When you look at a person your attention is drawn to their face and particularly their eyes. A person's eyelids, brows and cheeks are designed to convey emotions. Your face can appear tired or vibrant and energetic. Blepharoplasty is intended to produce a more youthful appearance.
Upper lid blepharoplasty surgery reduces the fold of eyelid skin and fat that hides the skin above the eyelashes. The visible skin between your eyelashes and eyelid crease is called the "eye shadow space." In females, make-up or eye shadow is normally applied in this area. A high "eye shadow space" is desirable. The height of the eye shadow is space is determined by the height of the lid crease and how much excess skin and fat hangs over the crease. Therefore, blepharoplasty creates a high crease and reduces the excess skin and fat.
Most males do not desire a high "eye shadow space" but wish to appear more masculine. However, a small visible area of smooth skin above the lashes is necessary to convey a youthful appearance.
The goal of upper lid blepharoplasty is not to simply remove excess skin but to reshape the lid.
If more skin is removed than necessary the eye brows can be pulled downwards. More importantly, if too much skin is removed difficulty closing the eyes and dryness of the eyes can occur. As an ophthalmologist, the health of your eyes is the most important factor in planning surgery. Some patients may feel that not enough skin has been removed. If safe, a touch-up can be performed in the office. However, if more skin is removed initially than is safe it is difficult to replace additional skin.
The eyebrows are the "curtain rods" of the eyelids. By raising and lowering your brows you can change the amount of visible "eye shadow space." Lowering the brows increases the amount of redundant skin which will hang down below the lid crease and cover the "eye shadow space." Therefore, it is important to address the brows when considering upper lid blepharoplasty. If a person has loose brows removing eyelid skin will simply pull the eyebrows downwards. The person will not have a more visible "eye shadow space" but will have cosmetically undesirably lower brows.
In addition, raising the brows helps create a friendlier appearance. During an endoscopic brow lift prominent furrows between the brows can also be reduced.
There are essentially three techniques to address brow laxity.
1. Internal Browpexy - The simplest procedure, internal browpexy fixates the lateral eyebrow above the bony rim around the eye. This procedure does not require an additional skin incision. Internal browpexy is used for those with mainly lateral brow laxity causing hooding over the outside corner of the eye. Internal browpexy may also be used to fixate eyebrows which are asymmetric or only slightly lax.
However, internal browpexy can cause some dimpling and folding of the skin above the outside corner of the brows. In addition, the area of fixation is often tender for a few months. Internal browpexy cannot be used to raise the inner eyebrows near the nose.
2. Endoscopic Brow Lift - In an endoscopic brow lift small incisions are made in the scalp above the hairline. Through these small incisions various instruments are introduced which partially remove the muscles which lower the brow. These muscles are located between the eyebrows and produce vertical furrows, called glabellar folds. Besides raising the brows, removing these muscles reduces these glabellar folds. The forehead and eyebrows are then pulled upwards and fixated with small screws which are removed in one to two weeks.
Because the nerves which supply feeling to the forehead run through the brows, patients will notice numbness of the forehead after surgery. This numbness usually improves or resolves with time.
Of necessity, an endoscopic brow lift raises the hairline. This is usually not a problem in females but prevents the use of this procedure in many males.
3. Direct Brow Lift - A direct brow lift is performed by excising skin just above the brow and fixating the brows at a higher position. This procedure does not raise the hairline and, therefore, is usually performed in males.
While very effective, a direct brow lift leaves a visible scar. In addition, it is difficult to avoid producing an arched brow with a surprised appearance. Forehead numbness may also result.
Lower lid blepharoplasty is used to reduce the puffiness and extra skin folds in the lower lids and mid-face in order to produce a more energetic, youthful appearance.
With aging, several changes occur in the lower lids and mid-face. Fat pads protrude producing lower lid puffiness. Both fine and hard wrinkles appear in the lower lids. In addition, the soft-tissues of the cheek droop producing a tear trough deformity and prominent nasolabial fold.
During a lower lid blepharoplasty the protruding fatty tissue is removed and the loose eyelid skin is redraped and trimmed in order to smooth the lower lid. A mini-cheek lift is performed through the same incision and lifts the cheek reducing the tear trough deformity, accentuating the cheekbone and reducing the prominence of the nasolabial fold.
Skin Changes
Please note that lower lid blepharoplasty will not effect skin pigmentation or hard ingrained wrinkles. Chemical peels or laser skin resurfacing are useful for improving the texture and coloration of the skin.
Behind the Lid Fat Removal
If you have only protruding fat pads without skin laxity, a technique can be performed in which the incision is made behind the lower eyelids to remove excess fat. This procedure does not produce a visible scar. However, this technique willl not tighten the skin folds in the lid or raise the cheeks.
Some physicians combine a behind the lid fat removal with a skin resurfacing procedure. However, no lifting effect on the cheeks is possible.
Lower Lid Blepharoplasty with Mini-Cheek Lift
This technique reduces excess fat, tightens the skin of the lower lid, and lifts the soft tissue of the cheek.
An incision is made across the lower lid just under the lashes continuing into the skin at the outside corner of the eye in the laugh lines. Excess fat is then removed. The lower lid is then tightened to prevent a "round-eye." The "round-eye" syndrome can be produced by pulling down the lower lid margin during a lower lid blepharoplasty in which excess skin is simply removed without redraping or lid tightening. The soft tissue of the cheek is then raised. By raising the soft tissue vertically a more natural appearance is produced than by the lateral tightening caused by a standard face lift. The skin of the lower lid is then redraped and trimmed.
The incision at the outside corner of the eye is constructed to blend with the laugh lines.
However, the scar produced can be noticeable. Dermabrasion or scar revision is occasionally indicated.
Tenderness at the eyelid corners and at the site of the cheek resuspension can result but usually resolves with time.
1. Will insurance pay for these procedures?
Health Insurance companies will reimburse procedures which are functionally necessary. In general, if the skin of the upper lid actually interferes with your vision, upper lid blepharoplasty may be reimbursed. In order to obtain insurance reimbursement we must submit photos and visual fields documenting interference with visual function for preauthorization prior to surgery.
Lower lid blepharoplasty and brow lifts are almost never covered
by insurance.
2. Can these procedures be performed in the office?
Yes, all of the procedures covered above, except for endoscopic brow lift, can be performed in the office. Endoscopic brow lift must be performed in the hospital and is usually performed under general anesthesia.
However, you may prefer to have your procedure performed in the
hospital under sedation or general anesthesia. Please note, I do not perform an upper and
lower lid blepharoplasty in the office during the same session. The time required is too
much for most people to tolerate without sedation. Of course, the procedures can easily be
combined if you are sedated in the operating room of the hospital.
3. Are there risks and complications associated with these procedures?
Yes, all surgery has risks. Results are not guaranteed. The following is not a complete list of possible complications.
Eye lid surgery can result in asymmetry, bruising, infection, undesirable scarring, excess residual skin, rounding of the lower lid and the need for additional procedures.
The upper lids will be tight after surgery and difficulty closing the eyes and dryness of the eyes may be produced. This may require the use of lubricating drops or ointments. Revision may be necessary.
In rare cases, excess bleeding can result in visual loss or even blindness.
IF YOU HAVE ANY QUESTIONS OR CONCERNS PLEASE
CONTACT DAVID S. GOLDBERG, M.D.
AT (610) 378-1344
Fig. 1, Fig. 2, Fig. 4 and Fig. 5 from Eyelid Surgery; Principals and Techniques by Clinton McCord, Jr., M.D., published 1995 by Lippincott-Raven. Used by permission.
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