Monday, January 31st, 2011
Cosmetic remodeling and rejuvenation of the eyelids has changed dramatically in the last few years as we have better defined the anatomy of the area, the forces on these and how changes occur over time. This has allowed us to developed better techniques that provide results that are more natural.
Both aging and inheritance cause cosmetic problems of the eyelids. Those due to aging are, by far, the most common. They result from changes in both the lids themselves and the surrounding tissues. Unfortunately, until very recently, all modification of this area was to treat the external appearance, not to correct the cause, return the tissues to their natural positions, or provide support against further change.
Direct aging of the eyelids results in loose, crinkly skin with all the other signs of aging that the skin in general exhibits. All the other changes are due to aging of the surrounding structures. Several things determine the eventual appearance. The most obvious is gravity. It, and the muscles surrounding and within the lids, constantly pull on the lids and the tissues around the eyes. How these respond depends on the strength of the support structures and their attachments.
The two muscles most responsible for the appearance around the eyelids are the same ones that make us look angry and/or tired. They cause lines between the brows and in the medial lid area and, because of deep attachments medially, the brow to fall more laterally. This worsens the wrinkled appearance laterally and pushes the brow into the upper lid, causing loss of youthful definition of the area.
As gravity pulls on the lower lids, ligaments to the underlying bone cause bulging of the orbital tissue, including fat, and flattening of the cheek. The fat, and even the bone of the orbit, atrophy with age. This adds to the cosmetic deformity. Previous techniques to rejuvenate the eye removed the fat that appeared to be bulging. Since that was not really the problem, and the residual fat and other tissues continued to atrophy, the eye eventually looked sunken and hollow.
The last change of aging of the lids is stretch of the tendon that attaches the lateral corner of the lids to the bone. This causes the eye to appear less wide and rounder. To reverse these changes, we first look at what has caused your problem. If the brow is the cause of your upper lid problems, then a brow lift may be all that is needed. If there is still too much skin in the upper lid, then removal of the excess usually solves the problem. Previously, when we avoided the brow and just removed skin and fat, we actually made the problem worse, since removing enough skin to make a difference, actually pulled the brow down further.
Instead of removing fat as we did until just a few years ago, I use the fat to fill areas of tissue loss. In the lower eyelids, instead of simply removing what appeared to be excess skin from below the lids, I now remove it mainly beside the eye after elevating the eyelid and the entire cheek. This tissue is stabilized to the bone to keep it from falling again. The corner of the eye is also resuspended to bone in its normal position. This not only returns the youthful appearance to the eye, but is safer than the older procedures. Congenital problems are due mainly to abnormalities in the amount of fat in the lids or the way the upper lid muscle attaches to the skin. Fat can be either too plentiful or lacking. Lack of proper muscle attachment causes droop of the lid or an exaggerated oriental appearance. The problem determines the correction.