Upper blepharoplasty aims at correcting the effects of aging on the upper eyelid. The anatomy of the upper and lower eyelids is similar only superficially. The details differ to a degree significant enough to fill specialized books. The process of aging is again similar in both areas, but from a surgical standpoint it makes a huge difference whether one operates “north” or “south”. If there is something like a simple procedure at all in cosmetic surgery for facial rejuvenation it would be upper blepharoplasty. Compared to lower blepharoplasty it simply has a tremendously reduced risk of complications. But like everywhere in plastic surgery the one pearl of wisdom also applies to upper blepharoplasty: if one ever starts to think of a procedure as easy, one just hasn’t done enough of them …
Aging in the upper eyelids again starts relatively early in all ethnicities, including those present in the Caribbean. In youth, a stable brow position and absence of redundant skin impart an “open” look to the eyes without folds of upper lid skin. A person appears thus fresh, alert, full of vitality. The upper eyelid contour is smooth and presents an easy platform to apply make-up to. With aging the eyebrows lose their firm anchoring, descend and contribute to increasing skin redundancy, which is aggravated by loss of elasticity of the upper eyelid skin and laxity of the underlying lid muscle. The eyes appear “closed”, the individual looks tired and aged and it becomes difficult to apply make-up. Loss of volume of fat and bone of the eye socket, particularly towards the nose contribute to the “hollow” appearance, another tell-tale sign of aging giving the impression of decreased vitality.
Important gender specific and ethnic differences do exist, however. Number one, the cosmetic corrections achieved by upper blepharoplasty make it an intrinsically “female” operation. Even in youth, a more “closed” orbit with a lower brow is a masculine feature, which should not be changed by upper blepharoplasty. Also, most males do not apply make-up to the upper eyelids. Nevertheless, droopy eyelids and redundant skin also make men look aged and tired. If performed for cosmetic reasons in males, an upper blepharoplasty should thus be more conservative than in females and also place emphasis on correcting volume losses in the upper lid. Male clients in general thus do present to us at a more advanced age for upper lid blepharoplasty, often quite late, when the redundant skin has become excessive enough to hang over the lid margin and interfere with vision. A restricted visual field due to upper eyelid problems is an excellent indication for upper blepharoplasty though, correcting form (appearance) and function (visual field) at the same time!
Secondly, in many clients of mostly East Asian ethnicity or Mexican descent there is an observable flatness of the bony eye sockets. The upper eyelids appear fuller and heavier with a constitutional tendency to have more fat in the upper lid. The degree of skin redundancy is quite similar. Under those circumstances it may make more sense to remove part of this fat during upper blepharoplasty, a step which is today by and large abandoned in Caucasians, where age related volume loss predominates in the upper eyelid.
Surgical finesse in upper blepharoplasty is still required in several key steps of the operation. In the planning stage it has to be decided if the muscle lifting the upper lid margin is affected by the aging process and thus the resting position of the upper lid margin warrants correction. If there is weakness of this muscle or a low position of the lid margin both will become worse after an upper blepharoplasty performed without correcting these issues. Furthermore, the degree of hollowing of the upper part of the eyes toward the root of the nose should be assessed just from an aesthetic standpoint and corrected with micro fat grafting if necessary. Importantly the excision pattern for the redundant skin needs to be designed in order to remove enough skin to create a smooth contour. As opposed to the lower eyelids, where excessive skin removal is one of the major sources of difficult to correct complications, inadequate skin removal is likely the most frequent reason for revision operations and touch-ups after upper blepharoplasty. The next decision is if to remove any of the lax eyelid muscle responsible for eyelid closure, and if yes how much. It should always be much less than the amount of skin excised and often is not necessary at all and would only contribute to loss of volume in the upper lid. While doing something with the fat in the lower eyelid is an integral part of lower blepharoplasty (take some out or redistribute it or use it as a graft), we think that in the majority of cases there is no necessity to do anything with the fat in the upper eyelid as removal, the only meaningful manoeuver, would again contribute to volume loss. The final decision is what to to with the eyebrow. A successful upper blepharoplasty has the tendency to result in a lower eyebrow position after surgery. While this does not always warrant a formal browlifting procedure, simple suspension to prevent descent is often a prudent step.
The big positive about upper blepharoplasty is that none of the operative steps resulting from preoperative decision making is difficult or lengthy. An upper blepharoplasty procedure can be performed under local anesthesia with minmimum postoperative discomfort. A small amount of swelling and bruising will be present after the operation and resolves after five to seven days. After about two weeks after surgery, the longterm positive results of upper blepharoplasty start to be visible – for many years to come!
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Trinidad Institute of Plastic Surgery – the superior choice for upper blepharoplasty in the Caribbean, Antigua and Barbuda, The Bahamas, Barbados, Belize, Dominica, Grenada, Guyana, Haiti, Jamaica, Montserrat, Saint Lucia, St. Kitts and Nevis, St. Vincent and the Grenadines, Suriname, Trinidad and Tobago, Bermuda, British Virgin Islands, Cayman Islands, Turks and Caicos Islands, Miami, New York, Toronto, London