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Aging of the eyelids and periorbital area is one of the earliest signs of facial aging. This makes blepharoplasty (eyelid tuck), and an upper blepharoplasty in particular, a workhorse procedure in the arsenal of facial rejuvenation procedures. Many patients fear, however, that such an eyelid procedure will change their appearance somehow rather than making it more youthful or rejuvenated.

When considering an upper eyelid procedure, one has to take into account the position of the eyebrow. A low or descended  eyebrow can make it appear that more extra skin is in the upper eyelid than really exists. But what defines if an eyebrow is too low or ptotic? That would depend on where one’s brow was in youth. I would submit that most people do not remember where it was in their youth in most cases. This leaves it up to the plastic surgeon to provide an assessment which often leads to an excessive amount of browlift procedures being performed. The benefits of a browlift should be looked at very carefully as they often do not achieve as much rejuvenation as one would think.

Traditional upper blepharoplasty procedures involve the removal of excessive skin and a strip of orbicularis muscle. Often times fat is also removed from the upper eyelid compartments. These eyelid maneuvers often leave the upper eyelid area hollowed with an eyelid crease that sits too high. As the new eyelid crease sits up too high, the upper eyelid sulci become too deep and creates an unyouthful volume-depleted appearance.

Today’s blepharoplasty techniques make several changes to avoid the aforementioned negative effects. First, the upper eyelid crease incision is made lower than a traditional approach. This keeps it from becoming retracted too high after surgery. Secondly, no orbicularis muscle is removed. There is no benefit to disrupting this muscle support system of the upper eyelid and introducing more scar. Skin only is removed . This also plicates or rolls the underlying muscle onto itself adding some fullness. Third, there is little if any need to remove fat from the upper eyelid. This will avoid the potential for creating a volume-depleted look. Last, the use of browlifts are used only when the brow has severe ptosis where it is positioned below the brow bone. When browlifts are done, there is more focus on lateral brow elevation rather than the inner part of the brow.

Patients fear undergoing eyelid surgery because it may make them look different. More likely with traditional upper eyelid methods, they may not look as rejuvenated or youthful as they would like. A more ‘conservative’ upper blepharoplasty with emphasis on fat and muscle preservation can lead to a more natural looking result that does not alter one’s appearance. Browlifting should be done with caution avoiding an overelevated result.    

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

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