Lidlift Keneth D. Steinsapir, M.D.
Cosmetic, Facial & Eye Plastic Surgery

Figure 1.

Figure 1 above demonstrates a female eyelid. Note the relaxed, relatively low eyebrow with a delicate arch. Below this is skin that is relatively thick and is shared by both the eyebrow and the upper eyelid. This skin becomes progressively thinner as it breaks to form the upper eyelid fold. Underneath the fold the skin inserts into a crease formed by an extension of the levator aponeurosis, the tendon that raises the upper eyelid. We will return to this point to consider how changes affect the position of the upper eyelid margin. Below the upper eyelid crease is the skin of the eyelid platform, which continues to the eyelashes and the eyelid margin. Note that in youth the eyelashes are pointed upward. Relative tension in the eyelid platform skin helps maintain the upward rotation of the eyelashes. Certain conditions lead to a laxity of the eyelid platform skin causing a downward rotation of the upper eyelashes, a condition known as lash ptosis. The fold should rest well above the lid margin exposing 3-5 millimeters of eyelid platform. A common anatomic variation of the upper lid occurs with a very high insertion of the levator fibers on the eyelid skin. This contributes to a relatively hollow upper eyelid or high sulcus. A relatively weak attachment of the levator tendon onto the eyelid contributes to a hollow sulcus. Over aggressive upper eyelid surgery can also change a full upper eyelid to a hollow sulcus—not generally a desirable result.

The configuration differs in Asian eyelids (figure 2). Here fibers of the levator tendon insert much lower in the eyelid and closer to the eyelashes to create a crease that is much lower. Also the fat that is held high in the eyelid in the Caucasian eyelid by a structure called the orbital septum, extends much lower into the eyelid. These differences account for the Asian eyelid (figure 2) with a full eyelid and a low crease and fold.

Figure 2. Asian eyelid crossection

Figure 3. Caucasian eyelid crossection

Common upper eyelid concerns include heaviness of the upper lid skin. In many cases the apparent redundant upper eyelid skin is actually caused by descent or ptosis of the forehead with a cascade of skin into the upper eyelid space. Usually this is associated with a relatively low eyebrow position. In this circumstance, the redundant skin is best addressed with a forehead lift rather than an eyelid surgery. This procedure has the advantage of returning tissue to its anatomic location and avoiding any incisions in the upper eyelid. This procedure will be discussed in great detail in the forehead lift section. For the appropriate candidate, upper eyelid surgery can be performed alone or in conjunction with a forehead lift to address the heavy upper eyelid. Upper eyelid surgery should be used to recreate youthful eyelid architecture. When performed alone in a setting of eyebrow ptosis, the key to natural surgery is to accept a lower eyebrow position. In many individuals, this is a very workable compromise.

The position of the eyebrow is determined by a number of factors including facial skeleton, congenital factors (relative brow position from birth), and muscle balance. Generally, altering the facial skeleton to adjust the brow anatomy is unsatisfactory and although advocated by some surgeons, it has been my personal experience that such procedures often result in disappointment and should be reserved for cases of highly unusual facial skeletal anatomy. This also applies to so-called eyebrow rim implants used to accentuate the superior orbital rim. Generally, a much safer approach to altering the contour of the orbital rim at the eyebrow is with the use of Perlane® or Restylane®. These products can be injected as an office treatment to subtly alter the shape of the eyebrow and have reasonable longevity of up to a year.

Relative heaviness of the skin that encroaches into the eyelid space and rests on the upper eyelid, lashes, or actually intrudes into the field of vision stimulates the brain to signal the frontalis muscle of the forehead, the sole elevator of the forehead to lift. The activity of this forehead muscle is responsible for the lines we see in our forehead. The muscles around the eyelids that depress the eyebrows oppose elevation created by the frontalis muscle. This includes the portion of the orbicularis oculi muscle that extents from the eyelid onto the low eyebrow. Muscular activity of the lateral aspect of the orbicularis oculi muscle is also responsible for crowsfeet lines. The tarsal portion of the orbicularis oculi muscle functions to close the eyes. There is constant tone in these muscles. This means that where the eyebrow sits is the result of a tug of war between these opposing muscle groups. At the eyebrow, the top fibers of the orbicularis oculi muscle interdigitate with the lowest fibers of the frontalis muscle. Where they meet creates an area of muscular ridging that is used for complex facial expression (i.e. expressions of menacing, surprise, anger, quizzical occur here) (More on this topic in the BOTOX® section).

Figure 4

In assessing an individual for eyelid surgery, a judgment must be made regarding the position of the brow and the likelihood that removing the skin in the upper eyelid will result in a reduced incentive to elevate the eyebrow. Figure 5 shows an individual who consulted me for eyelid surgery. I recommended that she have a forehead lift to avoid descent of the eyebrows that was likely if only upper blepharoplasty was performed. She did not like my opinion and had eyelid surgery with another surgeon. The two of them were dissatisfied with the results and after a year of going around, she again consulted me. The after picture demonstrated how the eyebrow has descended. Notice how deep her central glabellar lines have become. Does this mean that everyone needs a forehead lift? Not-at-all. However, the weight of the eyebrows and the possibility of their descent following eyelid surgery must be considered as part of the surgical consultation. If decent of the eyebrows is likely, a forehead lift either as an alternative to upper eyelid surgery or in conjunction with eyelid surgery may be the best option.

Figure 5

Now that we have had that important discussion of the eyebrow and the interaction with brow position and the upper eyelid folds, let’s now consider upper eyelid surgery. For quite some time and still today, surgeons considered upper eyelid surgery as a “take out the skin, muscle and fat” surgery. The result can be an upper eyelid with a high sulcus and no fold, i.e. the surgical look. Over aggressive upper eyelid surgery can weaken the ability of the eyelids to close either by damaging the muscles responsible for closing the eyelid or so shorten the skin in the upper eyelid that there is insufficient skin to permit full closure of the eyelids. When the surgeon fails to make an upper eyelid crease, the skin on the eyelid platform can become crepe making it very difficult to hold makeup on the eyelid skin.

Ideally there should be full upper eyelid fold. The fold should be several millimeters above the eyelashes exposing a uniform strip to eyelid platform skin. The skin itself should be smooth not crepe and in particular, the eyelid platform skin should be relatively tight below the upper eyelid crease to create support for the eyelashes so they don't point down. Notice this description does not differentiate between Western and Asian eyelids. The aesthetic goals are similar although there are important differences. In Asian eyelids, the orbital septum inserts lower in the upper eyelid, which means that the orbital fat also extends lower in the upper eyelid. Therefore, Asian eyelids tend to be more full in appearance than do western eyelids. Also, the Asian eyelid typically has an epicanthal fold with the upper eyelid fold inserting under the epicanthal fold. However, these are generalizations. Reality is more of a spectrum. The key is to perform surgery that harmonizes the eyelid with a more youthful ideal of what a particular eyelid should be. This often means deviating significantly from the type of eyelid surgery that is described in plastic surgery textbooks!

Many textbooks call for the lowest incision in the upper eyelid to be placed at 10 millimeters above the eyelashes. When the surgical wound heals, the incision usually heals with a slight upward creep of the scar so that the incision that was measured 10 millimeters above the eyelashes heals to 11 or 12 millimeters above the eyelashes. When a high incision is combined with aggressive skin and fat removal, a common surgical scenario, the result is a hollow upper eyelid, absent an upper eyelid fold. This appearance is a hallmark of a post surgical result and is unnatural, undesirable, and essentially unfixable (although there are things that can help) (figure 6).

Figure 6

Instead, the lowest incision of an upper blepharoplasty should be placed 6 to 8 millimeters above the eyelashes. A lower incision is essential for an Asian eyelid. Considerable judgment is necessary in performing a revisional upper blepharoplasty in someone who has had too high a crease placed in an original surgery. As this becomes the upper eyelid crease, this incision should be remeasured several times to be certain of its placement and its symmetry with the opposite incision. Like many things, this is easier said than done. Small differences in incision placement are highly visible to the human eye due to Vernier acuity.

Generally the goal in these cases is to place the platform skin on gentle tension so the platform skin is smooth. This also helps to rotate the eyelashes, which can point downward without firm support from the eyelid platform skin. Often the actual incision is placed several millimeters below the original incision. Anchor sutures to the underlying levator aponeurosis tendon reinforce the upper eyelid crease. This will have a number of effects depending on the individual circumstances. In the best cases where a hollow sulcus is associated with upper eyelid ptosis, repair of the ptosis at the time of the blepharoplasty, shortens the apparent lid platform and advances the orbital fat in conjunction with the levator complex recreating fullness and often a fold in the upper eyelid.

Figure 7

In the absence of prior surgery, the excision of skin in the upper eyelid is based on the desired amount of eyelid platform to be exposed below the upper eyelid fold. This requires knowledge of how the eyelid surgery will likely heal and the effect of post-operative eyebrow position on the eyelid fold. (Figure 7) Eyebrows tend to descend after surgery. This effect can be profound in certain individuals (think heavy eyebrows and numerous forehead wrinkles). However, with experience it is possible to anticipate these issues with good results. As part of the pre-operative assessment, the eyebrow is held in the position that it is likely to relax to after surgery and the lowest point of the eyelid fold is noted. This allows a more accurate assessment of how much upper eyelid skin needs to be removed from the upper eyelid. It is better to take out less skin than too much skin. More skin can always be removed as a little office procedure. While you might not be thrilled with the need to perform revisional surgery, this is a conservative approach. Taking out a pinch more skin is much easier than putting skin back.

Lower eyelid surgery is a much more complex affair. This is due to the delicate balance of forces that make the lower eyelid work as an aesthetic and functional structure. The lower eyelid is gently poised against the eye by a system of ligaments and muscles. Subtle changes can affect this balance. Further, the surgical paradigm of removing herniated orbital fat and excessive lower eyelid skin is faulty. There are individuals where performing standard lower blepharoplasty can make a very nice difference but this is the exception rather than the rule. The reason stems from how gravity and time affect the lower eyelid and cheek. As the orbitomalar ligament gives way, the cheek soft tissue descends vertically contributing to fullness of the cheek just behind the nasolabial fold. Many surgeons still labor under the false impression that this fullness is due to horizontal laxity of the lower face and attempt to correct this fullness with a lower facelift. Tugging this volume laterally rather than vertically can contribute to a surgical look. Midface lifts have become very popular also but generally these are also based on the wrong concept of facial aging. Many midface lifts (ribbon lift, meloplication, cable lifts, temple lift) elevate in a superolateral vector. This can cause a shift of the cheek volume and lead to a very unnatural post-surgical appearance that is nearly impossible to correct. The key with any procedure including these types of superolateral midface lifts is to not overdo the procedure or avoid them altogether. The correct vector of lift is primarily vertical with a small lateral component when needed. The vertical midface lift over a custom orbital rim implant restores the cheek fullness to a natural and more youthful appearance. More detail about this procedure is discussed in the section on midface surgery.

Alternatives exist to these midface procedures. The Deepfill™ method of under eye Restylane® treatment, a component of the Gel-Lift™, fills the depth of the under eye circle with Restylane® gel to reestablish the contour of the youthful lower eyelid cheek interface. Restylane® and Perlane® are sugar gels and are very similar to the sugar gels that occur naturally in the body. The major difference is that these fillers are cross-link so they function as tissue volumizers. The fullness in the lower eyelid and the cheek separate overtime as noted above. By placing volume within the groove the hollow is filled in. These treatments are very comfortably done in the office. The material lasts about a year and can be easily adjusted if necessary.

Traditional lower eyelid surgery involves either a skin incision just below the eyelashes, or alternatively and, generally preferred, an incision behind the eyelid so there is no skin incision. The lower eyelid fat is exposed and sculpted to the desired volume. When there is excess skin, the incision below the eyelashes is used to trim out an appropriate amount of excess skin. Even just a pinch of skin can make a very significant difference. Alternatively, the lower eyelid skin can be improved and tightened with the appropriate chemical peel. If the lower eyelid is lax, it may be necessary to support the lower eyelid with a stitch or in some cases a lateral canthal procedure. Conservation of the lower eyelid fat has become an increasingly popular ancillary lower eyelid surgery procedure. This is the so-called arcus maginalis release. The lower eyelid fat that is creating fullness in the lower eyelid is mobilized and rotated over the top of the cheek causing the under eye hollow to be filled and reducing the bulk in the lower eyelid. In certain cases, simply a chemical peel can be used to firm the lower eyelid skin and avoid the need to actually cut skin saving an incision.

Is eyelid surgery right for you? There is no substitute for a personal consultation with world-renowned Los Angeles and Beverly Hills Eye Plastic Surgeon Kenneth D. Steinsapir, M.D. He is a true eyelid specialist. He is fellowship trained in eyelid plastic surgery and cosmetic surgery. He is also a board certified ophthalmologist and a Fellow of the prestigious American Academy of Cosmetic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery. We encourage you to carefully review our before and after photographs, think about your goals, and talk with Dr. Steinsapir about what results you are looking for. Together you and the doctor will formulate a sensible plan that will help you achieve your goals.