It has been said that the eyes are the windows to our souls. Certainly we often remember our friends and love-ones faces with the eyes playing a prominent role in facial identification. Unfortunately the aging process can strike this region relatively early leading to appearances that project fatigue, disinterest, and lack of vitality. Aging will result in skeletal changes around the eye, shrinkage of muscle and fat volume in the temples causing lateral brow descent, thinning and loss of elasticity of the skin of the eyelids, prominence of the fat pads of the upper and lower lids as a result of a weakening of the eye socket surrounding these structures, and in some cases the muscles that control upper eyelid position stretch or change leading to the upper eyelid drooping with respect to the pupil giving a sleepy appearance. All these symptoms of aging can hide the bright and vibrant person inside giving the false impression of a tired worn out individual. Take back the youthful appearance that is hidden under the veil of aging by consulting a board certified plastic surgeon who has expertise in eyelid and brow rejuvenation.
As with all anatomic areas deformities of the upper third of the face can span a wide range of severities. Many times women in their late thirties and early forties can show signs of early brow descent which can narrow the opening of the eye and brow skin resting on the upper eyelids. Many times in these milder forms of age and gravity related deformities we can correct with muscle balancing procedures utilizing neurotoxins such as Botox to weaken the depressors of the brow and allow unopposed brow elevators to prevail and elevate the resting tone of the brow.
Another targeted area to correct non-surgically, the brow position, is to restore volume to the temple region of the skull. This area in front of and superior to the ear and lateral to the brow represents the temporal fossa. This houses a large flat muscle that helps to elevate the jaw and is surrounded by soft tissue including fat and covered by hair bearing scalp tissue. Bony and muscle remodeling coupled with overlying fat shrinkage can lead to a hollowed out appearance which causes the brow to fall downward making the brow skin begin to cover the upper eyelid skin. Volume restoration can be accomplished with any number of filler agents but I prefer to correct the volume with a guided tissue regeneration product call Sculptra which is a polymer of lactic acid which promotes collagen deposition over time restoring volume and allowing the brow to be supported at a higher level compared to a depleted state.
As the brow tissue descends lower, further concealing the upper eyelid, the options narrow to surgical intervention. I prefer an endoscopic assisted brow lift over an open approach to avoid scars and hairline shifts. Just a few small openings spread out over the hairline allows for the complete release of the forehead and fixation internally to correct brow drooping leading to a pleasing brow position which looks natural without changing the hairline and allowing for improved visualization of the upper eyelid. In most cases the upper eyelid skin will require modification to give a harmonious smooth result. Errors such as trying to remove excess upper eyelid skin which includes excess brow tissue instead of performing a simultaneous brow lift will result in a poor result with very high eyelid crease scaring and the inability to close the eyelids resulting in dry eyes. Expertise in the aesthetic and functional evaluation of the upper third of the face is important.
The most common cause of excess upper eyelid skin is the underlying result of periodic eyelid swell causing excess thinning tissue. This can be addressed with conservative blepharoplasty techniques which can include some judicious fat removal. Of course a thorough exam to determine if the resting eyelid position with respect to the pupil is too low because not correcting the drooping of the upper lid will give a less than adequate rejuvenation because the patients eyes will still seem tired due to the lid lag.
Common aesthetic problems of the lower eyelid include excess skin, lack of lateral support of the lower eyelid giving a rounded eye appearance and excessive show of the whites of the eye ball, large fat pads with or without loose skin, increased separation of the eyelid cheek junction, and lastly crow’s feet. If skin quality is reasonable without excessive crepey skin and there is increase separation of the eyelid cheek junction then a conservative injection of a hyaluronic acid placed on the cheek bone under the muscle that closes the eyelids can smooth out the tear trough as well as build up the lateral eyesocket boney rim hiding some mild bulging of the lateral lower fat pad of the eyelid. This can create a Photoshop effect smoothing out the eyelid. Another conservative approach to helping the aging lower eyelid is to diminish activity of the lateral muscle that closes the eyelids with neurotoxins which can lead to a reduction in crow’s feet and can slightly help to elevate the lateral third of the brow.
Surgical interventions of the lower eyelid include judicious removal of the two lower eyelid fat pads through the inside of the lid with transposition of the fat on to the cheek to hide the tear trough, surgically removing excess skin from under the lash line vs skin tightening with a C02 Laser, lateral lid support to the bone enhancements with or without shortening the horizontal length of the lid. These procedures need to be selected based on clinical exam with the goal to provide a youthful eyelid with good support while avoiding excessive hollowing of the lower eyelids and poor lid support leading to rounded eyes and increased exposure of the eyeball.
The upper third of the face contains the aesthetic units of the brow, upper and lower eyelids and are a very unique region of our body for both special senses of vision, and provide our unique individuality of facial appearance. Aging can have a detrimental effect on both the aesthetics and function of this region which can bias people’s opinion of our vitality and mental sharpness. Non-surgical and surgical corrections can be important tools to correct these deformities restoring our appearance and giving back self confidence.