Blepharoplasty is indicated to reverse the signs of aging of the upper and or lower eyelid. The eyes are the first facial feature to show signs of aging. Gravity begins to pull the upper eyelid skin downward towards the eyelashes creating extra creases and folds in the upper eyelid. For women, the first hint that Eyelid Surgery may be indicated are difficulty applying makeup and eye shadow to the upper eyelid do to these increased skin folds and creases. The tissue layer supporting the eyelid fat also becomes weak and bulges begin to appear along the upper eyelid. Blepharoplasty is designed to remove the excess skin and fatty tissue of the eyelids. Eyelid Surgery removes the excess tissues of the eyelid but let’s look at how this excess tissue develops. It turns out that the fatty tissue that creates excess bulges of the eyelids that is removed with a Blepharoplasty is somewhat unique in origin. The eye ball sits within a hard bony eye socket. To cushion the eye a fatty tissue layers surrounds the eye and the eye muscles. This fatty tissue does not increase with weight loss or weight gain. The fat that is removed during a Blepharoplasty represents fatty tissue that is held in place by a tough connective tissue layer within the eyelid. With aging and gravity, this connective tissue layer weakens allowing the fatty tissue around the eye ball to bulge outward. That’s the bad news. The good news is that because this fatty tissue will not accumulate with weight gain, once it is removed with Eyelid Surgery it typically won’t reappear for years. The Blepharoplasty, if performed properly, will remove the appropriate amount of excess skin, eyelid muscle and fatty tissue. With aging, some 10-20 years or more, some fatty tissue may again fall downward creating bulges in the eyelid. Because Eyelid Surgery may be repeated to selectively remove these excesses however, the procedure may not ever need to be done again. But what does a youthful eyelid look like? Let’s take a look and see.The upper eyelid has a defined crease that has a gentle curve following the curve of the upper eyelid. The eyelashes are turned upward and there is no excess skin or fatty tissue bulges of the eyelids. Blepharoplasty should ideally restore a female’s eyelids to this point. Obviously, Eyelid Surgery can be used to remove a small amount or an extreme amount of aging from the eyelids but regardless, this should be the endpoint no matter what needs to be accomplished.
Males and Females differ dramatically when it comes to Blepharoplasty indications and ideal endpoints of the Eyelid Surgery Procedure. Why is this? Blepharoplasty differs in what it is trying to accomplish for men and women because of two reasons.
First: Females and males have very different ideally shaped eyebrows. Club shaped initially, the eyebrow arches to a point measured by an imaginary vertical line drawn down from the outer Iris (colored portion of the eye). The eyebrow then begins to gently taper until its termination as measured by a tangential line drawn from the corner of the nostril through the outer canthus or corner of the eye. At its outer portion, the eyebrow should be approximately 1 fingers-width above the eye socket. Men’s eyebrows, on the other hand, are flat across the forehead without tapering or arching of the eyebrows. Why should this matter in a Eyelid Surgery Procedure? It affects the Blepharoplasty because the Plastic and Cosmetic Surgeon must take into account the amount of excess skin of the upper eyelid. If the female eyebrow is droopy the amount of perceived excess upper eyelid skin will falsely be seen as increased. That’s why it’s critical for the Plastic and Cosmetic Surgeon to elevate the female eyebrow into the ideal position, during the Blepharoplasty consultation. This maneuver allows an accurate assessment of the amount of excess skin of the upper eyelid to be removed during the Eyelid Surgery Procedure. For men, this is far less important until the eyebrows are so low as to literally obstruct the vision, which typically occurs ony with advanced age. What happens if this maneuver is ignored during the Blepharoplasty consultation?
We will discuss how the Eyelid Surgery is performed later in this section but I want to explain why the eyebrows play such an important role in the planning stages of a successful Blepharoplasty Procedure. As the eyebrows fall, they add to the amount of excess skin visible on the upper eyelids. If this amount of skin is removed during Eyelid Surgery the eyebrows will be pulled down further. During the Eyelid Surgery Procedure, an incision is placed within the upper eyelid crease. Excess skin above the crease is then removed and the edges of the incision are brought together to close the surgical wound. The edge of skin within the eyelid crease is attached to the cartilage that makes up the upper eyelid plate and does not move. However, the other skin edge will move towards the crease allowing the Blepharoplasty area to be closed. If eyebrow skin was mistakenly removed during the Eyelid Surgery Procedure, because it wasn’t recognized as being caused by a droopy, as the upper skin edge is brought to the crease skin edge the eyebrow will be pulled into a lower position. Once this skin is mistakenly removed during the Blepharoplasty it may be impossible to correct. Even after the Eyelid Surgery Procedure, if it is recognized that the eyebrows are now lower, they may not be able to be raised without preventing the eyes from closing.
During the Blepharoplasty planning stage it is paramount, in women, to accurately assess the position of the eyebrows and determine if the eyebrows are contributing, or not, to the amount of visible excess upper eyelid skin. This is done during the Eyelid Surgery consultation by the Plastic and Cosmetic Surgeon standing behind the seated patient and manually elevating each eyebrow to the ideal position that Dr. Hakan Demir has outlined above. As the eyebrow is raised to it’s ideal aesthetic position the amount of excess upper eyelid skin will either remain the same or be decreased by some amount. If during this maneuver the upper eyelid skin does not change, the eyebrows are in the ideal aesthetic position and the entire amount of excess upper eyelid skin may be removed with the Eyelid Surgery. If the amount of excess upper eyelid skin is completely gone with this maneuver, this indicates that the eyebrows are low and the only source of the perceived upper eyelid fullness...this indicates that the Blepharoplasty is not the appropriate procedure but rather some form of Brow Lift Procedure should be performed instead. If there is some reduction in the amount of upper eyelid skin with this maneuver this indicates that the eyebrows are lower than the aesthetic ideal but that there is still some excess upper eyelid skin that can be treated with a Eyelid Surgery. It does further indicate however, that only the amount of upper eyelid skin may be removed during the Blepharoplasty Procedure without causing the eyebrows to drop further in position. This is accomplished during the Eyelid Surgery by performing the same maneuver during the skin marking phase of the Blepharoplasty Procedure. This accurate marking of just the excess skin that truly belongs to the upper eyelid is one of the keys to a successful Eyelid Surgery outcome in Dr. Demir’s opinion.
Second: Men and women differ in the amount of upper eyelid that should be visible after the Blepharoplasty has been performed. Women ideally have a well defined crease in the upper eyelids without any excess skin of the upper eyelid. Men on the other hand tend to look best with a bit more skin and less visible upper eyelid. This means that during Eyelid Surgery that men will tend to have less upper eyelid skin removed than women.
During the Blepharoplasty consultation, the woman in this Image would be evaluated in the following manner. Using Dr. Demir’s suggested maneuver the eyebrows are noted to be in the proper aesthetic position. This means that the amount of excess skin visible in the upper eyelids (indicated by arrow) could be completely removed with Eyelid Surgery. This would open the eyes further and give a softer, more feminine appearance to the eyes. There is no evidence of excess fatty tissue of the upper or lower eyelids in fact there is a telltale sign (if you know what to look for) that warns against taking any upper eyelid fat. If fat is removed during Blepharoplasty the eyes will look too hollow. This horizontal crease is an important hint and warning. (right arrow)
Eyelid Surgery can also be done as a revision or secondary procedure to remove skin and fatty tissue. This may be a result of skin and fat that was missed during the original Blepharoplasty Procedure or tissues that have fallen with additional aging. The areas where residual fat are common are the inside (by the nose) portion of the upper eyelid and the outer (by the ear) portion of the lower eyelid. Revision Lower Blepharoplasty may create lower eyelid drooping. Certain Eyelid Surgery techniques have been known to cause this more than other Blepharoplasty techniques.