It is often the eyes that people focus on when they first encounter another person, and for many patients this is the first thing that they notice has changed as they age. Eyelid surgery is a great “eye-opener” and should not be confused with brow lift rejuvenation, although they are inter-related. The procedures around the eye are categorized under the heading periorbital rejuvenation. The youthful, natural looking eye is essential to provide harmony with the rest of the face, and eyelid surgery can be done in conjunction with other facial rejuvenating procedures. New York Plastic Surgeon Dr. Wallach recreates a natural looking youthful eye by treating the necessary fat and skin from the upper and lower lids. He tries to conserve as much of the soft tissue in and around the eye to prevent the “hollowed-eye” look, which is a sign of aging. If possible, Dr. Wallach will treat the lower eyelids using an incision on the inside of the lid. There are various methods for treating the eyes and they will be described below. The surgical procedure usually takes between one to two hours to perform with a recuperation period of about seven to ten days.
- Periorbital Rejuvenation
- Ancillary Procedures Approached Through The Upper Eyelid
- Lower Eyelid Rejuvenation
- Lower Lid- Cheek Problems
Upper Eyelid Rejuvenation
The upper eyelid area focuses on the inter-relationship between the brow and the upper eyelid. If the brow is too low, lateral excess of the upper eyelid region can be mistakenly assumed to be caused by excess upper eyelid skin when, in fact, many times it is caused by descent of the lateral eyebrow. When the brow is positioned in its ideal location, quite often there is little to no upper eyelid skin excess. This relationship is discussed thoroughly during consultation and then a plan is formulated to determine the best surgical approach. Sometimes an upper eyelid procedure is recommended with or without a brow lift. Since the upper eyelid also has two fat pockets, these may need to be addressed as well. The goal is to restore the youthful appearance of the periorbita without hollowing out the eye. A full upper eyelid is often the sign of a youthful appearance.
For some patients there is only skin excess and a simple crescent shaped excision is all that is necessary.
Skin And Muscle Excision
For patients with a poorly defined eyelid crease, sometimes a skin and muscle excision is performed. If Dr. Wallach needs to remove muscle, it is usually done conservatively. He does not like to remove muscle in most cases, because it may create a hollow eyelid look and cause the patient to appear older.
Skin And Muscle Excision Along With Fat Removal
There are two fat pockets in the upper eyelids: one centrally, and one medially (closer to the nose). If a patient has excess fat, loose upper eyelid skin, and a poorly defined eyelid crease, then some skin and muscle are removed along with the redundant fat. Usually this includes the medial fat only. On occasion, the central fat is removed conservatively. Dr. Wallach does not like to remove central fat in most cases because leaving this fat maintains fullness in the upper eyelid.
Double Eyelid Procedure
Often done for patients of Asian descent, the goal of this procedure is to create an eyelid crease that was not naturally present. There are numerous ways to do this including full incision, and partial incision techniques. Sometimes a medial epicanthoplasty is combined to open up the medial aspect as well. For more information regarding Double Eyelid Procedure, visit our blog.
Fat Injection, Fillers, And Neuromodulators
Non-invasive procedures using fat injection, absorbable filler products, and neuromodulators can affect the appearance of the eyelid. Fat injection is performed for permanent fill (See Fat Injection Section.) Injectable products like Restylane™, Restylane Lyft, and Juvederm™ (See Filler Section) can be used as well and last six months to a year. They can be used in the upper lid when the eyes appear a bit over-sculpted. They can also be used to raise the eyebrow when facial soft tissue atrophy has caused them to descend. Neuromodulators like Botox™ and Dysport can be used to help improve the position of the lateral brow and thus improve hooding.
Ancillary Procedures Approached Through The Upper Eyelid
A browpexy is a limited incision procedure that suspends the brow to the forehead. This can be performed through an upper eyelid incision. Often the brow is suspended with sutures, but it can also be done with mini-endotines. The endotine is a device that looks similar to a carpet tack and is secured to the outer portion of the skull. The brow is elevated and secured to the endotine to provide the brow elevation.
Corrugator Muscle Resection
The corrugator muscles cause the “11” lines between the eyebrows and can be treated from an upper eyelid incision. The muscles are located medially (centrally) toward the nose and can be removed to soften the “11” lines. Sometimes fillers are injected to soften the skin depressions created by the muscles.
Lacrimal Gland Resuspension
Sometimes a bulge is noted in the upper lateral eyelid. This is often caused by herniation of the lacrimal gland which is a gland that produces tears. Through an upper eyelid incision, the gland can be repositioned with sutures to the underside of the brow.
Procerus Muscle Resection
The procerus muscle is a muscle that contributes to transverse lines at the bridge of the nose, and these too can be treated through the upper eyelid incision. Fillers can be used as well to fill out these lines.
“I believe true confidence comes from a feeling of self-assuredness from one’s inner self. However, I also believe that it is heavily impacted by a lack of confidence with one’s outside appearance as well. Plastic surgery can help improve confidence in this way.”
Lower Eyelid Rejuvenation
The lower eyelid contributes to the overall aesthetic of the periorbital region. Proper evaluation and treatment of the skin, muscle, and fat will improve the appearance of the aging eye. Some of the characteristic changes in the lower lids with age includes: loose skin, herniated orbital fat, accentuation of the lid-cheek junction with accentuation of the tear trough region (by the nose), and weakness of the lower lid leading to lid laxity and scleral show (too much white of the eye is seen). Lower eyelid laxity when not addressed can contribute to scleral show, or worse, ectropion (the turning out of the lower lid) thus showing the conjunctiva. When the lower eyelid is weak a supporting procedure is necessary. This can be done by performing a canthopexy or even a canthoplasty procedure. Proper evaluation and good technique will minimize risks of eyelid surgery and provide for reliable and safe results.
This can be performed when there is only loose excess skin. An incision can be made just inferior to the eyelid margin and the skin can be elevated off the underlying muscle and then the excess skin can be removed. More commonly a “skin pinch” is performed without elevating a skin flap off of the muscle. With this technique, the skin is literally pinched together and the excess is removed. The theory to do it this way is that there may be less scarring and risk for ectropion or scleral show.
Skin And Muscle Excision
The “classic” incision used for lower lid surgery was performed using a skin-muscle flap that was incised just inferior to the eyelid margin; the skin and muscle are elevated as one unit. This is still performed by some surgeons, and is indicated for some patients. If the lower lid has weak tone then a canthoplasty/canthopexy can be performed.
Skin And Fat Excision
The philosophy regarding how to treat the lower lid has changed over the years. Some surgeons feel that “violating” the muscle layer may lead to a higher incidence of scarring which can lead to scleral show and even ectropion. That is why when some patients have loose lower eyelid skin and herniated orbital fat a different approach is used. A tranconjunctival blepharoplasty (TCB) approach is performed to remove fat from the three lower lid fat compartments. A transconjunctival blepharoplasty uses a hidden incision inside the lower lid. The incision is made in the tissue between the eyeball and the lower lid and through this approach fat is removed. Release of the arcus marginalis to expose the lower lid fat compartments can be performed. Correction of a “double-bubble” like deformity of the lower-lid cheek junction can be performed by releasing the orbito-malar ligament. Fat can be redraped in this region to camouflage the “double-bubble.” If there is loose skin a simple skin excision or skin pinch approach can be performed. This eliminates the more traditional skin muscle flap procedure which has a higher risk of scarring. If patients have weak lower lid tone, canthopexy or canthoplasty can be performed.
Skin, Muscle, And Fat Excision
Sometimes a skin-muscle flap technique is used to treat the herniated fat. Again, if the lower eyelid has poor support, a canthoplasty or canthopexy may be required.
Ancillary Procedure Approaches For/Through the Lower Eyelid
Lower Eyelid Suspension
Canthopexy/Canthoplasty – Lower eyelid laxity is a common phenomenon that develops with age. During the physical examination, the lower eyelid is tested for laxity. A “snap-back” test can be performed to see how well the eyelid will return to its normal position. In addition, if a patient has scleral show or even ectropion, then these are signs of poor lid tone. In addition, patients with a negative vector in which the eyeballs appear to be in front of the cheek prominence have a higher incidence of lower eyelid issues after surgery.
Canthopexy – A canthopexy is a procedure in which the lateral retinacular ligament, a structure next to the lateral canthus (corner of the eye) is supported to the bony orbital rim in a “suspenders” type fashion. This procedure supports the lower lid after eyelid procedures. It may initially create an “almond-shaped” eye but overtime, this usually relaxes.
Canthoplasty – A canthoplasty is a more invasive procedure for severe laxity. The goal is to create a tighter lower lid. It requires cutting the lateral canthus and making it shorter. This may or may not include a canthopexy to raise the corner of the eye.
Fat Injection, Fillers, And Neuromodulators
Non-invasive procedures using fat, filler products, and neuromodulators can affect the appearance of the eyelid. Fat injection is performed for permanent fill. Injectable products like Restylane™, Restylane Lyft, and Juvederm™ can be used as well, and last six months to a year. They can be used to fill the lower-lid cheek junction and the tear trough area. Sometimes herniated fat found in the lower lid can be draped over the lid-cheek junction to soften this “step-off” once the orbito-malar ligament is released. Neuromodulators like Botox™ and Dysport can be used to treat the crow’s feet along the lateral eyelid as well.
The mid-face lift is a procedure that focuses on the cheek and lower lid junction. The goal is to elevate the cheek fat pad and treat the lower lid region as well. This can be done as an isolated procedure using only a lower lid incision. The soft tissue around the cheek is freed and secured to the temporal fascia of the face. A canthopexy or a support procedure for the lower lid is also performed at the same time. Commonly, mid-face treatment is performed during other face lift procedures such as in a deep plane face lift.
Lower Lid- Cheek Problems
Malar bags or malar edema are areas of swelling along the lateral lid-cheek junction. They are similar to the condition causing swollen feet. Increased activity and salt intake may make them worse. Sometimes surgery around the eye may make them more noticeable. Commonly, as patients age, they can look worse because the soft tissue in this area descends and the overlying skin thins. There is no definitively one good treatment for this problem and it may not get better. Sometimes face lifting of this area can camouflage it.
Festoons are out-pouching of the muscle which cause the muscle and skin in the lid-cheek junction to hang like drapes. A “squinch” test is performed to see if the festoon is mainly muscle or skin. Often the best treatment for this is to elevate a skin flap during blepharoplasty and either imbricate the redundant muscle or take a crescent of muscle out directly over the festoon.
If you would like more information about Blepharopplasty surgeon Dr. Wallach and his success with New York City Eyelid procedures, we hope that you will not hesitate to contact our Manhattan offices at (212) 257-3263 or by mail at 1049 5th Avenue, Suite 2D in New York, NY 10028; or using our contact form to request additional details. For answers to general questions, visit our FAQ page. Also visit the patient gallery for before and after examples.
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