Upper Eyelid Rejuvenation Part II – Correcting the Hollow Look

In part I, I discussed the various procedures that need to be performed when there’s too much skin, fat etc.  But what needs to be done when too much fat was taken in the first procedure or the aging process has resulted in loss of fat, which is very common?  Let’s use the example to the right for the evaluation.


This patient has not had previous surgery.  You can see that her central and lateral brow have descended creating hooding of the lateral tissues over the lid.  There is fullness here, which we know is youthful, but this fullness isn’t fat but descended brow tissue.  Second, she has a very high lid crease.  In fact it’s underneath the orbital rim.  In addition, the lid margin is so low that this patient has a difficult time seeing her entire field of vision.  Finally the eyes have that sunken look which is indicative of loss of fat.  So let’s take a look at what needs to be done and the various options.

First, the lid position must be addressed.  The low margin combined with a high crease is classic for levator muscle dehiscence.  What? (Yes, I can hear through the computer).  The levator muscle is the main muscle that opens the eyes.  In the aging process and occasionally in congenital issues it can pull away from it’s attachment to the lid margin.  Because it attaches to the skin as well, separation causes it to retract, thus dropping the lid and elevating the crease.  This is corrected by repair of the levator muscle.

Once the lid levator muscle has been fixed, the brow needs to be repositioned.  In her case an endoscopic brow lift would be the most appropriate procedure.  If this patient’s lateral brows were slightly higher, for her, than an internal brow pexy could be used to elevate or stabilize them.

Finally, even if all of the above was done, she would still would not have youthful eyes.  Rejuvenated, yes but youthful no.  Fat is youth and this patient is clearly deficient.  Infiltration of fat graft under the muscle of the upper eye, in all areas, but especially toward the nose, would significantly add youth to the eyes.

So look for my next blog on the changes in fat grafting where I’ll discuss the new era of facial rejuvenation.  Click here or call my assistant at 703.752.6608 to discuss your eyes.

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