The upper eyelid and eyebrow are intimately intertwined. Altering one directly affects the other’s shape, contour and function. When upper eyelid surgery is considered it is imperative that the eyebrow is returned to an anatomically correct position. Most commonly patients consider the removal of skin and fat excess as their primary objectives when it comes to the upper eyelid. However the lid and the brow are not mutually exclusive—they must be addressed as one unit. The upper eyelid incision provides an easy and well concealed access for removal of the lines between the brows (see Surgical Botox under Unique Procedures) while providing an avenue for brow elevation at the same time. Other options include tightening a lax lower eyelid, treating “bedroom eyes” (lazy eyelid, droopy eyelid, ptosis), and enhancing the definition of the upper lid crease. Fat grafting is routinely used to enhance brow bone definition and treating orbital hollowing, softening the area around the eyes that sometimes takes on an unattractive skeletal characteristic.
The lower eyelid has a close association with the cheek and lid/cheek junction. Darkness and hollowing is one of the first complaints of facial aging. Surgery of the lower eyelid must be handled with caution. It is much more technique sensitive and poor surgical outcomes are more apparent aesthetically and functionally than in the upper lid. The lower lid can be approached from the inside (transconjunctivally) or outside (transcutaneously) but not all procedures related to the lower lid are possible through either approach. Prominent fat pads (from the eye socket) are easily approached through the inside. Skin excess requires a small incision under the eye lashes (transcutaneous—subciliary incision). Fatty Hollowing and darkness are especially amenable to fat cell-derived stem cells injections. Festoons (saggy lower eyelid muscles) are treated through the transcutaneous approach or can be part of a facelift procedure. Wrinkling of the lower eyelid skin can be treated with chemical peels, laser, or Ulthera® often in combination with fat grafting.
Techniques used during the first generation of eyelid surgery did not take into account the true mechanisms of aging. As little as 15 years ago, when someone talked about “having their lids done” it meant some amount of skin, muscle and fat was removed from the eyelids. These operations produced their fair share of eyelid distortions and altered eyelid shape was a very common issue. This operation did not take into account the true mechanism of aging. At about that time, I was among a small group of physician-pioneers who started to experiment with volume replacement by studying the effects of fat grafting. This began to elucidate and treat the true cause and effect mechanisms of aging versus a superficial intervention.
Patients with dry eye must be identified pre-operatively and special precautions taken to prevent issues post-op. Patients with existing dry eye are naturally at a higher risk for worsening symptoms post operatively and special precautions must be taken to prevent post-operative problems including pain and ulceration. Make sure you let Dr. Kornstein know if you have any issues with your eyes, including excessive tearing or if you must use drops all day. If you can wear contacts comfortably, your eyes are naturally well lubricated. Be sure to let our practice know of all your previous eyelid and eye surgeries and if you had any issues post operatively.
Many of the negative issues associated with coronal browlifts were laid to rest with the advent of a properly performed endoscopic brow lift. Brow lifts are actually much more forgiving than eyelid surgery though the public’s perception seems to be the opposite. I believe this all started with the open (coronal) brow lift—incision from one ear to the other across the top of the head. This operation lent itself to overcorrection/ elevation of the brows, lack of expression, hair loss and temporary nerve damage. Many if not all of these issues were laid to rest with a properly performed endoscopic brow lift (five small incisions within the hair, no shaving necessary, and no nerve regrowth phenomenon in most cases). Brows can also be lifted through the upper eyelid incisions or with injections of filler or fat in combination with Botox® or Dysport®. The male and female brows are different in terms of height and configuration they must be treated as such. Patients with high hairlines can have them lowered to help balance facial aesthetics and create an overall more youthful look. See Hairline Lowering in the Unique Procedures tab.