For sure, blepharoplasty can be combined with other eyelid procedures. It is often combined with fat removal and ptosis repair for the upper eyelids and fat repositioning for the lower eyelids. Blepharoplasty is also commonly combined with brow lift. They should all be considered when evaluating for blepharoplasty. Otherwise, it’s like focusing on the tree and missing the forest. Although a cliché, it is very poignant in overall rejuvenation of the eye or upper face.
Here’s why…While most people recognize heavy skin fold and know about blepharoplasty, they may not discern fat herniation or blepharoptosis (also known as ptosis). Most patients who come in for blepharoplasty consultation think they have too much skin that causes the eyelids to look puffy or droopy. It may be true that they have excess skin. However, the puffiness is more likely due to fat herniating forward from the orbit, especially in the corner closer to the nose, as skin, muscle and fibrous tissue thin over time and fail to hold the fat back, in which case removing the skin alone will not rid the puffiness. Also completely different from saggy skin is droopiness of the eyelid, or ptosis. Ptosis is when the lash line comes down and sits closer to the center of the cornea, reducing the eye opening between the upper and lower eyelid. This is independent of excess skin and, rather in most cases, is due to retractor muscles, called levator muscle and Muller muscle, stretching, thinning and being replaced by fat and thus not holding the eyelid up higher. Therefore, removing skin alone and not repairing the muscle will not raise the lash line up or increase the eye opening. Blepharoplasty will only remove the excess skin and unveil whatever eye opening currently exists. This includes normal, small or asymmetric eye opening.
When looking at the eyelids, we have to pay attention to the eyebrows, as eyelids and eyebrows are really a unit. It is common that patients come into the office thinking they have excess skin and turn out to have brow ptosis. Brow ptosis is when the eyebrow sits on or below the orbital rim, instead of above the rim. As the eyebrow comes down it pushes into the eyelids, causing the eyelid to sag or even appear puffy. Elevating the eyebrow up to immediately above the orbital rim or even on the rim raises the eyelid fold and mitigates the heavy, puffy skin fold. This is one of three reasons why patients still note puffy eyelids after blepharoplasty. (The other reason is as we discussed above, due to fat herniation, and the third reason is due innately thick skin.)
In addition to the eyebrows, the lower eyelids should also be considered as part of that complete eye unit. When repairing the upper eyelids and ignoring the lower eyelids, there may discordant appearance between the two. The rejuvenation is incomplete.
The most obvious change of the lower eyelid is orbital fat herniation. Like in the upper eyelids, orbital fat can herniate forward in the lower eyelid. Fat herniation in the lower eyelids tends to be more diffuse across the lids.
In addition to fat herniation, most patients demonstrate hollowing of the tear trough, or nasojugular deformity. This is when fat at the junction between the eyelid and cheek descend down into the nasolabial fold, causing “dark circles” under the eyes. Many patients mistakenly think removing the eye bags, the herniated fat, will address the dark circles. In fact, removing fat deepens the volume loss and exacerbates the dark circle. Instead of removing the herniated fat, we want to reposition the fat, from where it is in abundance, into the tear trough where there it is deficient. This will then bring the convexity of the eyelid and the concavity of the tear trough into a smoother, even plain. After repositioning fat, we may want to remove excess skin of the lower eyelid or even tighten the eyelid with a canthoplasty; so there is not saggy skin or eyelid, respectively.
I look at all of these elements when I evaluate my patients’ eyes. More specifically, I am looking at the eyes in the context of whole face and trying to rejuvenate the upper face to really achieve the balanced, refreshed appearance.
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