To understand blepharoplasty and eyelid tightening better an understanding of the relative importance of different parts of the face is necessary. The central part of the face relates most to blepharoplasty and eyelid tightening. The central part of the face consisting of the oval around forehead, eyes, cheeks, nose, mouth and chin is where much of aging, beauty and harmony of the face are determined. We like to look at it as an aesthetic unit. Its beauty is through harmony as a unit. All parts have to be structurally correct and in balance with each other. We like to refer to parts like eyelids as aesthetic subunits. At our plastic surgery practice in Mississippi we actually subscribe to the view that cheeks and lower eyelids together form one aesthetic subunit and upper eyelids, brow and forehead form another one.
For our clients this means that we try to look at the eyelids not in isolation but as part of a lower lid and cheek complex or part of an upper lid, eyebrow and forehead complex. The subunits have to be harmonious so that the entire aesthetic unit of the central face can be in harmony.
Given the aesthetic importance of the central face it follows logically that cosmetic procedures in this area tend to be very powerful in their anti-aging effects. Blepharoplasty is no exception, provided that it is undertaken as part of a restoration of the entire subunit they are part of.
The benefits in terms of a more youthful appearance of the upper eyelid without redundant skin are usually immediate and very noticeable for the client and her environment. The tired look disappears and make up can again be applied with ease. I intentionally use the female gender as upper blepharoplasty in a male has to be approached with less skin removal while setting the eyelid crease a bit lower than in a female to avoid creating an effeminate look. In both instances we follow the central paradigm of our plastic surgery practice in Mississippi – structure is beauty and the skin just drapes over it. The correct structure is in our opinion achieved by respecting the characteristics of aging – loss of volume of soft tissues and skeleton, descent of soft tissues and intrinsic loss of skin quality. By consequence we aim at minimal resection of fat or muscle in the upper eyelid, just enough to create a platform over which the skin can drape. While an often considerable amount of skin can be removed in the upper lid, upper blepharoplasty is not a skin procedure. Skin removal enables the remaining skin to drape over the underlying structure. Not what is removed, but what is left behind determines the result. An important consideration during upper blepharoplasty is the position of the eyebrow. This too needs to be correct. In my opinion there is only one correct vertical eyebrow position – the same as it was in the client’s youth. There is not much point to lift it any higher. If it is still in the same position while the forehead muscles are relaxed the gains from combining upper blepharoplasty with a brow lift are more than uncertain. A second important consideration is the position of the upper eyelid itself. Descent of the lid may be caused by age related, neurological or congenital problems in so called levator muscle (literally the “muscle that lifts”- namely the upper eyelid). Descent of the lid must be diagnosed prior to and in my opinion must be treated while performing an upper blepharoplasty. As a pleasant side effect of such a treatment an additive cosmetic and rejuvenating effect is obtained by setting the lid itself into a correct vertical position. The “lazy eye” look disappears and depending on the degree of preoperative descent the client’s field of vision may improve markedly.
Rejuvenating the lower lid with a cosmetic surgical procedure is performed with the same principles in mind. The lower lid is viewed as part of the lid cheek complex and is affected by the same mechanisms of aging as the all other structures in the face – loss of volume of skeleton and soft tissues, descent due to loosening of retaining structures and intrinsic loss of quality of the skin itself. Even more so than in the upper lid it has to be borne in mind that lower blepharoplasty is not a skin operation and it is not at all about nibbling fat out. Taking out the wrong amount of skin or fat at the wrong time and the wrong place and with the wrong hands holding the scalpel has resulted in the majority of the myriads of complications associated with lower blepharoplasty over the past decades.
Lower blepharoplasty is not about skin or fat removal, in fact it is not about removal of anything at all to make it very clear. Any small amount of skin or fat removed is just incidental to these not having a place to go when structure is created. At Trinidad Institute of Plastic Surgery we follow the paradigm that structure is beauty. The skin just drapes over it. So we need to create structure to create beauty and while entire conferences and meetings have been dedicated to the somewhat tricky issue of creating better structure in the lower lid the salient points are tightening the lid horizontally to keep it apposed to the eyeball and preventing shape distorsions following lower blepharoplasty and tightening in vertically by a vertical lift of the muscle encircling the eye or even better a complete midface lift. The vertical lifting maneuver takes redundancy and apparent bulging out of the lower lid, shortens the transition from lid to cheek and makes the lower lid look fuller as it did in youth. If there is any redundant fat it is used to fill areas of volume loss particularly towards the nose at the lid-cheek junction. After completing the tightening and lifting there will be some redundant skin in the eyelid, which is very very conservatively removed. Again, lower blepharoplasty is not about removing skin, but creating structure in the lower lid. Skin removal does not create structure, only potential complications. Lower blepharoplasty also does not treat intrinsic changes in aging skin. Fine wrinkles, dyspigmentation, sun damage and so on are better addressed by laser resurfacing and peeling. And yes, resurfacing treats only the top couple of micrometers of skin as does peeling. Neither of them have a structural effect. Without correct structure the resurfaced or peeled skin still drapes over an aged lower lid. Structure is beauty.