Procedures | Eyelid Surgery
Perhaps nothing in facial cosmetic surgery does so much for the patient for so little as eyelid surgery. These operations remove the weary look that comes with heavy and puffy eyelids. The eyes are also more attractive because more attention is given to the eye itself when the distracting bags and wrinkles have been removed.
Eyelid operations are short in duration, the incisions practically invisible, and the results predictably good. Although all operations have risks, those of eyelid surgery are decidedly uncommon. The satisfaction rate is extremely high with a very short convalescence, little pain, and observable results almost immediately.
- Can excess skin be corrected without surgery?
- What are the risks of eyelid surgery?
Aging around the eyes occurs as a result of three general phenomena. The skin, muscle, and fat in the eyelids become redundant and create prominences-puffiness and even bags. Second, as a consequence of eyelid muscle function combined with aging in the skin, wrinkles around the eyes become a signature of age-crows feet. Finally, the brow, as a consequence of gravity, may drop a bit and contribute to heaviness in the upper lid area. An individual patient's problem is a product of the particular combination of these three factors.
In general, there is no way to significantly shrink skin. When thinking of tightening the skin, there is confusion about the role of excision of skin vs. resurfacing with the laser, chemicals, etc. As a rough analogy, picture an unmade bed. The top sheet is gathered up in the middle, and "making" the bed tightens and smooths it. This is the equivalent, in my example, of surgical excision of skin.
After the sheet has been re-draped, there may be wrinkles in the sheet itself. The good housekeeper would iron the sheet to remove these intrinsic wrinkles. In our example, ironing is the rough equivalent of resurfacing (laser). Folds of skin that are manifestations of excess skin must be surgically removed. Wrinkles and creases that are the end-product of intrinsic aging of the skin (as a consequence of sun damage, etc.) are treated by laser resurfacing.
Eyelid surgery is extremely safe. Infection and hematomas (collections of blood) are almost unheard of. Blindness has been reported but I have never personally heard of a case from any of the numerous surgeons that I know. It occurs in less than one in 10,000 cases.
Revisional surgery for eyelid operations is uncommon. The most often seen problem involves position of the lower lid. The lid is supported by a sling of connective tissue that loses its elasticity, and thus its ability to support the position of the lower lid, with age. The stress of swelling and tissue rearrangement commonly pulls the lower lid to a slightly low position after surgery. Conservative treatment usually results in correction of this problem.
Occasionally, the lid may not return to the desired position against the eyeball and a revision is indicated. These operations, although relatively minor, must be precisely executed to restore normal lower lid position and function.
About the procedure...
- How is upper eyelid surgery performed specifially?
- Is surgery and laser resurfacing ever done together?
- How is surgery of the lower eyelid performed specifically?
In the aging lid, excess fat may exist in discreet pockets in the upper and lower lids. There are two compartments in the upper lid and three in the lower. Removal of the surplus fat from these pockets is part of the operation known as "blepharoplasty."
The aging eyelid also has excess skin and muscle that are pruned during blepharoplasty. Generally, there is considerably more surplus in the upper lids than in the lower. There may also be asymmetries that can be addressed by eyelid surgery. (same as from original website-can be cropped from 1st patient in the present facelift gallery)
Eyelid surgery alone will not correct problems created by a heavy, hanging brow. This is a more common phenomenon in males who generally have a protuberant forehead. Occasionally, blepharoplasty must be combined with a browlift to obtain an acceptable result. This is an issue that is sorted out during patient consultation.
Aging of the upper eyelid results from redundant skin, prominent fatpads, and possibly brow ptosis (drooping). Surgical correction is aimed at these components, accommodating differences in the relative contribution of each. Most of the time, the amount of redundant skin is generous. Because of this, laser resurfacing alone generally is inadequate to generate a satisfactory aesthetic result. Direct excision of a strip of skin is almost always performed. Resurfacing may be added later to refresh the appearance of the skin.
After excision of the redundant skin, a strip of the orbicularis oculi muscle the muscle that closes the eyelids) is usually removed. This does not effect function of the muscle and in most circumstances is necessary to achieve the desired aesthetic result. Removal of this muscular strip exposes the orbital septum (a connective tissue wall) which is an approach to the fat pads, the structures that make the lids look puffy.
The orbital septum is opened and, when there is excessive fat, removal of a portion of the pads is performed. There are two discreet areas of fat deposits which must be trimmed with precision. Too little will leave the problem of puffiness uncorrected. Too much can leave the eye and the eye socket with a hollowed out look.
Lifting of the brow is only occasionally necessary to get an excellent result from eyelid correction. Browlift is discussed thoroughly in another section. For now, let's just say that a browlift (and there are different kinds) is a consideration when assessing aging around the eyes.
Occasionally both excision of skin and resurfacing is required for the best result. Very rarely, they will be done together at the same sitting. More often, the operation will be staggered by a few weeks.
In general, the recovery from surgical excision is briefer than resurfacing. Sutures come out in about 5 days and make-up can then be used. Most patients can resume normal activities without embarrassment in about a week occasionally assisted by make-up or glasses.
Skin resurfacing after laser therapy also takes about 5 days, but the area of treatment will remain pink for several weeks. Although make-up can be used shortly after the actual operation, a little more effort is required to achieve ideal coverage.
The lower lids usually have only a modest amount of excess skin. Because of this, reduction of this surplus may commonly be accomplished by laser resurfacing (which modestly shrinks the skin) or by direct excision of the skin. Much more commonly, direct excision is chosen. The laser is best for those patients that have minimally excessive skin and a significant amount of sundamage to that same skin. This is an infrequent situation.
For the more commonly performed surgical excision, the incision is directly below the eyelashes. The resulting scar is nearly invisible. The sutures used to close this incision are extremely delicate and dissolvable.
In contradistinction to the upper lid which has two, there are three fat pockets behind the lower lids. These may be approached through the inside of the lid (the transconjunctival blepharoplasty) or through an external incision. Usually the transconjunctival approach is combined with resurfacing, if excess skin with sun damage is a problem. In younger patients, where prominent fat pads may be more a family trait than a forme fruste of aging, a transconjunctival removal of fat can be accomplished without leaving any external scar. Resurfacing may not be needed since the skin in younger patients is seldom in excess.
Regardless of the approach, rejuvenation of the lower lids yields excellent results. Patients look rested and attention is returned to the eyes themselves, not the distracting features of aging around them.