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About Face

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

A patient already suffering from mild scleral show is easy to spot, but the test for laxity must be cone on everyone. A patient with an undetected tendency toward scleral show might develop if after a lower blepharoplasty because the procedure removes fat and extra skin that would otherwise prop up the loose lid. Excess laxity must be surgically corrected during the blepharoplasty by tightening the lid. We can do this by cutting a tiny wedge out of the lid, at the outer corner, which shortens it horizontally. More often I’ll reinforce the shortened lid with a suture that anchors it to a ligament solid to the orbital rim - the bony area surrounding the eye.

On the operating table, the search for fat pads is conducted where the incision has been made (sometimes behind the eyelid, sometimes under the lower lashes). The pads lie deep below a delicate layer of sinew called the orbital septum. The septum has the consistency of an embryonic sac, and, with age, it loses its elasticity and allows the fat pads underneath to herniate, or bulge - the way your body sometimes reveals its outline by pressing against the shower curtain. When I find the fat, it pops up slightly, distinguished by a bright yellow color.

Before snipping each fat pad away, it must first be anesthetized, because for the blepharoplasty operation, we use a local anesthetic that does not penetrate to the deep layer where the fat pads are contained in the bony orbit around the eye. So it’s a matter of popping each pad, injecting it with anesthetic (usually, Xylocaine), waiting a moment for the anesthesia to take effect, snipping the pad at its root, cauterizing any tiny blood vessels bleeding into the area, and moving on to the next pad. It’s a rhythmic and totally absorbing procedure that I find very satisfying, especially knowing the sometimes dramatic improvement in appearance that will follow.

The medial fat pads, those located near the inner corner of the eye, present the biggest challenge during the blepharoplasty operation. They’re the hardest to find, partly because they are located furthest away from where a surgeon must stand to carry out the procedure. Remember that there usually is a surgeon accompanied by an assistant or a nurse in the operating room. The assistant is sometimes given the job of cauterizing blood vessels and the nurse is busy monitoring a patient’s reaction to anesthetic and other, intravenous fluids.

Medial fat pads can also be elusive because they’re not always exactly where they’re supposed to be (within millimeters, of course), or they are not as yellow or other fat pads. They tend to be whiter. But it’s important that they be removed, because to leave them in would noticeably affect the overall postoperative appearance of the eye - there would be an odd pocket of fat toward the lower inner corners, made more obvious by the removal of fat centrally and laterally.

With a lower blepharoplasty, it is wise to avoid removing too much fat from the lateral compartments at the outside corner of each eye. This can result in a “hollowed” or cadaveric look if the eye globe outlines start to show. Instead of snipping out the lateral fat pads, it is sometimes wish to merely reduce them in size by cauterizing. We call this process “fat frying”.

The eye region can also be affected by sagging in the forehead area; this affects the way the eyelid skin drapes over the upper eyes. Occasionally, it will even create a small hood of skin between the eyes at the top of the nose but most often it creates excessive skin at the outer, lateral edge of both eyes. Patients usually want their upper face done because their friends or coworkers have begun to remark that they look tired, or worn out. We read a lot into the face others present us with, and sometimes people with sagging foreheads are thought to be dour, or worse, dissipated.

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