For years when patients went to a plastic surgeon with complaints of tired, aging eyes the standard was to recommend an upper lid blepharoplasty and maybe a brow lift if the surgeon thought the brows were “too low”. The standard upper lid surgery would involve removal of skin, muscle and fat and that was about it. But we have come so far in eyelid rejuvenation that removal of skin, muscle and fat alone is applicable in only a few cases.
Evaluation of the periorbita (eye area) involves not only the obvious, eyelids and brow, but also the forehead, nose and cheeks. For years we’ve been taught that the female eye brow starts medially at the orbital rim, peaks above the rim at the lateral limbus (colored area of the eye) then extends in a slowly upward angle. But the more you look around, the more you realize that very attractive women have eyebrows that don’t follow this rule. So surgically changing the brow position to fit the “standard” may not be appropriate. Next, removal of eyelid fat was standard in the original eyelid surgery. However, we’ve learned that not only are there deeper areas of fat but also fat directly under the eye muscle called ROOF fat that contribute to lateral brow fullness. Removal of too much fat gives the eyes a hollow sunken appearance, which is of course, much less youthful than eyes with fullness. But bulging fat isn’t attractive either, so serious consideration has to be given to if fat has to be removed and if so what fat and how much needs to be removed.
One of the main concerns patients present with is the tired look which is largely attributable to excess skin, drooping of the brows and loss of the lid crease. And while removing this skin and muscle may somewhat improve the eye appearance, unless strict attention is given to securing the brows (via an internal brow pexy, and recreating the fold) the result will only be adequate. And who wants to pay for adequate? Recurrence of the excess skin will happen as the brow is pulled down from tension created by removal of the skin. Then you’re right back where you started.
So no longer is upper eyelid rejuvenation a simple 20 minute procedure. It’s complex surgery that involves many variables that the surgeon must appreciate.