Fundamentals In Aesthetic Surgery Of The Upper Eyelid
7 May 2021 onur
I know, I know. The title sounds too academic.
It feels like the title of a chapter.
But I couldn’t find a cuter title.
Aesthetic surgery of the eyelids is not something simple and straightforward. You cannot acquire sufficient knowledge in this field by reading things on a forum, browsing on Google Images, or hearing and observing the experience of a couple of your relatives.
An attempt to understand eyelid aesthetic surgery via the superficial learning tools above causes greater confusion for you. For me, it leads to ambiguous questions that cannot be answered with brief responses.
-My friend had eyelid surgery. Her eyelid has drooped again. That wouldn’t be the case with me, would it?
-What do you mean when you say, ‘Her eyelid has drooped’? Persistence of excess skin? The inability of the skin to disperse along the eye contour due to a lack of folds? Or mechanical eyelid ptosis? Or fat atrophy that creates the illusion of a drooping eye? The drooping of the brow and its getting closer to the eyelid after eyelid surgery? The ongoing loss of eyelid support due to bone failure? Or the squint from mimic hyperactivity?
Of course, this is not how we answer the question above.
– If you wish, I will gladly see you and your friend for an examination and inform you in terms of your upper eyelid problems. Together we will surely create a solution.
That’s what I say.
But you don’t have to come to my office to get some basic information, nor do I have to repeat the same things to different visitors over and over.
This blog post is written to give you an idea of what the key matters you need to know in aesthetic surgery of the upper eyelid are. The fundamentals of eyelid aesthetic surgery are also the main determinants of the surgical plan. The surgical plan varies according to the problems with these fundamental elements and may be quite simple in some patients but more comprehensive in some others.
Before I start listing them, I would like to emphasize the following important point. Each of the fundamental elements that I will list below affects another. We call this relationship between elements a “dynamic interaction”. The problem you see in one element may be triggered or exacerbated by another element.
So let’s start.
Excess eyelid skin
As the area around the eyes ages, the upper eyelid skin starts to get loose and to sag. Patients can grab and pull this skin with their fingers, which is uncomfortable. So, does our body constantly produce skin as we age? Not exactly.
Excess skin on the eyelid is a relative excess. In youth, the volume of this area is much higher. As the volume decreases, the cover on the surface loosens and hangs like a pillow that empties. In other words, the amount of skin remains relatively higher than the tissue volume.
In almost all eyelid aesthetic surgeries, this excess skin on the eyelid is removed. However, the biggest mistake at this point is to reduce eyelid problems to excess skin. In the past, there was an opinion that the more skin was removed from the upper eyelid, the better. This view is no longer applicable. The modern approach is based on the principle of understanding the effects of other factors that I will list below on the relative eyelid skin excess and correcting them simultaneously.
You may be thinking that eyebrow and eyelid are two different components. However, the skin on the lower surface of the eyebrow and the skin on the eyelid are in continuity. When the eyebrows lose their high position in youth and droop, the skin just below the eyebrow – which belongs to the eyebrow – piles up on the eyelid. It looks as if there is excess skin on the eyelid. In patients with low eyebrows, if you reduce eyelid skin instead of raising the eyebrow, you will cause further drooping of the eyebrows and bring them closer to the eyelash. The eyelid will not open, and the eyebrows will not straighten. Therefore, it is important to make sure that the eyebrow is in the normal position while examining the eyelid aesthetic. When you raise your eyebrow, if the excess eyelid skin disappears and this eyebrow position is more attractive to you, then the treatment should be eyebrow lift surgery, not upper eyelid surgery. Most patients over the age of 50 have significantly drooping eyebrows. In order to achieve the ideal result, we often bring the eyebrow to its normal anatomical position and intervene in the excess eyelid skin in the same session. This is one of the major differences between the plastic surgery approach and the ophthalmological approach.
Inside the eyelid, there is a deep muscle that starts from the upper/back of the eye and extends to the front of the eyelashes.
It’s called the Levator Supercili.
Its main function is to open the eyelid and lift it.
This muscle wears out during the aging process. This wear is often asymmetrical. After the age of 40, the eyelash line moves down at an average of 1 mm every 10 years. The upper eyelid fold rises. The patient raises their eyebrow to open the eye on the same side.
Eyelid drooping, namely “ptosis”, is a pathology completely independent of excess eyelid skin. You cannot restore the function of this muscle by only removing eyelid skin. During surgery, it is necessary to open the orbital septum and go down to the deep plane of the eyelid to repair this muscle. Otherwise, you will not be able to achieve the vitality of the gaze as well as a sufficient eye aperture. Normally, the eyelashes should cover the colored halo (iris) of the eye by 1 mm from the upper border. In the presence of ptosis, we see less of the colored halo of the eye, and the eye has less aperture. Our rate of successfully correcting ptosis during eyelid surgery in patients over 50 is 90%.
There is a vertical connection between the Levator muscle and the eyelid skin, which I mentioned in the section above. This connection determines the level and depth of the eyelid fold.
The anatomy of this fold matters. It may deteriorate due to aging or surgery. It is located very low or sometimes not developed at all in Asian eyelids. The aesthetic eyelid ideal cannot be achieved without restructuring the fold. Period.
Imagine the path the skin follows when we look at the eyelid from the lateral view. The skin goes down from the eyebrow, curls behind the eye along the fold when the eye is open and then turns towards the eyelashes. That is, a part of the skin folds towards the back of the eye in a V shape. When the fold is disrupted, the skin folds directly onto itself vertically, like an accordion. If you think that uneven skin distribution caused by the disruption of the fold is “excess skin” and remove it, you will only increase the existing deformity.
Fat anatomy inside the eyelids
There are two large fat pads inside the eyelids. These fat pads have key functional importance. As we age, the protective layer on these fat pads loosens and the fat herniates. In the past, these fat pads were removed. The removal of fat does not only create a prominent hollow in the eye in the long run but also pushes the eye back into the bony cage in which it is located. Thus, we rarely remove these fat pads anymore. Most of the time, we shape these fat pads within the deep anatomy and preserve them in their ideal anatomical places. Sometimes there is lacrimal gland sagging in the outer part of the upper eyelid. We fix them with protective methods, just like we do with fat.
Fat anatomy outside the eyelids
I explained how the eyelid skin and the skin on the lower half of the eyebrow are just a continuation of each other. However, the anatomy in these two areas is different from one another. There is free subcutaneous adipose tissue under the eyebrow. Yet, there is no fat tissue under the eyelid skin. Fat injection is not done on the eyelid, but it is done successfully under the eyebrows. In the aging process, following the decrease in the volume of adipose tissue under the eyebrows, the bone contours become prominent, the expression hardens, and the deep structures (bags and lacrimal gland) become visible externally. Balancing the volume of this area in treatment is very important to achieve the ideal result.
Bone anatomy around the eyes
Bone anatomy around the eye closely determines the eyelid aesthetics. In almost every person, the right and left bony cage (orbita) are slightly different from each other. In 10-15% of the population, there is a clear difference between the vertical position of the eyes (vertical dystopia) and their protrusion (proptosis). These factors affect the visual appearance of the upper eyelid, but perhaps the most important determinant in terms of upper eyelid aesthetics is the structure of the bone under the eyebrows. If this bone is underdeveloped or regressed, it cannot support the eyebrow. In this group of patients, the eyebrows rest on the eyeball starting from the early stages of life. The Levator muscle that opens the eye is tired by the weight of the eyebrow, which causes droopy eyelids in the long run. It may sometimes be necessary to support this bone anatomy with implants and often with CAHA/HA fillers on the bone.
In other words, a patient’s under-brow bone deficiency may first cause the eyebrow to droop, then the eyelid mechanism to wear down, and then a related excess of skin. If the patient and the doctor interpret this situation only as an excess of upper eyelid skin, this will result in an inadequate treatment. It is highly important to understand and correct bone deficiency, particularly in male patients. That is because we can raise droopy eyebrows via forehead lift in women. High eyebrows suit women. In men, raising the eyebrow is aesthetically inappropriate. In men, it is necessary to move the eyebrow forward, not up. The only way to bring the eyebrow forward is to put a support on the bone.
Mimic activity around the eyes
Finally, the movements of the mimic muscles around the eyes closely affect the eyelid aesthetics. When you close your eyes or frown, you may observe that the eyelid skin becomes loose and wrinkled. If there is mimic hyperactivity or if the wrinkles that bother the patient are associated with mimics, removing skin from the eyelid alone will not be beneficial. We can use Botox to weaken the muscles that close the eyes and frown the brows or we can weaken them surgically (permanently) during upper eyelid surgery. It would be useful to diagnose mimic hyperactivity before surgery and to include it in the surgical treatment plan if it bothers the patient.
Weakening of the mimic muscles around the eyes with random, standard applications also has negative implications on the aesthetics of the upper eyelid. When the large horizontal muscle (Frontalis) on the forehead contracts, it raises the eyebrows. Weakening this muscle with repetitive Botox injections will lower the eyebrows in the medium/long run. The result is a straight and shiny forehead, flattened eyebrows and squinted eyes. In this group, it may be risky to plan an upper eyelid surgery before the effect of Botox completely disappears and before the forehead muscle is reactivated and restores its usual strength.
This post is getting a wee bit too long. There are other things that could be added to what I have already stated. Past traumas, surgeries, configurations of the connective tissue system in the eyes, hormonal pathologies and numerous other factors closely affect eyelid aesthetics.
Aesthetic surgery of the eyelid is not difficult for the patient. It is a relatively comfortable, quick healing and pleasing procedure. However, correct diagnosis, correct planning and correct application are key in achieving the ideal result.
Please feel free to contact us for more detailed information on eyelid surgery.
Take good care…
… of yourself and your beauty.