sometimes
down into it. This is called a nasojugal groove and
has lead to the great consternation among those of
us who try to repair this defect. It leads to a very
tired look to the eye that standard blepharoplasty
will not correct. There have been many attempted
ways of correcting this from fat injection to
implants to modified lower eyelid blepharoplasties.
There is an excellent anatomical way to correct this
problem that is called a mid-face lift. This is a
rather detailed procedure that is beyond the scope
of this book. Suffice it to say that it is a major
surgical procedure and that the healing time and
time of swelling is even longer than that for a
classical facelift. It does, however, correct the
problem.
Convalescence
After a week the patient
can use makeup to camouflage most of the residual
bruising. Strenuous activities are restricted for a
short time after surgery. The patient is not able to
wear contact lenses for several days after surgery
due to eyelid swelling.
Risks
The risks are
minimal in the right hands. There have been rare
cases of asymmetry of the eyelids (each eye not
exactly the same). This condition also exists with
those who have not had eyelid surgery. A rare
drooping of the eyelid can happen. When the muscle
tone in the much older patient is especially weak or
the lid has been stretched out, additional surgical
techniques are available to correct this problem. As
with any surgery, infection or bleeding can occur.
These problems are very rare. The removal of too
much skin (a rare occurrence) can result in
overcorrection, requiring additional surgery.
However, in the majority of patients, eyelid surgery
is very successful and provides removal of excess
skin and fat resulting in a rested and more youthful
appearance. In those cases where the hanging upper
eyelid skin is partially obstructing your field of
vision, the operation can actually improve you
ability to see.
Your eyes are most often
the first facial contact anyone makes in your
presence. Make sure they express the real you.
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