Traditionally, tissue has been removed from the eyelids, prompting one surgeon to call older techniques "blepharectomies." Today, we recognize the problems with such procedures. They can produce hollowed-out looking eyelids, which are not at all youthful. Many older women treated with these techniques have this unfortunate appearance. Men worry that they will have an overly alert or "deer in the headlights" appearance. Indeed, some older male actors and celebrities have overly rounded eyes, which looks effeminate. If you look at male models, the lower lid is typically almost horizontal which is the ideal masculine appearance. It is very important for the surgeon to avoid changing the shape of the eyelids.

Newer Technique = More Natural Results

Today, the emphasis is on preservation of tissues and avoidance of over-resection of skin or fat. I no longer trim any muscle from the upper lids, which I was trained to do routinely in residency. Any fat removal from the upper lids is conservative; I remove what is "poking out" and nothing more.

Fat Injection of Tear Troughs

Although some surgeons have advocated transposing the fat pads of the lower lids into the tear trough areas, I have found that this is inadequate. I prefer to trim the fat pads where they cause bags, and introduce fat into the tear trough using fat injection, taking the fat from an entirely different source, such as the tummy. More fat is available this way and there is no need to pull fat from the orbit or cause tension on the septum.

Tightening of the Lower Lid

One area of controversy in plastic surgery is whether the lower lid should be horizontally "tightened" at the time of the lower blepharoplasty using older reconstructive techniques that shorten the lower lid horizontally. The problem with this maneuver is that any shortening of the lower lid can make the eye look smaller. The "beady-eyed" look is impossible to correct. I avoid routine shortening of the lower lid ("canthoplasty"). Larger eyes are attractive and any surgery in the corner of the eye can leave an unnatural-looking result.

Instead, I prefer to tighten the orbicularis muscle and redrape the tissues of the lower lid and cheek, avoiding any incisions into the lower lid margin itself or any shortening of the lower lid which might produce this unattractive appearance. Any small malalignment of the lower lid is very conspicuous and best avoided.

Eyelid Surgery: Anesthesia and Procedure Description

Eyelid surgery may be performed with the patient either awake or asleep. If just the upper lids are treated, this is usually done awake, under local anesthetic alone. The patient just has to put up with a few needles and then there is no pain at all. The procedure takes 30 minutes or less and most patients find it easier than a trip to the dentist.

The lower lids are usually treated under intravenous sedation because the fat pads are typically treated and there can be a little discomfort from pulling on these fat pads. For transconjunctival eyelid surgery (blepharoplasties), anesthetic drops and then lubricated corneal shields are placed to protect the eyes during surgery. The extra fat is trimmed away through this incision, removing the bags. The incision is closed with an absorbable suture. When an external incision ("transcutaneous") is used, the running suture comes out in three to five days.

Laser Skin Resurfacing: Simultaneous Wrinkle Treatment

I am cautious in the use of the laser around the eyes. Usually, I perform just one pass with the Ultrapulse^® (CO2) laser; or two or three passes with the erbium laser. Because the eyelid skin is so thin, too many passes with the laser may cause the skin of the lower lid to tighten too much, causing unsightly traction on the lower eyelid. Because some lines and creases will persist and others will appear in time, laser treatments may be repeated. I tell patients that they will likely return for "maintenance" laser treatments and fat injections. It is better to be cautious and avoid overtreatment, accepting,that some lines will persist. Almost all bad outcomes from laser resurfacing have been due to overtreatment, which is easy to avoid. Also, the recovery period won't be as prolonged.

Commonly, patients elect to have full face laser resurfacing (not just around the eyelids) to treat additional signs of aging such as wrinkles and brown spots, that often accompany bagginess of the eyelids.

Upper and Lower Lid Incisions

The incision for the upper lid is placed within the crease above the eyelid. In this location, the incision is inconspicuous. Fortunately, eyelid skin heals exceptionally well. Even patients whose scars heal poorly on other parts of their body find that their eyelid incisions heal nicely. The amount of skin removed depends on the amount of excess tissue present and may be more than most patients realize. Sometimes, the extra skin weighs down the upper lid causing an uncomfortable feeling of heaviness and may limit vision. In the past, surgeons have often placed this incision too high, leaving a scar where it could be seen. The scar tends to be very well hidden if it is placed lower, in the lowest wrinkle of the upper lid (typically less than a centimeter from the lid margin).

The incision for the lower lid may be placed either just below the eyelashes, which is the traditional "transcutaneous" approach, or on the inside of the eyelid, the "transconjunctival" approach, where it is completely hidden.

The incision for both the upper and lower eyelid (when the external incision is used) extends laterally about a centimeter beyond the outside corner of the eye ("lateral canthus"). This is necessary to sufficiently remove excess skin.

What determines the approach?

One factor in determining the surgical approach is whether laser resurfacing is to be performed simultaneously. Laser resurfacing causes the skin to tighten a little, so that it may not be necessary to actually cut out extra skin. An external incision may be avoided. I prefer to use the "scarless" incision inside the lid when treating young patients (under 40) with baggy lower lids but minimal skin laxity. The transconjunctival incision is placed well on the inside of the eyelid so it is completely invisible. The extra fat is trimmed, removing the bags, and the incision is closed with an absorbable suture.

Treatment of Dark Circles

The semicircular areas of dark discoloration of the lower eyelids, extending to the orbital rim, are due to hyperpigmentation (darkening) and translucency of the skin allowing the dark color of the muscle under the thin skin to show through. Dark circles have been traditionally difficult to treat. When I was a resident in plastic surgery, there were no good treatments. We told patients to apply makeup to hide the discoloration as much as possible.

Modern laser resurfacing and fat injection have now made it a treatable condition. The three techniques: lower blepharoplasty (lower lid surgery), laser resurfacing, and fat injection can be used in combination to provide maximum improvement as demonstrated by some of the patient photos in the next section.