II. ADJUNCTIVE PROCEDURES

II.B. Blepharoplasty

The eyes are typically the first place to show signs of aging. The upper eyelid skin begins to droop as early as age 30, making the eyes appear smaller and tired. By age 40, fine wrinkling and unattractive pouch­ing may appear below the eyes, and "crow's feet" (or, more optimistically, "laugh lines") begin to form. The eyebrows may droop along with the eyelid skin, which also makes the eyes appear smaller. The aging process continues and these changes progress into the 50s and beyond.

Blepharoplasty is the cosmetic surgical treatmentof aging changes around the eyes. One of the reasons that cosmetic eyelid surgery is so popular is that the eyes are often a person's most attractive feature, and the most often noticed. It is therefore unfortunate that the first signs of aging appear around the eyes. Hap­pily, a number of conservative procedures are available that can address these inevitable changes.

As with any patient concern, the first step is to learn from the patient what specific aspects of the aging changes are of greatest concern. Then, the facial plastic surgeon performs a careful examination to determine the exact reasons the patient's eyes look as they do. If, as is most common, there is simply excess upper eyelid skin, then this can be removed in an operation called an upper eyelid blepharoplasty (Fig. 2). If, there is sagging or puffiness of the lower eyelids, a lower eyelid blepharoplasty may be offered (Fig. 3).

Sometimes, the only part of the lower eyelid that is sagging or bulging is the fat that surrounds the eye. In this situation, the incision may be hidden inside the eyelid, where it is not visible to any observer. This is the so-called "incision-less" eyelid surgery.

FIGURE 3. Lower eyelid blepharoplasty (a) preoperative, (b) postoperative.

However, when the skin and muscle of the eyelid are sagging as well, some of it must be removed, so an incision may be made just beneath the eyelid. This incision allows the surgeon to tighten the eyelid skin to achieve a refreshened, smoother appearance. The incision is hidden in a natural crease just 1-2 mm beneath the eyelid, and is typically extremely difficult to see.

Many patients do not realize that with aging, the eyebrows sag along with the eyelids. Therefore, the eyebrows may also require a lift. In some patients, this is the main problem, while in other patients this is a secondary problem whose correction is therefore optional.³ Browlifting elevates the skin above the eyebrow and the eyelid skin beneath the eyebrow, so after a browlift less skin needs to be removed from the upper eyelid. For this reason, the patient needs to decide before the blepharoplasty whether a browlift is also desired (see Fig. 5 below).²

When patients state that their eyes get tired at the end of the day, there are several medical problems that should be checked for with the family doctor, optometrist, or opthamalogist. However, sometimes heavy excess skin can weigh down the patient's eyelids and put extra strain on them, and hence cause them to tire by the end of the day.

The most common patient worry during the ini­tial visit is that they have heard that cosmetic eyelid surgery can cause them to be permanently unable to close their eyes. The technical term for this is lagoph­thalmos, which means "inability to close the eyelids." If too much skin is removed from the upper eyelid, itwill not be able to close. There are a number of special precautions that the wise surgeon undertakes before and during surgery to minimize this risk. There are other risks of this surgery that are not common, but that the surgeon should discuss in detail during the presurgical office visit.

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