Important considerations in eyelid rejuvenation

Plastic surgery procedures aimed to improve the appearance of the eyes are some of the most sought after aesthetic rejuvenation treatments. Last year alone, more than 200,000 women and men underwent eyelid lift surgery, or blepharoplasty, at the hands of board-certified plastic surgeons.

Pre-operative assessment of blepharoplasty patients requires a meticulous evaluation of their anatomy and ophthalmologic examination, as well as eliciting any history of eye problems such as dry eye.

Patients who wish to undergo eyelid rejuvenation often complain of one or more of the following:

• Looking tired or fatigued
• Heavy, droopy lids
• Undereye bags or puffiness
• Excess, wrinkled, crepey skin

Most of these issues can be successfully corrected with eyelid lift surgery of the upper and/or lower lids. These surgeries focus on improving the three main tissue components of the lids: skin, muscle and fat. When determining the best procedures for periorbital improvement, there are additional physical characteristics to be assessed in order to formulate the most appropriate treatment plan. Here are some important factors that come into play and that plastic surgeons and patients need to consider prior to any aesthetic surgery around the eyes.

Upper eyelid droop: Is ptosis present?

Most patients who complain about the appearance of their upper eyelids notice that they have heavy, hanging upper lids, or hooding of the lids. An upper eyelid lift, called an upper blepharoplasty, involves removal of the excess skin and muscle as well as the fat that bulges out from deep below the muscle. The operation produces an immediate result with an improved contour of the lids, a more open look to the eyes and an overall more rested or refreshed appearance. Determining the exact amount of soft tissues to be resected requires precise and detailed pre-operative evaluation, and differences between the ideal result men and women seek should also be taken into account so as not to remove too much tissue.

In some cases where the upper lids overlie the eyes excessively, vision may be impacted with part of the visual field being obscured by the hanging eyelids. The medical term that describes a droopy upper eyelid due to poor eyelid muscle function is ptosis, and it may be either congenital or as a result of a number of different conditions, including changes in the muscle due to age or temporary weakening from Botox injections.

The function of the specialized muscles that lift the upper eyelid should be assessed prior to eyelid surgery in order to determine if it is functioning properly. This is crucial in determining if any procedures to correct ptosis are required to ensure an optimal result. Ptosis repair may be performed concurrently with cosmetic eyelid surgery. In some patients, a brow lift may be indicated in addition to the eyelid lift if the soft tissues of the forehead have become lax and contribute to upper eyelid droopiness.

Lower eyelid skin: Manage with surgery or noninvasive treatment?

The most common aspects of the lower eyelids that patients would like to improve upon involve excess skin and undereye bags. Lower eyelid skin is extremely thin and sensitive, and with age, it becomes thinner, with wrinkles, crepe-paper like appearance and bulging of the underlying fat. The most significant and only permanent improvement in the appearance of the lower lid is usually achieved with a lower eyelid lift or lower blepharoplasty. This surgery involves direct excision of excess skin, with or without a portion of the underlying muscle layer, and removal or repositioning of the deep fat.

An alternative is to perform a skin pinch only, which is indicated in patients with lesser amounts of redundancy and results in smoother lower lid contour. In addition to surgery, there are increasing numbers of noninvasive treatments aimed at improving the appearance of lower eyelid skin. Nonsurgical options that can provide some degree of skin tightening include microneedling, chemical peels and technologies that use either radiofrequency or ultrasound to tighten loose skin:

• Microneedling involves a process called collagen induction therapy (C.I.T.), which stimulates new collagen and elastin production and results in smoother, tighter, younger looking skin.
• Chemical peels with different formulations of botanical or natural acids can also stimulate skin rejuvenation with fewer wrinkles and smoother texture.
• Laser treatments produce smoother skin by using heat to stimulate skin turnover and contraction.
• Similarly, newer technologies such as radiofrequency and ultrasound can produce temporary skin contraction and smoother skin.

Lower eyelid laxity: Is canthopexy/canthoplasty required?

Any rejuvenation procedures on the lower lid must be individualized to each patient, and both potential benefits and inherent limitations of treatment options should be reconciled to ensure optimal results. Addressing skin laxity and redundancy requires either skin tightening by noninvasive treatment such as microneedling, chemical peel or laser resurfacing or by surgical excision which eliminates extra skin.

One of the most important factors to be considered prior to proceeding with either surgery or nonsurgical treatment is to properly address lower eyelid tone and to determine if the lower lid is strong enough to keep its natural shape following any intervention.

In patients whose eyelids are lax, any procedure on the lid may lead to eyelid retraction or pulling away from the normal position, resulting in eyelid distortion. In order to prevent this from occurring, patients may need to undergo additional eyelid reinforcing or stabilizing surgical procedures, such as canthopexy or canthoplasty, concurrently with blepharoplasty to maintain a natural appearance of the eyes.

Careful and precise pre-operative assessment is key in deciding which patients are candidates for these procedures, and in avoiding potential complications.

Tear trough correction: Add volume, resurface skin or both?

An essential corollary to eyelid aesthetics is the tear trough area, which is the hollow that develops at the junction between the lower lid and cheek. The tear trough may become more prominent with age as the soft tissues of the face lose volume and gravity causes them to pull downwards. This results in a pronounced arch below the eyelid that can give the appearance of dark circles under the eyes, and of looking tired and aged.

Any plan to rejuvenate the eyes should take into account the area of the tear trough and determine the best way to improve it. The two components of the tear trough that can be improved are loss of volume and thin, crepey skin. The tear trough can be concealed by either:

• Repositioning fat from within the lower eyelid over the bony rim
• Adding volume to the area with fat injections (fat grafts or fat transfers) or fillers (e.g. hyaluronic acid fillers like Juvederm)

In addition, the skin may be made to look more youthful, thicker and tighter, by:

• Skin resurfacing measures mentioned above, such as microneedling or noninvasive radiofrequency and ultrasound methods
• Platelet Rich Plasma (PRP) injections that are rich in growth factors which can also stimulate skin rejuvenation overlying the tear trough, and may be performed in conjunction with microneedling or independently

The best solution for correcting a prominent tear trough may require a combination of procedures or several treatments to provide optimal results.

Globe position: How prominent are the eyes?

Another important part of the pre-operative evaluation for an eyelid lift is noting the patient's eye position relative to the bony orbit. Some patients may appear to have prominent, bulging eyeballs, also called exophthalmos. This may be due to underlying medical conditions, most notably hyperthyroidism, or simply be a patient's normal appearance and familiar trait. Medical problems should be worked up and corrected and patients optimized for surgery prior to undergoing eyelid lift or any other cosmetic procedure.

Furthermore, in patients whose natural eye position is more prominent, surgical technique may require adjustment and patients should be advised pre-operatively about what results can be expected due to modifications in technique. As with all aesthetic surgery procedures, the plastic surgeon and patient should have a comprehensive discussion prior to surgery to address expectations and what results may be reasonably be achieved.

Plastic surgery of the upper and lower eyelids can yield immediate, long-lasting and noticeable results. Although it may seem like these are simple, straightforward aesthetic procedures, the area around the eyes is extremely delicate and should be fully evaluated prior to any treatment in order to include all appropriate techniques and interventions in the rejuvenation plan.

When performed correctly by experienced, board-certified plastic surgeons, and while ensuring that all pertinent details are appropriately addressed, eyelid rejuvenation procedures produce outstanding results and extremely high patient satisfaction.