Blepharoplasties and Browlifts

Upper Blepharoplasty

Blepharoplasty is the physicians term for plastic surgery of the eyelids. Browlifts  are included in this category because for most patients, a sagging of the eyebrows is a key ingredient to the ageing eyelid complex. The anatomy of this area is made up of several important muscles. The Frontalis muscle extends across the forehead and lifts the eyebrows, similar to a curtain lifting up in a theater. The frontalis does not extend across the entire forehead, leaving either side of the forehead to sag with the force of gravity. This is a prime reason why many people have a heavy fold of skin on the outer half of their upper eyelid and in the temple area, adjacent to the eye. The Orbicularis Oculi muscle is a circular muscle that surrounds the eye. Contraction of this muscle closes the eye and cause the wrinkling on the outer half of the eye, known as crow’s feet.

The skin around the eye has several important features. First, eyelid skin is the thinnest skin on the body. In contrast, eyebrow skin is much thicker. The junction between eyelid and eyebrow skin is very unique and gradually thickens from eyelid to eyebrow: it for this reason that the junction should not be touched. If you were to excise the excess eyelid skin, eyebrow skin and the junction between them, the resultant scar from the joining of thick and thin skin without the junction would be thicker and more noticeable.

The eyeball is protected by bone on four sides, and is supported within the bone by a shock absorber of fat. As you age, the tissue that holds the fat in place weakens, and fat will bulge out from above and below the eye. These bulges are the bags that you see when you are tired and more permanently visible as you get older.

With a little basic anatomy lesson, lets look at what happens during the ageing process. As gravity pulls down on the forehead, the frontalis muscle will fight back, pulling skyward, this creates those horizontal furrows on your forehead. On the outer part of the eye and temple, the absence of frontalis pull, will show up as excess eyebrow skin on the upper eyelid and temple area. At ab

out the same time, gravity and age have conspired to push the fat bathing the eyeball forward, resulting in the bags below the eyes and above the eye. Finally, as with all skin, the eyelid skin has lost some elasticity and sags and looks crepey.

Lower Blepharoplasty

As with all parts of the plastic surgery continuum, all patients are unique and will not have all the problems described above. Some will have other issues, not covered in this brief overview, but we can be sure each patient will require a procedure tailored to their unique concerns. My choice for most patients in need of a browlift, is my version of the lateral browlift. This is a technique that I was awarded “Best Scientific Exhibit Award” from the American Society of Aesthetic Plastic Surgeons in 2003. This technique has limited small incisions, does not raise the hairline and allows for a natural arched appearance of the eyebrow. Although, this is my favorite approach, I continue to use different approaches depending on the patients anatomy and desires.

Upper eyelid blepharoplasty involves removing excess skin, excess muscle, herniating fat (the bags), as well as corrugator muscle to eliminate frown lines permanently. In performing the removal of the corrugator muscles, the vertical lines between your eyes are lessened and the need for Botox is eliminated. Note that although the scar for this procedure is very difficult to see, when combined with a browlift the incision is shortened even further.

Lower eyelid blepharoplasty is the more difficult component of eyelid rejuvenation. The uniqueness of the anatomy exposes the lower eyelid to sagging with any excess scarring or overzealous removal of skin or muscle. The Transconjunctival blepharoplasty is a method to protect the muscle and skin, but allows removal of any herniated fat. The drawback to this technique is that no skin is removed. Therefore, a separate skin excision has to be performed. Aside from the fear of overresection of tissue resulting in a pulled down look, is the fear of a hollow look. The hollow look can be the result of cheek sagging from normal aging or overcorrection of the herniated fat that surrounds the eye. Correction of either of these problems is easily corrected with fat injections (as described above).