Upper Eyelid Surgery (AKA Upper Blepharoplasty)

Before & After

Eyes are the focal point of one's face. They are the first thing people notice and are the key to facial expression. This is the main reason why so many people seek cosmetic eyelid surgery. It is not uncommon to hear over and over again, My eyes always look tired and old even when I feel wide awake. This is very profound because often if you look old and tired you will feel the same way. How many times have you dressed up and prepared to go out feeling good about yourself only to look in the mirror to see that your eyes look older than you feel. The reason for this is that during the aging process the region around your eyes shows the effects of aging much sooner than other areas.

In the attractive, youthful eye lid, the lateral canthus should be higher than the medial canthus. With age the brow and lateral canthus sag.

Aging affects the entire face. Aging around the eyes, however, is usually the first area that is noticed. The aging process can be simplified by thinking of it in terms of the three most important components of the face. These components are the skin, the underlying muscle, and the fat. Most people do not think of aging as involving the latter two structures but, in reality, these are probably the most important ones. Have you ever looked at a baby's cheek? It is full and fatty. Look at a model’s cheek. It is not as full as a baby's cheek but still it has significant volume due to the underlying fat.

There is a substantial amount of fat situated around the eye region. As we age, the fat will either descend downward on the face or may go away completely. When this happens, it exposes the underlying facial skeleton resulting in the familiar gaunty appearance that we recognize as aging. Also, the fat and underlying muscles act as a filler creating the volume seen in the cheeks of youth. When this filler descends or goes away, we see wrinkling. This process is similar to a grape which turns into a raisin when the water is removed.

The importance of the underlying fat and muscle has been revolutionary in the field of plastic surgery over the last 10 years. It is no longer acceptable to think of eyelid rejuvenation as merely a procedure to tighten the skin. This is why Dr. Cruise feels it is so important to correct the problem itself and not just the effects of the problem.

When evaluating the upper eyelid there are three important components of the upper eye region that must be considered. The eyebrow, the upper lid itself, and the lateral canthus. Typically, these three areas sag at different rates and, therefore, each patient must be assessed individually.

Most patients need removal of fat and skin to create an elegant upper eyelid crease.

Descent and laxity of the lateral canthus is a major contributing factor to the appearance of old age within the eye region. This sagging gives a depressed, tired appearance. The upper eyelid of youth has a bright, open appearance. Of particular note is the fact that the lateral canthus should be higher than the medial canthus. Dr. Cruise feels that it is important to address this issue to create the best look possible. Often, he will elevate the lateral canthus in conjunction with the upper blepharoplasty to re-create that youthful, almond-shape appearance. See above.

Others need correction of all three elements comprising the upper eye: The eyebrow, the eyelid, and the lateral canthus.

Often, Dr. Cruise will perform a Temporal Brow Lift instead of a conventional brow lift when he does upper blepharoplasty. This is much less invasive, yet, still effective. The Temporal Brow Lift only addresses the temporal area but this is usually what needs elevation the most. The decision as to what is best for you can only be determined during consulation.

There is a forth potential problem area when addressing the upper eyelid that is not talked about much and often goes unaddressed. This is eyelid ptosis, also know as, descent of the upper eyelid. See example below.

Example of 26-year-old female six weeks before her wedding. She complains that her left eye(right side of picture) was lower than her left. Notice in the BEFOR how the left upper eyelid touches the pupil, whereas, the left eye is wide open and bright. Also notice difference in eyelid height. After shows both lids at the same level and similar eyelid height.

Eyelid ptosis becomes quite common as we age. The muscle that elevates the upper lid simply breaks off and the lid lowers. It may be one side or both. It gives the appearance of a chronic tired eye. Correction opens the eye and gives a brighter, more awake appearance.

The take home point to all this information is that there are several elements of the upper eyelid region that must be evaluated during and upper blepharoplasty exam.

It is important to understand the limitations of upper blepharoplasty. An upper blepharoplasty alone will not correct crow's feet. It will help but often a concurrent brow lift or temperal brow lift is necessary. Often, Botox&reg may also be helpful.

It is often very useful to perform fat transplantation, as well as either chemical peeling or laser skin resurfacing, in addition to eyelid surgery. This allows Dr. Cruise to address all the components associated with aging around the eye. Remember, the aging eyelid is a result of problems within the skin, muscle, and fat.

Dr. Cruise's philosophy regarding Eyelid Surgery

Plastic surgery has made significant progress in the understanding and treatment of eyelid rejuvenation. Personally, I have been actively involved in this progress. I find it very satisfying that I now can address the various causes that create an aged appearance to the eye. Instead of treating it with a one size fits all procedure I can specifically address each problem. This allows me to more effectively rejuvenate the eye region in a way never before possible. This is the artistry of plastic surgery.

As mentioned above, aging of the upper eyelid area can be simplified into thinking of it as aging of the three components that make up the upper eyelid area: The eyebrow, the eyelid, and the lateral canthus. Remember, this is a simplification but it works very well for me when I try to explain the dynamics of eyelid aging.

During consultation, I will examine your upper eye lid region. With the help of a mirror, you will show me what it is that bothers you. We will look at the skin, the muscle, and the underlying fat individually, and as a group, to see what is necessary to create the look you desire. It is very helpful to bring pictures of a magazine with eyes that you would like to resemble.

My philosophy is to try and accomplish the desired results with the least invasive procedure available. Often, it is necessary to combine procedures such as eyelid surgery, chemical peeling, brow lifting, and/or lateral canthoplasty. This allows me to improve the texture and skin quality as well as to reposition skin. From experience, I have determined that the best results are when all the problems are addressed during one procedure. Post operative downtime is minimally increased but the result is much better.

Benefits

There are many benefits to eyelid rejuvenation surgery. The key is to determine exactly what the problem is.

Lower eyelid surgery benefits.

• Tightens and smoothes out bags underneath the eyes.
• Repositions lower eyelids into a more elegant, almond-shaped appearance.
• Repositions underlying fat to get rid of the sunken, aged appearance.
• Repositions skin and underlying muscles to smooth out wrinkles.
• Markedly fills out the deep crease known as the tear-trough between the eye and nose.
• Eliminates circles underneath the eyes.
• Improves dark discoloration within the lower eyelid.
• Improves fine wrinkles.

Upper eyelid surgery benefits.

• Removes excess fat and skin of the upper eyelid.
• Creates a sculpted, more attractive upper eyelid.
• Creates a double lid and removes excess eyelid fat in Asians.
• Elevates the upper eyelid to give a brighter, and youthful expression.
• Repositions upper eyelid fat into more youthful position.
• A temple lift or brow lift can can be performed at the same time.
• Allows easier make up application without smudging.

Possible complications

The most common complication is inadequate correction of the problem or asymmetry. If this is the case, correction can usually be made with a minor additional procedure. One must understand that complete symmetry is not possible. Nobody is completely symmetrical. Sometimes, the underlying bony structure is so different from one side to the other that symmetry can not be achieved.

Complications that can occur with any surgery include infection, blood or fluid collection, and unfavorable scarring.

Are you a good candidate?

Most people as they age can obtain improvement from upper eyelid surgery. Specifically, good candidates include people with the following problems around the eyes:

• Excess skin and fat within the upper eyelid.
• Sagging of lateral eye.
• Sad or tired appearance of upper eyes.
• People who desire an elegant, well defined upper eyelid crease.
• Asians who desire a double eyelid.
• Ptotic eyelid that make the upper lids appear tired.

Prior to surgery

• Medications. Certain medications thin your blood and should not be taken within three weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery. Dr. Cruise will go over this more thoroughly prior to the procedure.

• Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask Dr. Cruise for something to help you sleep.

• Smoking. Do not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, makes anesthesia much more difficult.

• Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with Dr. Cruise and the anesthesiologist.

• Washing. It is a good idea to wash the surgical area thoroughly the night before and the morning of surgery. Wash your hair and comb it straight back. Do not apply makeup. Remove all jewelry including wedding rings and body piercings.

• Arrival. It is best to arrive on time so things go smoothly. Please be sure to have someone else drive you.

• State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned. Dr. Cruise and ICRS are both well trained and experienced. Excessive worrying can actually be detrimental and you should discuss this with Dr. Cruise prior to surgery so that something can be prescribed to make sure you remain calm.

Consultation For Upper Eyelid Surgery

• General Health

• Past Surgical History

• Medications

• Allergies to Medications

Proper evaluation can determine the two different types of fat. Regardless, it is often necessary to remove both types in order to clean up the upper eyelid. Once again, there was a time when plastic surgeons routinely removed all this fat but this is no longer the case. Complete removal can lead to a hallowed out appearance especially toward the nose. If you look at an adolescent, you will see plenty of fat. Fat is youthful and must be removed only as needed.

Asians typically require a more aggressive fat removal. With them, almost all the fat is removed to achieve the desired result.

3) Sagging Lateral Canthus

This is one problem that many plastic surgeons fail to recognize and treat. Dr. Cruise began elevating the lateral canthus early is his career and noticed such an elegant result that he began performing it routinely. He found that it is especially useful on patients with lax lower eyelids or patients with a downward tilt of the eye. In youth, the lateral canthus is 2-3mm higher than the medial canthus. This is exemplified in the picture of the ideal eyelid above. As we age, this elevation is lost resulting in what many call a hound dog appearance.

Below is an anatomic depiction of the descent of the lateral canthus.

4) Eyelid Ptosis

This is another upper eyelid problem that many plastic surgeons fail to diagnose and treat. Eyelid ptosis simply means that the upper eyelid sags. In cosmetic patients the most likely causes is 1) The upper eyelid fat is pushing it down. Here fat removal will take care of the problem or 2) The muscle attaching to the upper eyelid has torn. This is more complicated to treat but still can easily be done at the same time as an upper blepharoplasty.

 

Normally, the upper eyelid well above the pupil.

With eyelid ptosis, the upper eyelid falls to the level of the pupil. This gives a tired appearance and increases the vertical height of the eyelid on that side. People notice the asymmetry. Sometimes both sides have ptosis and, therefore, the asymmetry is not as noticable but the eyes appear almost shut.

26-year-old female complains that her left eye(right side of picture) was lower than her left. Notice how the left upper eyelid touches the pupil, whereas, the left eye is wide open and bright. Also notice difference in eyelid height. AFTER shows both lids at the same level and similar eyelid height.

 

• Typical Incisions

The amount of skin removal depends on the amount of excess skin present. Here is a typical upper blepharoplasty excision. The end result is a straight line the becomes almost impossible to see after 3-4 months.

Anesthesia

ICRS uses only board certified anesthesiologists to make sure you have the best anesthesia possible. The anesthesiologist will discuss with you what type of anesthesia is best for you. He/she will take into consideration your medical history, the procedure, and your personal wishes.

Eyelid surgery can be performed under general anesthesia or under local anesthesia with or without sedation. If several procedures are being done at once then general anesthesia is the better option. This will be discussed during your consultation with Dr. Cruise and the anesthesia team.

After the procedure

The procedure itself will take about 1 - 1 1/2 hours. If other procedures are also being done then, obviously, the operative time will be longer.

Immediately. Right after the operation you will be watched by a nurse for 1 or 2 hours and encouraged to walk around. Dr. Cruise is a strong advocate of good pain relief so you will be given as much pain medication as necessary both immediately after the operation and for the next 4 to 5 days. You will have dressings around your eyes as well as ice packs to reduce swelling. It is very important that you keep your head elevated to decrease swelling. Still, you can expect that your eyes will swell up and there will be bruising. You will be able to eat and drink when you get home.

That evening. It is recommended that you take it easy. You can walk around, eat, but not much more. Eyelid surgery is usually not painful. Still, you should take as much pain medication as necessary and try to go to sleep early. It is very important to keep your head up the first 3 days. This will markedly decreased the swelling and bruising. The eyes tend to swell and bruise quite easily, so do not be concerned by this. It will go away. If oral steroids are prescribed be sure to take them as they help decrease swelling significantly.

First 48 hours. You can take a shower the day after. Just be gentle. Do not use hot water. Allow cool water to hit your scalp and then trickle over your eyelids. You can gently wash with soap but do not rub. Mild oozing will continue for about 2 to 3 days. Dressings are not necessary after the first day. Your first post operative appointment with Dr. Cruise will usually be 1 week after surgery.

First week. At about day 2, the swelling will be at its maximum. The majority of the bruising and swelling will go away in about 2 to 3 weeks.

Beyond. Swelling will not completely resolve for about 6 months but, as mentioned above, the majority of it will be gone by 2 weeks. The final result will not be evident until at least 3 to 6 months when all the swelling has resolved and skin contraction is complete. Patients who have fat transplantation tend to swell more.

Recovery time

Usually, people are off work for about 1 to 2 weeks depending on how self-conscious a patient is about the swelling and bruising.