As leaders in eyelid and blepharoplasty surgery in Houston for nearly 25 years, we will share our perspective on this group of widely variable surgical procedures.
Blepharoplasty [blef-ah-ro-plas-tee] means plastic surgery of the eyelid and is derived from blepharon, Greek for “eyelid,” and plastia or plastos, Greek for “molded” or “formed.”
Other physicians often ask us how we perform our blepharoplasties, seeking a formulaic process to follow. Our answer is always “one eyelid at a time, working to make the change vanish into the background.” No two patients’ blepharoplasties are the same. Yes, there are some basic principles we follow, but the fine details and the final combination of the multiple variables always change.
In this light, we find it bewildering when patients come to our practice distraught over prior eyelid surgery and report that their surgeon told them, “I don’t know what went wrong. I do exactly the same surgery for everyone.” In part, this explains why 50-70% of what we do every month is re-operating the work of others.
Blepharoplasties and related eyelid surgeries are among the top five most commonly performed surgical procedures both in Houston and across the United States, usually falling behind liposuction, breast augmentation/reduction, rhinoplasty (nose surgery), and brow lifts. Even so, according to the American Academy of Plastic Surgeons, the average, busy plastic surgeon performs 23 blepharoplasties each year, or roughly one every other week. Compare this experience to ours, where Drs. Patrinely and Soparkar perform nearly 20 blepharoplasties each week, or some 1,000 / year, each procedure carefully customized to each individual’s needs.
For many people, a blepharoplasty is a defining cosmetic procedure and can have as much, if not more, impact than any other facial procedure. Why? Because when you first walk into a room and look at someone, you look at their eyes. Did they notice that you entered? Are they happy to see you? What do they think of what you are saying? Expression and awareness are most strongly conveyed through the eyes, so the focal point of attention also becomes the eyes. The impression made by the eyes carries over to the whole face, and then to the whole person. First impressions truly do count.
In assessing a person’s aesthetic needs, many factors must be taken into account.
In general, the male upper eyelid should be left relatively fuller, heavier, and with slightly greater skin redundancy than the female eyelid. Raising the eyelid crease (break point) and over-sculpting the upper eyelid are sure ways to feminize the male eyelid and face, a result that is most often not the goal. Heavy brow fat, skin, and muscle should never be left hanging out toward the ear, but in a female eyelid, this area is generally much more tightly sculpted.
The benefits of upper and lower eyelid blepharoplasties will continue on throughout life. People continue to age, and so do their faces and eyelids. In general, though, one may think of an upper eyelid blepharoplasty “lasting” 10-15 years, depending greatly upon skin care and brow position, whereas a lower eyelid blepharoplasty generally “lasts” about 10 years, depending greatly upon the stability of the mid-face. Doing “more aggressive” surgery to “make it last longer” is not a sensible approach. How many people ask their hair dresser or barber to shave them, so they don’t have to come back for a year or two?
Eyelid surgery needs to be planned in the context of other aging changes in the face. Nobody wants a 20-year-old’s eyelids on a 70-year-old face. So, overall facial structure and features must be considered as well as a person’s plans (or lack thereof) for other rejuvenative procedures.
In opposition to what most people immediately think, a younger eyelid is a fuller, less sculpted eyelid, but without hanging bags and sags. A more mature eyelid is often more defined, more sculpted.
Race is an extremely important consideration. Although populations have obviously mixed considerably, there remain subtle, but important differences in the contour and weight of upper eyelids among African Americans, Southern Europeans, Celts, Native American Indians / Central and South Americans, Arabs, Asian Indians, and Asians. Asians, in particular, deserve special mention since variations in crease position and type can be profoundly important. In the vast majority of cases, people do not want to become “westernized” or “Americanized,” but to simply reverse some of the changes they’ve undergone over the years. If a true change is desired, we find most often that people of rich ethnic backgrounds most desire to approximate paragons of handsomeness or beauty in their own culture and race. They are not looking for a “cookie cutter” solution.
The single most important factor in determining whether similar eyelid surgery is conducted on both eyes is pre-existing facial asymmetry. Often, people will have one eye farther forward or lower than the other. There may be differences in upper eyelid height, in cheek projection, eyebrow position, or skin changes from having one side of the face always turned toward the sun (a hazard in some occupations). If asymmetries are not recognized before blepharoplasty and eyelid surgery appropriately adjusted, then asymmetries will be more apparent afterwards, when the distracting extra eyelid skin and bags have been removed. Careful planning can minimize the perception of post-operative asymmetry.
A prominent forehead or bone projection above the upper eyelid often requires three adaptive changes: 1. Relative elevation of an eyelid crease, so that the eyelid can show deep within the shadow of the overhanging brow, 2. Relatively greater fat sculpting, to accentuate the upper eyelid, 3. Consideration of elevating the upper eyelid edge to make an eye lost in shadow appear larger and farther forward. In severe cases, the eyes can actually be brought forward in an easily performed, rapid procedure.
Conversely, a receded forehead or under-projecting bone above the eyelids generally requires an opposite set of adjustments.
The relationship of cheek projection relative to the eye projection is extremely important when considering lower eyelid blepharoplasty or cosmetic eyelid surgery. Looking from the side, the cheek should project beyond the eye or to the same degree. If the cheek is receded relative to the eye position, extreme care must be taken to avoid lower eyelid descent after surgery resulting in cosmetic deformity and severe dry eye problems. Several options exist to correct a cheek-eye projection mal-proportion, depending upon each individual’s needs, including resuspension of the cheek and eyelid muscles, transposition of fat from behind the eye to the top of the cheek, and cheek implants.
CHEEK BULGES AND BAGS
When assessing a lower eyelid for possible blepharoplasty, multiple bags and folds are often present. Many of these represent descended fat pads or muscle groups (generically called festoons) within the top of the cheek. The cause of each of these must be determined and, if desired, addressed during lower eyelid blepharoplasty. Otherwise, only half of the lower eyelid-mid-face issues will have been corrected.
Although brow lifts (upper face lifts) are extremely popular among plastic surgeons, one must critically review whether or not an elevated brow position up the forehead has an aesthetic appeal or not. In men, this can be profoundly feminizing. In women, there may be a “frozen” or “surprised” look after surgery.
For most, if the eyebrow falls on the edge of the projecting forehead bone in women or just below this bone in men, this is a good eyebrow position. In some, however, a droopy eyebrow on one side (or both) needs to be addressed. Failure to recognize this need before blepharoplasty may lead to a situation where so much tissue is removed in the blepharoplasty that when the brow lift is performed, the eyelids are no longer able to close – a disaster!
LACRIMAL GLAND PROLAPSE
The lacrimal gland normally resides in the upper, outer edge of the eye socket. This gland is responsible for making a large component of the tears that normally bathe the eyes. In some people, the attachments of the gland to the surrounding bone relax, and the gland descends into the eyelid where it may be mistaken for fat and removed, creating a major problem of dry eye after surgery. Conversely, not recognizing that the gland has fallen and carefully repositioning it will result in a bulge in the outer corner of the upper eyelid.
A change in the upper eyelid height (position of the eyelashes relative to the center of the eye) should never be significantly influenced by how much eyelid skin is removed. Raising the upper eyelid height (ptosis repair) is accomplished by carefully identifying the major muscle responsible for eyelid elevation and tightening it. Lowering the upper eyelid is also possible by repositioning this same muscle. Changes in the upper eyelid height may be performed if one or both eyelids are droopy, if eyelid position asymmetry exists, or for eyes that are too far open. Additionally, changing the eyelid heights can simulate moving the eyes forward or back, making them appear larger or smaller, as needed.
Changing the position of the lower eyelid (raising or lowering) can be a more complicated endeavor, but is also very possible and routinely performed in our practice.
SHAPE OF THE EYE (The Canthi)
The overall shape of the eye (“round eye,” “sad eye,” “almond eye,” “cat eye,” “Asian eye,” etc) is determined to a large extent by the position of the corners of the eye (one near the nose and the other towards the ear). The relative positions of these canthi (or corners) one to the other as well as to the eye and surrounding tissues can have a big impact on upper and lower eyelid positions, tightness of the eyelids against the eye (important for tear film mobilization and eye comfort), and the final shape and aesthetic appearance of the eyes. Frequently, modification of these angles is an essential part of a successful blepharoplasty.
FAT, SKIN, AND MUSCLE
We are frequently asked by physicians and informed patients alike whether or not we will remove or transpose (move from a bulging area to a hollow area) fat, make skin incisions and remove skin, and remove some of the Orbicularis eyelid muscle that helps the eyelids to close, but can be redundant and lax and require tightening. The answer, of course, depends upon each individual eyelid and what we are trying to accomplish. We have some general rules we follow, but even these are often broken when necessary. In short, careful consideration of all these options must be part of the final surgical plan.
Perhaps the single most devastating feature neglected or misjudged by many plastic surgeons in their preoperative blepharoplasty assessment is the quality of the skin. Fine wrinkles in the skin from allergy, sun exposure, and certain disease conditions reflects damaged skin, not excess skin. Pulling the eyelid skin so tight during surgery that these lines completely vanish will invariably lead to incomplete eyelid closure, exposure of the eye, and serious, painful, vision threatening dry eye. Ignoring the presence of severe sebaceous hyperplastic changes may lead to prolonged healing and even scarring.
There are many disorders which may significantly affect the timing and degree of cosmetic eyelid surgery. Not only do these need to be recognized, but they may certainly require specific considerations and alterations in surgical plan. Such conditions include Floppy Eyelid Syndrome (tightly correlated with sleep apnea), autoimmune thyroid eye disease, muscular dystrophies, neurologic disorders, rheumatoid arthritis, lupus, diabetes, and other autoimmune disorders. Interestingly, many of these conditions may be diagnosed just by looking at the eye.
TEAR FILM AND GENERAL EYE HEALTH
When we lecture to general plastic surgeons and facial plastic surgeons, we are frequently asked to describe the best eye tests to “clear” a patient for a blepharoplasty. There is no check box on a person’s forehead that you can mark and say, “this patient is safe for eyelid surgery” or “this patient is not safe.” One patient with profound dry eye and very heavy upper eyelids may be excellent candidates for blepharoplasty, because he suffers from a condition we described called Frontalis Antagonist Blink Syndrome, whereas another patient with mild Toxic Tear Syndrome should definitely not have surgery.
Undertaking cosmetic eyelid surgery, blepharoplasty, is a complicated matter, as evidenced by the large number of patients who come to us for revisions of other surgeons’ work. Having said that, it can be a very rewarding, completely painless, fast, and relatively inexpensive path to significant rejuvenation performed in the office under local anesthetic.
There are very few absolute indications or absolute contraindications to cosmetic eyelid surgery or blepharoplasty. Every person’s situation must be carefully considered in the light of all of the factors we’ve described here, and the surgery must be thoughtfully tailored to each person’s needs to best meet their goals.
If you visit or have visited our office for a consultation, we may or may not verbalize our assessment of each of these factors, unless you specifically ask, but you can be certain that every one of them is integral to the formulation of your unique surgical plan.