Eye

1.  Ideally, there is no extra skin, or fold, in the upper lid.  There is a natural crease in the center of the upper lid, demonstrating the roundness in the eye. 

2. There are no bags hanging from below the lower lid.  

3. The eyebrow is positioned above the bone that forms the upper ridge over the eye. 

COMMENT:  The eyes are an important center of beauty.  High eyebrows are a sign of youth.  If you look in a beauty magazine, you can verify that the models invariably have high brows.   An extra fold in the upper lid can begin at any age, even childhood.  Many young models and actors have eyelid surgery to correct this.  In some sense, the goal of upper lid surgery is to allow women to wear makeup.   Bags or fullness below the eye, referring to the out-pouching from below the lower lids, can also begin at an early age. 

Oriental eyes are a completely different aesthetic consideration.  The eyelid design may be considered a desirable ethnic characteristic.  There are simple operations designed to eliminate these features if the patient prefers them changed. 

SELF-EVALUATION:

1. Check your brow position.  Are they symmetric?  Feel the ridge of bone underneath the brow.  Where is it placed relative to that bone? 

2. Pull up directly over the brow to see how high it will go. 

3. Is there extra-skin of the upper lid?  Grasp it and pull out.  Do the upper lids rest on the eye lashes?  This is the final stage of lid drooping. 

4. Pull up on the sides of your forehead.  Does this correct the eyelid fold?  Does it also correct a low brow or is the brow now too high? 

5. Take a blunt tool, like a pencil, and press in on the bag below the lid.  Try to envision the crease developed by removal of the bag. 

HOW MUCH CAN BE IMPROVED?

1. Often the extra skin in the upper lid is a consequence of a sagging forehead.  If the eyebrow position is improved and the extra lid skin is also reduced when you pull on the forehead, it may be advisable to have some form of forehead lift done in place of or in addition to eyelid surgery. 

2. Bald men with saggy eyebrows have few places to hide the scar.  Sometimes the incision is made directly in the brow or in a wrinkle of the forehead.  Brow position may be limited by the tension in the forehead. 

3. Upper lid skin can be removed fairly generously until the fold is gone.  However, the eyelid must be able to close completely and this may require some fold to remain. 

4. Lower lid bags can be completely eliminated.  When the bags are gone, excess skin may fall into the new crease and tighten. 

5. Lower lid wrinkles are a difficult problem.  Unfortunately, tightening the lower lid skin is filled with potential complications, like the lid pulling away from the eye. 

6. If you wear contact lenses, dry eyes after eyelid surgery can be a problem.  The surgeon must be conservative. 

7. Women with high brows requesting a forehead lift may have a problem with a brow position that is too high. 

1. Eyelid Surgery
2. Blepharoplasty

THE GOALS OF EYELID SURGERY- UPPER LIDS VERSUS LOWER LIDS 

Surgery of the eyelids can be a very complex subject.  From the surgeon's point of view, there are hundreds of articles and books written about eyelid surgery technique.  Here, we hope to review some of the basic ideas and explain what you should expect. The problems with the upper and lower eyelids tend to be different.  The upper lid develops extra skin with age.  In women, the goal of the upper lid blepharoplasty is usually to remove skin so that they can wear make-up in the eyelid fold.  As people get older, the upper lid skin may also interfere with vision. In lower lids the problem is usually bags.  These are from extra fat pouching the skin outward.  Although the extra skin from the bag may also seem to be a problem, it usually tightens underneath the curve of the eye socket when the fat is removed. 

INCISIONS FOR UPPER LID SURGERY 

Surgery itself follows some standard guidelines, though some aspects may vary from patient to patient.  Routinely, upper lid surgery must go through the skin.  There is no place to do this without an incision, although these edges usually heal up virtually invisibly.  The incisions almost invariably ends up about seven or eight millimeters above the eyelashes. How far the doctor carries the incision past the corner of the eye depends on the amount of skin to be removed and their personal preference.  The degree of scarring has to do with the quantity of skin removed.  The more skin that is removed, the greater the risk of scarring.  Patients need may need to accept some trade-off. 

LOWER LID INCISIONS- OUTSIDE VERSUS INSIDE (SCAR LESS) 

There are two general approaches to the lower lids. One is through this skin, or the external incision, and the second is the internal of "scar less" incision. The external incision goes about two millimeters below them the lower lashes in a crease and extends about a centimeter past the corner of the eye. The "scar less" or the sub conjunctival incision goes on the inside of the lid.  If you pull down on your lower lid, you will see the pink area on the inside in which that incision is made. There are several differences between these two incisions.  Through the inside incision, only fat can be removed.  Through the outside incision, skin and muscle may also be removed. In many patients, particularly younger patients, removal of fat alone is adequate and can produce a tremendous cosmetic improvement.  However, in older patients with a large among of extra skin, it may be desirable to remove a small skin strip from the edge. Some patients prefer the scar-less incision no matter what the result.  The wrinkles of the lower lid can be treated with skin peeling to enhance the result. 

EYELID AFTERCARE 

1. NOTIFY YOUR DOCTOR immediately of any loss of vision other than from swelling of the lids. 

2. NOTIFY YOUR DOCTOR immediately of any unusual pain in one eye more than the other. 

EYELID SURGERY COMPLICATIONS 

1. BLINDNESS / LOSS OF VISION-   Fortunately, this is rare after eyelid surgery.  It occurs from bleeding behind the eyeball causing pressure on the nerve that carries vision.  If it is drained early, usually permanent loss of vision can be avoided. If you notice one eye being pushed out significantly more than the other eye or a great deal more pain in one eye than the other, CALL YOUR DOCTOR IMMEDIATELY. 

2. DRY EYES-The incisions in the eyelids may interfere with the drainage of the tear glands.  If you wear contact lenses, this may be a problem.  You may need to get your tearing checked before surgery.If your eyes don't close well because of the skin that has been removed, dry eyes may follow.  You may need revision surgery. 

3. ASYMMETRY-   Usually, the doctor measures each eye to take out the same amount of fat, skin, and muscle.  You may need a small touch up to balance them out if it doesn't appear even. 

UPPER LIDS 

1. MILIA-   Small bumps, skin cysts, may form in the lid where skin glands were cut.  The surgeon can pluck these out for you.

2. SCARRING-   Usually the incision heals in the natural crease above the eye and is completely hidden.  Even the crows feet area heals well. 

3. EXCESS SKIN-  If your surgeon is conservative, they may expect to trim off some additional skin on a later date.  This is usually a small procedure. 

LOWER LIDS 

1. EVERSION OF LID (ECTROPION)-Too much skin was removed or excess scarring has forced the lid outward.  A small revision procedure can shorten it and tighten the rim. 

2. PERSISTENT BAGS-   Fat remains. 

3. CORNEAL SHOW-  Too much of the white below the iris is exposed because the lower lid is pulled down.  Some sort of lid suspension procedure is needed to repair this .