The eyes are a unique focus of expression and communication for the human face. We instinctively look into them to judge the emotions and intentions of others. They are also the part of our face we attempt to manipulate most in order to convey a certain look or feeling. This manipulation is not verbal or conscious, but rather a change in how we present ourselves to the world through the use of muscles to shape our brows and lids, and fat to fill or hollow them. Eyelids and eyebrows have well-defined structure and function, and have aesthetic and practical roles to play in creating an overall facial appearance. With time, however, the aging process, environmental exposure, and other forces conspire to rob the periorbital area of skin elasticity and soft tissue fullness. The result is an eye region that may appear prematurely aged, often giving the person a tired, dull, sad, or angry appearance. Eyelid and brow surgery is the collective name for a series of specialized cosmetic and reconstructive procedures that can refresh the area around the eyes, often in the process addressing mild to moderate vision obstruction due to functional lid ptosis (drooping).
Skin, fat, and muscles around the eyes age in complex ways that are dictated by a combination of genetic and environmental factors, as well as the effects of gravity. In the upper lid, skin loosens and sags, contributing to drooping or hooding of the lid (ptosis) that can make the eyes appear heavy and dark. Ptosis that is severe enough may even interfere with one’s superior field of vision. Fat pads under the upper lid can also herniate forward in some patients, resulting in a puffiness or fullness in the inner corner of the eye. Aging changes in the lower lid involve wrinkling and loosening of the skin, as well as fat herniation that results in bags under the eyes. Muscles and ligaments may also weaken as we age, contributing to lower lid malposition (ectropion or entropion). The brow complex slowly descends as a result of volume loss in the forehead and the relentless pull of gravity. A lower brow position exaggerates the heavy upper lid appearance and contributes to a sad, angry, or even simply tired appearance that is not congruent with one’s inner emotions.
Blepharoplasty is a type of surgery that corrects eyelid deformities and defects. An upper blepharoplasty is one that addresses upper lid skin and muscle, usually performed through an incision in the natural crease of the lid. Through this incision, excess skin can be trimmed away, muscles tightened, and sometimes fat removed or repositioned. The result is often a more open, wide-eyed appearance, as well as a functional benefit in terms of superior field of vision in the case of marked lid ptosis. A lower blepharoplasty addresses defects in the skin and soft tissues of the lower eyelid. There are different surgical approaches to this procedure, depending on the amount of skin or fat involved. A transconjunctival incision, made inside the lower lid, is used to trim or reposition fat with no external scar. If skin needs to be trimmed as well, then an external incision just below the lash line is made. Newer surgical techniques tend to focus on repositioning of the fat in the lower lid rather than its removal in order to fill in the tear trough, or groove under the eye. The newer philosophy in modern blepharoplasty is that filling in this groove helps the lower lid blend in better with the cheek to prevent a hollowed-out appearance that can sometimes occur after older methods of surgery.
Eyebrow position has a huge impact on the overall appearance of the eyes, and an upper blepharoplasty will be drastically different if an accompanying brow lift is performed or not. A brow lift or forehead lift is a procedure that elevates the brows to a higher position, smooths deep horizontal creases in the forehead skin, and sometimes also corrects frown lines between the brows. There are many surgical approaches, each with its own advantages and disadvantages. The old-fashioned coronal lift involved making an incision from ear to ear across the top of the scalp. This has mostly been replaced by newer, less invasive techniques. The endoscopic brow lift is now very popular and involves making several tiny incisions along the hairline through which a small camera (endoscope) and specialized instruments are used to release and elevate the underlying tissues. The advantage of this technique is less visible scarring, a shorter recovery time, and less risk of loss of scalp sensation. The temporal lift is a smaller procedure for patients who tend to have their brows drooping mostly in the lateral (outer) part of the brow. The direct brow lift is an option in a few select cases in which a small amount of skin is removed just above the brow itself. As the scar in this case is in such a visible location, extra care must be taken with scar revision in these cases. As with all surgery, the specific technique used is a joint decision between the patient and the surgeon based on anatomy, aesthetic goals, and hairline considerations.
The art of facial rejuvenation surgery is not so much in the individual procedures themselves, but in the realization that they are not isolated or mutually exclusive in most cases. A patient presenting for consultation with heavy upper lids can on close examination be found to have significant ptosis (drooping) of the brow, making an upper blepharoplasty without brow correction a rather fruitless and potentially “overdone” exercise. Removal of skin and fat from the upper lid, when the brow position has not been improved, will achieve only a minimal cosmetic or functional change, as the sagging brow will still have taken up a lot of upper lid territory. Lifting the brow in such a case will have improved upper lid function and appearance on its own, after which only a conservative, well-placed blepharoplasty will be required. This is the reason why a detailed consultation is so important. A thorough, attentive surgeon will examine the entire periorbital complex—the brows, skin, fat, muscle, and bone—to design a truly personalized surgical plan that takes into account the individual needs and structure of each patient. The goal of surgery in these cases is never to make the eyes look like they have been “operated on”, but rather to refresh, rejuvenate, and enhance the patient’s appearance while preserving their unique identity.
Any surgical procedure has its attendant risks, and eyelid and brow surgery is no exception. Although these procedures are now highly refined and safe, there are side effects and potential complications that patients must understand and accept. Blepharoplasty and brow lift may involve bruising, swelling, dryness, irritation, blurred vision, and other side effects. Complications are relatively rare but can be more serious, such as infection, bleeding, hematoma, asymmetry, lagophthalmos (inability to close the eyes completely), or loss of skin sensation. The most important step a patient can take to minimize these risks is to select a board-certified plastic surgeon or oculoplastic surgeon with significant experience in these specific procedures. The recovery period will usually last several weeks. While much of the initial swelling and bruising will have subsided after the first 2 weeks, allowing patients to rejoin most social activities, the ultimate results take longer as the residual swelling goes away and the scars mature. This process can take several months. Patients are advised to follow the post-operative instructions given to them closely in the first week or two. This may include head elevation, use of cold compresses, and diligent lid care to encourage a smooth healing process.
Patients who choose to undergo eyelid and brow surgery do so for many different reasons. Some have difficulty with visual obstruction from upper lid ptosis. Others simply want to correct or reverse signs of aging in the eye area. For many, it is both these things, and there is often a significant improvement in self-confidence and self-esteem as a result. At the end of the day, eyelid and brow surgery is a strong example of how medical science and aesthetic artistry can work together to improve one’s quality of life. These procedures can help to erase some of the signs of aging that nature forces on all of us and ensure that the “windows to the soul” stay bright and clear.
