Eye-lid Makeover

Posted Thursday, September 13, 2007 to PROCEDURES > Face

Posted by The Original Anti-Aging & Cosmetic Surgery Magazine

When eye-lid makeup in no longer enough, we start thinking eye-lid make-over. New York plastic surgeon Norman V Godfrey MD explains how to decide what's right for you.

The plastic surgeon's eyelid make-over armamentarium has expanded dramatically in the past few years. Unfortunately, while that has improved treatment effectiveness, the blizzard of information and misinformation about the subject has made a rational choice more difficult than ever. Patients can make sensible decisions, however, if they understand the problems that affect the appearance of the eyelids as well as the treatment mechanisms. Fortunately, virtually everything we need to know about eyelid deformities can be learned from a careful visual inspection of the eyelids.

Some important definitions are in order. By understanding the proper use of the terms, you can avoid miscommunication with your doctor. First, we must distinguish between the eyelids and the eyes (or globes) themselves. In the effort to restore a more youthful, pleasant, alert, and energetic look, surgeons treat problems of the eyelids. Furthermore, it is appropriate to think of (and treat) the upper and lower eyelids as separate and different entities. The upper eyelid is comprised of the skin, muscle, ligaments, fat, and other structures located between the eyebrow and the upper eyelashes. The lower eyelid is the corresponding group of tissues below the lower eyelashes and above the arc (sometimes referred to as the tear trough) that separates the eyelid from the cheek itself. Finally, the term medial means toward the midline and lateral means away from the midline.

The types of problems that commonly affect the eyelids include: 1) drooping of upper eyelid skin down toward and onto the upper eyelashes, 2) bulging of the medial upper eyelid, 3) fine surface wrinkling (crepiness) of the skin of both upper and lower eyelids, 4) bulging of the lower eyelid making it look puffy or baggy, 5) sagging of lower eyelid skin into long deep folds or lines, 6) deepening of the dark circle under the lower eyelid, and 7) dark pigmentation of the lower eyelid skin. A related concern that is not directly an eyelid problem, but can have a profound effect on the appearance of the eyelids, is drooping of the brows. If a patient has severe drooping of the brows, it will not only make the face look angry or sad, it will make the eyelids appear to have more excess skin and sagging than they truly do. Effective treatment for this requires some form of browlifting, but that is the subject of another article in an upcoming issue.

Mechanisms of treatment are the other crucial elements in decision making regarding eyelid rejuvenation. Today we can choose from treatments that affect the surface texture and pigmentation of the skin as well as procedures that address problems with the amount of skin, fat, and tone of ligaments. While each of these methods offers its benefits and risks, the choice of the most appropriate one must be based upon matching the nature of the problem with the focus of the treatment.

Drooping of upper eyelid skin onto the upper eyelashes gives the eyes a tired, dull, angry, and aged look. In addition, it may make the eye 'feel' tired and smudge eye make-up. When brow drooping is not a cause, upper eyelid drooping is a manifestation of an excessive amount of upper eyelid skin that results from a loss of elasticity. The best treatment is removal of the excess skin. This is accomplished by an elegant surgical procedure that tailors the remaining skin to the eye contour. It leaves a scar that is located in the fold of skin above the eye, and leaves the patient looking rested, alert, pleasant and more youthful.

Bulging of the medial aspect of the upper eyelid commonly occurs by the fourth or fifth decade. It is the result of an inherited tendency to have excess fat in this location combined with some laxity of the skin, muscle, and ligament that confines the fat. Since the fat is structural fat, unaffected by metabolic balance, diet and weight loss will have no effect on this problem. The most effective treatment removes some of the fat through the skin crease incision in the upper eyelid. SUrface treatments such as laser ablation and chemical peeling reach only the uppermost 1mm of the skin. As a result, they heal without significant visible scar formation; also as a result, they exert no effect whatever on the fat that lies three layers deeper. Claims that laser resurfacing 'tightens' the fat are completely unfounded and preposterous.

Fine surface wrinkling is also a common finding in aging eyelids. Largely as a result of sun damage, the surface layer of the skin (epidermis) has become uneven and leathery. The wrinkling causes light to be less effectively reflected and therefore gives the skin a darker appearance than its actual pigmentation. Both chemical peeling and, more recently, laser ablation of this surface layer force the skin to regenerate a new surface. This new surface is typically smoother and less leathery in appearance. Surgery, which can remove excess, loose skin, has no effect on the surface of the skin that remains. Claims that the surgeon can pull the skin tight are not valid: the nature of eyelid anatomy means any amount of tension would pull the lid margins from the eyeball, creating a staring, bulging eye look. Because it is so well controlled, laser resurfacing has emerged as superior to chemical peeling for treatment of fine surface wrinkles in most patients.

Bulging of lower eyelids into "bags" is one of the most commonly seen eyelid deformities. It can be seen as an isolated finding in younger patients or in combination with sagging of excess lower eyelid skin in older patients. It is the result of an inherited tendency to have a little too much fat for perfect contour combined with laxity of the retaining structures. Surgery to remove some of the fat or tighten the retaining structures is the only effective treatment. The surgery can be performed through incisions on the inside of the eyelid or on the outside just below the lower eyelashes. If the bulging of fat is combined with excess skin sagging into lines, the surgeon will typically recommend the eyelash incision so as to permit the simultaneous removal of some of the excess skin. If no excess skin is present, the interior (or transconjunctival) approach is often chosen. Surface treatment methods have no effect on the fat or retaining structures.

Sometimes puffiness of the lower eyelids is aggravated by a deepening of the 'tear trough' immediately below. Atrophy of the normal fullness of the cheek structures causes a deep shadow to fall in the trough and thereby increases the aesthetic problem. The most effective treatment fills in this deepening trough with a flap of fat brought from within the eye socket at the time of eyelid surgery, or with fat grafts injected through the skin. Surface treatments have no effect on the thickness of the tissues beneath the surface.

Dark pigmentation of the eyelid skin, more frequently problematic on the lower eyelids, is the result of sun damage to the superficial layer of the skin in which pigmentation resides. It gives the eyelids a heavy, tired, sad look. Laser surface ablation, with its excellent control and ability to remove the surface of the skin, combined with pigment controlling medications, offer the best available treatment for this condition in the majority of cases.

For some patients, the appearance of their eyelids is largely affected by one type of problem alone. For others, problems combine to detract from their appearance. In either circumstance, the treatment best suited to the specific problems will yield the best result. Not all physicians are skilled in all treatment modalities. Some physicians may be more likely to recommend a treatment familiar to themselves in preference to a procedure more appropriate to the patient's particular concerns. Consultation with a knowledgeable and ethical plastic surgeon will help most people understand the nature of the problem as well as the most appropriate options for treatment.

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