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Chapter Three The Eye Region Upper and Lower Lid Surgery Forehead-lift The Single Lid (Oriental Eye) Permanent Lash Enhancement

Upper and Lower Lid Surgery

The blepharoplasty procedure is generally referred to as upper or lower blepharoplasty, relating to the upper or lower eyelids. Quite often, a patient will assume the need for an upper blepharoplasty when, in fact, the excessive skin of the upper eyelids can be corrected with a forehead-lift, which I describe later in this chapter. There are instances when an upper blepharoplasty is called for: if a patient has sagging, or draped-looking, “hooded” upper eyelids, no forehead wrinkles and the brow is resting where it should, it’s an indication that the problem is limited to the eyelids and I’ll go ahead with a blepharoplasty.

Another situation in which an upper blepharoplasty might be done is when a patient refuses to undergo the more extensive operation of a forehead-lift. This can be a bit frustrating for the surgeon, partly because the results won’t be as good as they might have been, and partly because the forehead-lift, if the forehead is what is causing the trouble in the first place, is a more effective solution. The patient can expect a more wide-eyed, bright-eyed look after a forehead lift.

In a piece I wrote for The Journal of Otolaryngology, with Dr. David K. Ward, we began with a description of the simplest upper blepharoplasty. This procedure would be suitable for a youthful patient with no droop to the forehead and only a small amount of excessive skin in the upper lid.

Once the patient has been anesthetized, a crescent-shaped segment of lid skin is cut out directly above the eye, where the resultant scar can be hidden in the natural fold. A think strip of muscle called “orbicularis oculi” is then removed, along with any fat we might find. Often, most of the fat is found in the upper inside (medial) area of the eye and above the pupil. To close the incision, we used to have to use pull-out stitches, as opposed to stitches that needed to be snipped out. Today, we use a surgical type of Krazy Glue, sold under the brand name Histoacryl. The glue does a fine job of holding the incision shut while the skin heals, and the patient is spared the ordeal of having the stitches removed. The glue flakes off within five to seven days.

In an older patient, there will be more advanced changes in the upper lid, including increased lateral hooding and a correlating increase in what we call “redundant” orbicularis oculi, or excess muscle that contributes to sag. The solution is to take the incision out a little further toward the corner of each eye, to remove the extra muscle and skin. This results in a tiny visible scar in the skin just above the upper eyelid “sulcus,” or groove. With time, however, the scar will become quite inconspicuous. A forehead-lift may also be needed.

A successful upper blepharoplasty results in a deeper, move clearly defined groove above the eye and more eyelid skin show between the groove and the eyelash line. The upper lid looks attractively sculpted. The highest compliment a surgeon can get is when people stop asking why his patient looks so tired all the time, and start commenting that his patient looks remarkably “well rested”.

Fat around the eye in the upper lid is found in two distinct areas: medially, toward the inside corner of the eye and centrally, directly above the center of the eye. Fat around the eye in the lower lid is found medially, centrally and laterally - toward the outside corner of the eye. As you might recall from Chapter One on facial assessment, the way to find these pockets of fat, or fat “pads” as we call them, is to have a patient lean her head well forward in the examining room, and then look up into a mirror. This usually revels where the skin around the eye is bulging due to excess fat.

A lower blepharoplasty operation is almost always carried out to eliminate the so-called “bags” under a patient’s eyes. Sometimes it’s done to get rid of coarse wrinkles, though I’d probably recommend a chemical peel for someone with no bags and only fine wrinkles or etchings, depending on whether the wrinkling was caused by too much sun, or extra skin.

In addition to the examining-room test for fat pads, a patient in need of a lower blepharoplasty must submit to the ‘pinch” test for laxity, or natural elasticity of the lower lid. Using my thumb and forefinger, I will lightly grasp the lower lid, pull it out a bit, then let go. If I can pull the lid out further than about ten millimeters, the lid lacks laxity. Similarly, if the lid fails to “snap back” into its original position, with the margin hugging the globe of the eyeball, then it lacks laxity.

We check for laxity to avoid exacerbating a phenomenon known as “scleral show” by performing a blepharoplasty. Sclera refers to the outermost layer of the three concentric layers of tissue that cover the eyeball: it is the white of the eye. Scleral show means too much of the white is showing below the iris, or colored part of the eye. You sometimes see advanced scleral show in elderly people who have lost the laxity of their lower lids. If the condition deteriorates any further, it can result in severe lower lid “ectropion”, where the margin flips out and completely disengages from the eyeball. It’s a look that only hound dogs should have to endure.

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