In my practice, I find that most consultations for facial aging are driven by a patient’s concern about a particular feature of their face that bothers them. Rarely do they ask me for my opinion as to what is making them look older, nor do they have concerns about large areas. And the fact is, many times what the patient is concerned about is a minor factor in making them look aged or tired, and they are overlooking more significant factors. All the components of the face age simultaneously. Around the eyes, sometimes the uppers or the lowers may look more severely aged than the other. Rarely, however, does the patient appreciate the role played by the brow in the appearance of age in their face.
In order to evaluate the upper eyelids, first you need to assess the brow. If the brow is low, there may be hooding of the brow over the upper eyelid; the patient may think they have an upper eyelid problem. The thing is, you do not want to remove excess brow skin to “tighten the upper eyelid” when the problem is, in fact, the eyebrow. If you do this, then you will just tether the brow down, when if fact it needs to be elevated. I manually elevate the brow to where I think it belongs and then I assess the upper eyelid for excess skin. If there is still excess skin after elevating the brow or fat protruding through the skin, then an upper blepharoplasty is indicated. If the brow doesn’t require elevation, then no browlift is required.
In a consultation for a blepharoplasty in my Stony Point plastic surgery office, the lower eyelid is evaluated independently of the upper eyelid. If there is excess skin, then an external incision just under the lashes is required to remove the excess skin. If there is no excess skin, but there is excess fat protruding through the lower eyelid, then I make an incision just inside the eyelid to approach the fat only. When there are a combination of problems, sometimes I use an approach from both sides. This allows me to preserve the middle muscular layer of the lower eyelid to prevent the development of deformities due to scar contracture later.