Periorbital Rejuvenation:
A Systematic Approach

James J. Romano, MD

More people are taking advantage of improving the look around their eyes—not only with makeup, skin treatments, or products, but with surgery as well. During the past few years, the fields of cosmetic surgery and professional skincare have experienced an explosion of new techniques and procedures that significantly contribute to rejuvenating the eyes and making them look more youthful. Clients are asking more questions and requesting highly technical information about the new procedures from their estheticians. For this reason, it is important for you to become acquainted with and recognize the full spectrum of anatomic features and the new and different eyelid and periorbital treatments available. In response to many inquiries, I have listed below the 20 most common questions asked of me about eyelid rejuvenation procedures and what can be done to take years off your age:

  1. Why is eyelid and upper facial surgery suddenly so popular? Over the past ten years, eyelift surgery has become one of the most popular facial cosmetic surgery procedures. Patients become frustrated with creams, cosmeceuticals, folk remedies such as cucumber slices, and constant comments from friends about how tired they look. They often are in denial about their features; they wear dark glasses or creative makeup until the day comes when someone, often their esthetician, informs them about the benefits of surgery. They want results. Eyelid and periorbital surgery can easily make patients look five to ten years younger.
  2. What is the ideal age for an eyelift? It can be very early if there is an inherited trait such as an eye tilt, eye bags, or thick muscle rolls beneath the lower eyelashes. It can be seen in patients as young as their 20s. More mature patients experience drooping eyebrows, wrinkled skin and puffy eye bags. Eyes can show age and look tired before the rest of the face.
  3. What can be done for wrinkle lines around the eyes? This is an important starting point for anyone considering periorbital rejuvenation and as a preparation for any surgical intervention and also as a definitive therapy in and of itself. This works well for patients with mild wrinkle lines, pigmentation, and very mild looseness to the skin. Skincare is directed specifically at treating the texture of the skin and not folds or skin excess. This includes creams, ultrasound, Retin-A, microdermabrasion, facials, and peels.
  4. Which peels are good for around the eyes? There are many effective peels that can remove wrinkles. It depends on the wrinkles and the anatomy of your eyelid. If there are folds and hanging skin, then an eyelift is needed. If the wrinkles are in the texture of the skin then there are many good peels available. These can all be done in the office, and most heal over the course of a long weekend. Peels start with glycolic acid, Jessner’s solution, TCA, and modified phenol, getting deeper as you move up this list. They are often repeated at several-month intervals for patients who want a very thorough result.
  5. How does Botox affect wrinkles around the eyes? It is an adjunct to an eyelift and often goes hand-in-hand with surgery, but will rarely replace surgery when surgery is needed to improve eye wrinkles. Botox is a chemical that has the sole mechanism of action of paralyzing the muscles of facial expression. It is very effective in relaxing and decreasing wrinkle lines and creases that are due to muscle activity. The greatest effect is seen in removing the lines related to the activity in the muscles of the crow’s feet, between the eyebrows, and the forehead.
  6. What is the role of filler materials around the eyes? These play a huge role in periorbital rejuvenation. There are many popular materials that are used, and exciting new materials that I currently use. Wrinkle lines due to muscle activity respond well to Botox, but Botox cannot be used in all areas, such as where muscle activity needs to be preserved or where the lines are etched deep into the dermis and wrinkle lines are present that need to be filled. Here is where fillers play an important role. Typical fillers I use include collagen, Perlane, Restylane, Artefill, and your own fat.
  7. What is laser surgery for eyelids all about? When talking about laser surgery, it should be considered within the category of using it either for cutting or for resurfacing. In terms of cutting, all eyelid surgery involves cutting of some sort. This can be done by a scalpel blade, an electric current and needle, or by the cutting modality of the laser. Although laser cutting has been promoted as causing less bleeding and lending itself to faster post-operative healing, there is no evidence that this is the case. In fact, recent studies have shown that there is no solid scientific advantage to laser cutting, and many feel it adds significant risk. On the other hand, laser resurfacing is an entirely different function from cutting. This is where the laser energy is used to remove a specific layer of skin down to a specific depth. In so doing, wrinkles are softened or removed, pigmentation often is removed, and the skin is tightened. This is very helpful in treating the eyelids, especially lower eyelids with loose wrinkled skin. Care must be taken to test the lid elasticity, as noted above, to identify patients who have loose lower eyelids, since these need to be treated by canthoplasty first.
  8. What is brow sagging and what about forehead lifts? This is for eyebrows that are sagging or drooping and falling into the upper eyelid skin. The most common reasons for needing forehead rejuvenation are to smooth forehead wrinkles, raise the eyebrows, smooth out the skin of the upper eyelids, smooth out prominent eye-socket bones, even up the eyebrows, or remove the corrugator frown muscles.
  9. How are eyebrow or forehead lifts performed? Forehead surgery can be performed with minimal-incision endoscopic surgery using cameras on the end of small tubes placed through tiny incisions, or by incisions hidden behind the hairline. Both of these procedures raise the hairline by the same amount the eyebrows are raised. These should be avoided in patients who have high foreheads. If, on the other hand, the incision is placed at the edge of the hairline, the forehead will not elongate, and in fact, it can make the forehead shorter and the hairline can be lowered if this is what you need.
  10. How can sagging at the upper outer eyelid and eyebrow be treated? This is called hooding. Heavy sagging of the outer half to third of the eyebrow and excess skin in the upper outer eyelid can be treated by a temporal tuck. This is performed to raise the tail of the eyebrow and reduce the excess skin overlying the outer edge of the upper eyelid. An incision is made at the hairline or inside the hairline in the temporal region. It is made inside the hairline if not much lift is needed, and at the edge of the hairline if there is a lot of looseness and you do not want to pull the hairline back too far.
  11. What can be done to treat my upper eyelid drooping? Upper eyelid rejuvenation consists mostly of removing excess skin and fat. Excess skin of the upper eyelids may be made worse by drooping eyebrows folding the skin down, so this needs to be evaluated and treated first. The upper eyelid incision is designed to remove the excess skin, and it should be placed perfectly so that the final healed incision is in the natural eyelid crease line.
  12. Where is the incision to treat the lower eyelids? Lower eyelid rejuvenation is more involved and often more risky than upper eyelid surgery. Lower eyelid anatomy of concern is the amount of excess skin, tightness and position of the eyelid as it crosses the eyeball, the position of the outer corner tendon, wrinkles, and pigmentation. The lower eyelid incision can be just below the eyelashes, called transcutaneous, or on the inside of the eyelid, called transconjunctival.
  13. What is done to treat the puffiness of lower eyelids? There are different ways to treat the fat under the lower eyelid. This depends on if a tear trough is present, the eyelid skin thickness, cheek skin thickness, and the amount and distribution of fat. Fat then is excised or repositioned and turned down over the cheek. The removal of fat needs be done extremely carefully—it is easy to remove too much fat and create a sunken eyeball look. If fat is repositioned, it is pulled out and then down to fill in the crease between the eyelid and cheek, and enhances the lower eyelid and upper cheekbone.
  14. My eyes look tired and droop. What is the cause of this, and what can be done for it? The tendon at the outer edge of the eyelid can be moved up and connected higher on the bony rim to correct sagging or “hound dog” eyes. This is canthopexy, a corner eyelift, and is different from canthoplasty. The slant of the eyes and the lower eyelid curvature is controlled with a corner lift. This lift also can tighten loose lids, but mainly is done to change the eye shape from round to more almond, or change a sad, bowed lower eyelid to a more cheerful, snug, and pleasant look. This procedure also treats clients with too much white of the lower eyes showing, especially in the outer half, and improves lower eyelid bowing and excess tearing. The surgery is done by grasping the tendon where the upper and lower eyelid fuse, and then sewing it up higher onto the bony eye socket edge. This is all done through the eyelid incisions, and no new incisions need to be made or are visible. Corner lifts are meant to give a tiny, graceful lift and won’t produce cat eyes unless the procedure is intentionally overdone.
  15. My eye sockets feel “heavy.” What can be done for this? The edge of the eye socket often can play a role in the upper eyelid esthetics. The appearance of fullness of the upper outer eyelids may be due not only to eyelid and brow fat, but also to a prominent bony orbital rim. Excessive bone on the orbital rim can be removed through the upper eyelid incision. This softens the upper outer eye socket.
  16. I want a fuller, rounder face. What can be done for this? The anatomy of the cheeks and upper middle face has an impact on lower eyelid anatomy and esthetics. If the cheekbone is very small or flat, implants can improve this. These usually are placed through an incision on the inside of the mouth. The implants are made of various materials, but most often silicone is used. They are safe and “anatomic,” which means they are shaped to follow the size, shape, and contour of the cheekbone they’re intended to increase. Working through the small incision above the gum line inside the mouth, a space is made exactly to fit the dimensions of the implant. This is put in place, and the incision sewn up. The implants are soft and pliable, do not move, and give increased width and more prominence to the cheeks.
  17. Where is the surgery done? All surgery of the eye is performed in the outpatient center under anesthesia with an anesthesia doctor present. You do not feel any pain at all. It takes about three hours from the time you come in until the time you go home.
  18. What is recovery after surgery like? Every patient wants to know how long it will take to recover and when they can attend a party, go back to work, or meet with others at the office. Every patient heals differently. There is no way to compare healing from one patient to the next, just as you cannot compare technique from one physician to the next. I instruct patients to keep their head elevated 45–60 degrees while healing. Ice is helpful. No bending, stooping, heavy lifting, or vigorous activity should be performed for one to two weeks. Makeup is allowed after three to four days when the stitches are removed. Green-colored base will help conceal the redness. Avoid mascara for about two weeks. Often, patients can return to work within a week.
  19. What can be done to aid in preparation for surgery? There is a lot of preparation that can be done before surgery that will accelerate recovery. This makes a dramatic difference in decreasing the healing time, bruising, and swelling. The combination of dietary recommendations, supplements, reduced activity levels, skincare products, and knowing which drugs to avoid can make a huge difference in the healing.
  20. How long does the surgery last? Any cosmetic surgery has the potential to last a long time depending on the elasticity of the tissue, and will be long-lasting in the sense that it always will look better than if it were not done. There is no limit as to how many times these procedures can be repeated as long as there is ample excess tissue and not too much is removed on any one occasion.

These procedures are all very effective and not experimental. They range from older and time-honored techniques to newer state-of-the-art procedures. Considered together, there are numerous ways to turn back the hands of time around the eyes. Teach your clients how your services, combined with the outcome of cosmetic surgery, can contribute to total well-being. As an esthetician, it’s not only important to provide services and pre- and post-operative care, but also to educate clients.

The eyes often are the first or only area to show signs of aging, especially in younger clients. The periorbital area consists of the eyelids and surrounding areas including the eyebrows, bony eye socket and rims, cheeks and forehead.

The eyes and eyelids are very complex and delicate areas, and as such need to be approached and treated with care. Healing with even 2 mm of an abnormal scar can make the difference between a normal or a horribly unsightly bowed lower eyelid. For this reason, the more you learn and teach your clients, the better prepared they are for a surgical procedure, the more complications you can help prevent, the better they look, and the more valuable your service becomes.

Over the past ten years, eyelift surgery has become one of the most popular facial cosmetic surgery procedures. Your clients can become frustrated with creams, cosmeceuticals, folk remedies such as cucumber slices, and constant comments from friends about how tired they look. They are often in denial about their features; they wear dark glasses or creative makeup until the day comes when someone, often their esthetician, informs them about the benefits of surgery. They want results. Eyelid and periorbital surgery easily can make clients look five to ten years younger.

What follows is an explanation of the anatomy of the eyelid area and a description of how to evaluate the different features in this region, especially with respect to what your clients may want to focus on or will express concern with you about in consultations. This is followed by a discussion of the various cosmetic surgery options. Surgeons often have very different opinions and approaches, but this article is intended to take the mystery out of eyelid treatments and offer a concise explanation and reason for the different procedures. It should provide the information needed to very accurately counsel your clients. For simplicity, the anatomic areas have been subdivided, but they are interrelated in the evaluation and treatment.

There still is a lot of talk about credentials and who should perform cosmetic surgery. There are many specialists participating in these procedures, including cosmetic surgeons, otolaryngologists, ophthalmologists, and oculoplastic surgeons. Occasionally talented and well-trained dermatologists and general surgeons perform this surgery. Clients should check the credentials of any physician or surgeon before undergoing any type of surgery.

Evaluation and Anatomic Features
What’s the ideal age for an eyelift? It can be very early if there is an inherited trait such as an eye tilt, eye bags, or thick muscle rolls beneath the lower eyelashes. It can be seen in clients as young as their 20s. More mature clients experience drooping eyebrows, wrinkled skin, and puffy eye bags. Eyes can show age and look tired before the rest of the face.

What do your clients desire in terms of rejuvenation? It is important to narrow down the specifics. Let your clients describe this to you in detail. Use this opportunity to carefully and systematically evaluate clients about their needs and expectations, taking into account their lifestyle. Discuss sun exposure and protection, diet, exercise, supplements, and vitamins taken. There are many internal anti-aging interventions that contribute significantly to better skin and overall well-being. At this initial evaluation, also discuss general medical background, medications, allergies, any health or eye-related problems, and prior surgeries. Teach your client how important it is to review these with their cosmetic surgeon. Then review the specifics of what your clients see and dislike and perform a systematic examination from the top down.

Skin and texture
Begin with the overall evaluation of skin and textural features such as wrinkles and their size and location, pigmentation, any skin lesions, and status of the skin elasticity. If any of these features are prominent around the eyes, be aware that there are many interventions that can improve these conditions, from topical products to peels to laser to filler materials.

Hairline and Forehead
Note the hairline location, especially in relation to shape and height of the forehead—whether the hairline is thick or thin and how the hair grows. This will determine where to place an incision. Note the hair styling and whether the hair is often combed down in an effort to hide a high forehead or transverse wrinkles. Examine the forehead skin and the creases and furrows. Look for lines between the eyebrows either at rest or with gentle frowning. Test the forehead skin and eyebrow laxity by pulling directly up or out on the eyebrows and look for improvement in the eyebrow shape and excess upper eyelid skin. All of these features can help to determine if a forehead lift is needed for the specific purpose of removing wrinkles, removing frown muscles, raising the eyebrows, lowering or raising the hairline, or all of these. Sometimes wrinkle fillers, a peel, or Botox1 is all that is needed.

Eyebrows
Carefully observe the eyebrows and their shape, position and symmetry. Be careful not to be misled by tweezed or colored high-arched brows. Look for the location of the hair follicles. Feel the bony rim and note that the normal eyebrow position should be about one finger’s breadth above the rim and curved. Ask the client to gently close the eyes and relax them. The eyebrows and forehead often settle downward when the client is asked to do this. Then have the client slowly open the eyes. Notice if the eyebrows are sagging and if there is a tendency for your client to unconsciously want to raise the eyebrows or wrinkle the forehead to lift up the drooping eyebrows to help open the eyes. This test demonstrates the situation in which clients are using the forehead muscles to raise the upper eyelids. Both of these findings signal the need for a forehead lift to allow the eyes to be open wider and let in more light.

Next, have clients look straight ahead in the mirror and pull the eyebrows gently straight up and out slightly. Note if you and your client like the posture and shape better, and note if the skin between the eyebrow and eyelid improves. All of these maneuvers signal the need for a forehead lift.

At this point, focus on the tail of the eyebrow and the skin beneath it to see if it is drooping or puffy. If only the tail of the brow droops and excess skin is seen mostly over the outer upper eyelid and beyond, this is called lateral hooding and is often treated by a temporal tuck. The brow may droop over the years, especially in mid and outer thirds, and causes the “hooding” problem of extra skin folding over into the upper outer eyelids. The forehead can fall over into the upper eyelids and cause extra skin and pleats. In this case excess eyelid skin is not the only problem, but the falling eyebrows are as well. Pinch this area under the tail of the brow, and feel if there is a fullness that signifies a fat roll. This may suggest a tube of what is called “brow fat” that needs to be removed. Feel the bony eye socket rim and determine if this is large and prominent. This is often accompanied by the appearance of deep-set eyes and can signal the need for the bone to be contoured and reduced.

Upper Eyes
Next, working from the top down, look at the features of the upper eyelid—the skin, texture, contour, and shape. Are the eyes round or almond, and what does the client want? Are the corners of the eye drooping, and do they need to be lifted? Determine if there is wrinkled skin or discoloration and where. Note how the upper eyelid skin and any excess is very closely related to the position of the eyebrows. With the eyes shut gently and are relaxed, pick up the eyelid skin with tweezers. If you can pull much up and out and not move the eyelashes, then there is enough excess skin present that needs to be removed. With your client looking straight ahead in a mirror, press gently on the eyeball and point out any bulging areas. This is usually seen in the upper inner corner. You will see bulging in the lower eyelid as well. Any of these areas that are bulging at rest then bulge more with pressure signify fat pockets that need to be removed. Note any previous incisions and whether or not the eyelids shut completely. Look at the eyelid crease and note its location or if it is present at all. Asian clients are often missing this and want to surgically create a crease to “Westernize” an eyelid.

Lower Eyes
Most clients like the look and shape of their eyes but just want to remove the lower bags and puffiness. Again, evaluate the skin texture, skin excess, and fat as just described. Look carefully at lower eyelid shape and elasticity. Determine if there is excess skin or fat, or both, that needs to be treated. Next, ask your client to gently smile and see if a “sausage roll” pops up just below the eyelashes. This suggests an excess muscle roll that needs to be removed by surgery. Ask clients to look straight into a mirror with their eyes open, and then gently press on the eyeball and look for bulges on the skin surface. This signifies where fat pads are present and need to be removed.

Determine if the lower eyelid just covers the lower colored portion of the eye, which is normal, or if it is bowed or slightly low, and if excess white of the eye shows or if the lower lid bows outward. Note the position of the outer corners of the eyes as related to the inner corners. Examine the overall shape of the eyelids from the inside to the outside corner and look to see if they mostly are level or tilt down to the outside corner. Note if the eyelids are really loose, relaxed or droopy, either in the lower lid margin or at the corners. Any of these may signify the need for a canthoplasty, a term for lower eyelid tightening and elevation. Pull out the lower eyelid gently, and see how far it comes out and if it snaps back quickly. This is the snap test, and the eyelid should pull out less than _-inch and snap back quickly and adhere to the eyeball. Pull the eyelid down and hold it there. Ask the client not to blink, then let go. The eyelid should return to the eyeball snugly in less than four seconds. This is the retraction test. If there is any abnormality of these tests or exams then the lower eyelid needs to be tightened or lifted by a canthoplasty before any other surgery, otherwise abnormal eyelid drooping and a “hound dog” look will result.

Next, note if there is a deep furrow in the lower eyelid starting at the corner of the eye and nose and running downward between the cheek skin and the eyelid skin. This is called the “tear trough” and can be treated with fat grafting procedures. Lastly, look at the client in repose and again with slight smiling, this time focusing on the wrinkles. In the lower eyes especially these wrinkles can be disturbing and difficult to treat. Make the distinction between wrinkles in the texture of the skin or when smiling and related to muscle activity, dynamic wrinkles and crow’s feet, or from loose hanging folds of skin. Each type of wrinkle needs to be distinguished and pointed out to the client, and each is treated differently. Some may never completely go away. Textural wrinkles are treated with creams, peels, fillers, or resurfacing. They are only “softened” by excess skin removal. Dynamic wrinkles such as in the area of the crow’s feet respond best to Botox.

Cheeks
Now look at the cheekbones in relation to the eyes and especially the lower eyelids. Note if the cheekbones are unusually flat or small. Look at the eyelids and cheeks from the side; the cheekbone should project slightly beyond the surface of the eyeball. The normal anatomy is for the lower eyelid to curve gently down and outward to meet with the upper edge of the cheekbone. If this is not the case, then the eyeball is very prominent or the cheekbone may be small—or both. This situation puts lower eyelid surgery at some increased risk for bowing. Cheekbone enhancement, canthoplasty, or both procedures may be necessary to correct this feature.

Laser Surgery
When talking about laser surgery, it should be considered within the category of using it either for cutting or for resurfacing. In terms of cutting, all eyelid surgery involves cutting of some sort. This can be done by a scalpel blade, an electric current and needle, or by the cutting modality of the laser. Although laser cutting has been promoted as causing less bleeding and lending itself to faster post-operative healing, there is no evidence that this is the case. In fact, recent studies have shown that there is no solid scientific advantage to laser cutting, and many feel it adds significant risk. On the other hand, laser resurfacing is an entirely different function from cutting. This is where the laser energy is used to remove a specific layer of skin down to a specific depth. In so doing, wrinkles are softened or removed, pigmentation often is removed, and the skin is tightened. This is very helpful in treating the eyelids, especially lower eyelids with loose wrinkled skin. Care must be taken to test the lid elasticity, as noted above, to identify clients who have loose lower eyelids, since these need to be treated by canthoplasty first.

Skin Treatments
This is an important starting point for any client considering periorbital rejuvenation, and is a preparation for any surgical intervention and also as a definitive therapy in and of itself. This works well for clients with mild wrinkle lines, pigmentation, and very mild looseness to the skin. Skincare is directed specifically at treating the texture of the skin and not folds or skin excess. Skincare is recommended for all facial surgery regardless of the anatomy or the procedure. It is an excellent preparation for surgery, preserves the surgical results, and can delay the need for further surgery. Medical-grade skincare includes the use of Retin-A2, hydroquinones, glycolic acids, trichloricidic acid (TCA) peels, ultrasound therapy, and lymphatic drainage. These are very effective in decreasing pigmentation and spots, softening wrinkles, reducing pore size, decreasing swelling, accelerating healing, and increasing smoothness and elasticity of the skin. Peels and laser resurfacing are excellent for eyelid rejuvenation, as they remove pigmentation and tighten the skin and remove or soften wrinkles. Laser cannot be combined with an external lower eyelid incision, as this may complicate healing.

Botox can be included in this category. It is an adjunct to an eyelift and often goes hand-in-hand with surgery, but will rarely replace surgery when surgery is needed to improve eye wrinkles. Botox is a chemical that has the sole mechanism of action of paralyzing the muscles of facial expression. It is very effective in relaxing and decreasing wrinkle lines and creases that are due to muscle activity. The greatest effect is seen in removing the lines related to the activity in the muscles of the crow’s feet, between the eyebrows, and the forehead. It also has an effect in the lower eyelid lines, elevating the tail of the eyebrow, and reducing the vertical bands in the neck. Botox is safe and has very few complications. It can be applied within minutes during an office visit. The effect is seen in two days and lasts about five to six months.

Filler materials are also part of this category. These play a huge role in periorbital rejuvenation. There are many popular materials that are used, with exciting new materials becoming available soon. Wrinkle lines due to muscle activity respond to Botox1 well, but Botox cannot be used in all areas, such as where muscle activity needs to be preserved or where the lines are etched deep into the dermis and wrinkle lines are present that need to be filled. This is the case in which fillers play an important role. Collagen is the most popular, followed by Artecoll5, which is near approval in the United States. Perlane3 and Restylane4 are very successful.

Surgical Options
There is a spectrum of options available to surgeons for treating each of the anatomic areas discussed and the associated conditions. It is a good idea for estheticians to familiarize themselves with these procedures.

Forehead Rejuvenation
This is for eyebrows that are sagging or drooping and falling into the upper eyelid skin. The most common reasons for needing forehead rejuvenation are to smooth forehead wrinkles, raise the eyebrows, smooth out the skin of the upper eyelids, smooth out prominent eye socket bones, even the eyebrows, or remove the corrugator frown muscles. Less often this procedure may be indicated to raise or lower the hairline. A variation of the forehead lift is the temporal tuck. These can be performed alone or in combination with eyelid surgery to obtain optimal rejuvenation.

Forehead surgery can be performed with minimal incision endoscopic surgery using cameras on the end of small tubes placed through tiny incisions or by incisions hidden behind the hairline. Both of these procedures raise the hairline by the same amount that the eyebrows are raised. These should be avoided on clients who have high foreheads. If, on the other hand, the incision is placed at the edge of the hairline, the forehead will not elongate, and in fact, it can make the forehead shorter and the hairline can be lowered if this is what your client needs.

When a forehead lift is performed through an incision, the forehead is folded down all the way to the upper eyelids, the frown muscles are removed, and then the skin is folded back and pulled up tight. The excess skin or scalp is then removed and the stitches put in. When a temporal tuck is performed, this means there is laxity only at the eyebrow tails or upper outer eyelids. An incision is made inside or at the hairline in the temporal area, the tissues are loosened underneath the skin down to the eyebrow edge, and this is pulled up tight and the excess skin or scalp is removed.

Eyebrow Rejuvenation
Before surgery, the esthetician should help the client be aware of the shape, contour, hair growth, and how the client styles, colors, and tweezes the eyebrows. The hair follicles and the relationship of the eyebrow to the bony orbital rim should be evaluated. If the eyebrow is at or below the rim, then it is sagging. The eyebrow inner corner should be raised up straight, and the outer corner up and out. The eyebrows can be raised and occasionally made more even. It is sometimes possible to change the shape and make straight eyebrows arched or arched eyebrows straight by adjusting the degree and direction of the tension when performing the forehead lift as previously explained. Raising the eyebrows, especially if they are sagging, will have a dramatic impact upon the upper eyelids and excess skin, folds, and lateral hooding. It usually is best at elevating the outer two-thirds of the eyebrow.

Normally, the upper eyelid incision is made in the natural upper eyelid crease unless this is absent. It goes from the inner corner to the outer corner of the upper eyelid and then slightly up into one of the crow’s feet, depending on how much excess skin is present. It usually is 7 to 11 mm above the eyelashes in most clients, and 4 to 5 mm above the lashes in Asians. The upper eyelid surgery is performed through the incision and excess skin and fat is removed. The healed incision should be located in the exact location of where the crease naturally was before the surgery. The brow fat is removed through the same incision. This is a sausage-shaped fat accumulation that can be present in excess. It is located under the outer third of the eyebrow and can give the appearance of excess fullness and some heaviness. The corrugator muscles can be removed through the inner corner of the same incision. These are the same muscles that cause the frown lines or creases between the eyebrows. If clients do not like continued Botox use, the muscles can be removed. Once these muscles are removed, some of the fat that is otherwise discarded can be threaded into the frown lines for an even better result. The combination gives an excellent and permanent result.

The eyebrows can be elevated modestly through the central and lateral aspect of this same upper eyelid incision. It usually allows elevation of only the outer half of the eyebrow, and only a modest amount. This usually is perfect for clients, especially men, who do not need or want a lot of eyebrow lift. Stitches are placed from the underside of the eyebrow to the bony orbital rim. The eyebrows still can move up with expression, but just don’t sag down as low. If one eyebrow is higher or lower than the other, it can be adjusted slightly by a browpexy.

Rarely is a direct eyebrow lift performed by making an incision in the skin over the eyebrows just at the edge of the hair follicles, removing the skin, and closing the incision. This results in raising the eyebrow by the amount of skin that was removed.

Heavy sagging of the outer half to third of the eyebrow and excess skin in the upper outer eyelid can be treated by a temporal tuck. This is performed to raise the tail of the eyebrow and reduce the excess skin overlying the outer edge of the upper eyelid. An incision is made at the hairline or inside the hairline in the temporal region. It is made inside the hairline if not much lift is needed, and at the edge of the hairline if there is a lot of looseness and you do not want to pull the hairline back too far. Either way, a space is made under the skin up to the edge of the eyebrow and loosens up the skin and wrinkles. The skin and eyebrows are pulled up and out, and the excess skin removed and the incision closed.

Upper Eyelids
Upper eyelid rejuvenation consists mostly of removing excess skin and fat. Excess skin of the upper eyelids may be made worse by drooping eyebrows folding the skin down, so this needs to be evaluated and treated first. The upper eyelid incision is designed to remove the excess skin, and it should be placed perfectly so that the final healed incision is in the natural eyelid crease line. Clients are evaluated and marked while they are sitting up since positional changes due to gravity play an important role in this case. The excess skin is pinched up and marked at several points along the upper eyelid from the inner to the outer corner, and beyond into the crow’s feet if there is also excess skin there. These dots then are connected. The skin is pinched up again to make sure this does not raise the eyelid—this means too much skin will be removed and the risk of incomplete eyelid closure may result. The excess skin and the underlying muscle that is often bulging are removed. Beneath it is a ligament called the orbital septum. The eyeball fat lies below here in three pockets. An incision is made over the fat pockets and just the right amount is removed to add smoothness to the upper eyelid and remove the bulge. Removing too much can cause a sunken look, and this should be avoided. If a client has a “lazy eye” due to a drooping eyelid, this can be fixed at this time. Wrinkle lines can also be treated by the appropriate peel or laser once the incision is closed.

Lower Eyelids
Lower eyelid rejuvenation is more involved and often more risky than upper eyelid surgery. Lower eyelid anatomy of concern is the amount of excess skin, tightness and position of the eyelid as it crosses the eyeball, the position of the outer corner tendon, wrinkles, and pigmentation. The lower eyelid incision can be just below the eyelashes, called transcutaneous, or on the inside of the eyelid, called transconjunctival. Scars or visible incisions are a natural and unavoidable byproduct of any surgical procedure. The incision inside the eyelid is still an incision, but less visible. The thin eyelid skin heals better than almost any tissue in the body. When performed in the correct location—exactly along the upper eyelid crease and just below the eyelashes—the skin incision is virtually imperceptible. The reason for choosing an incision is not always purely cosmetic. The inside incision allows only removal of excess fat, and can safely be combined with laser resurfacing of the skin. The skin incision allows for removal of excess fat, skin, and muscle. The muscle is usually a thick roll present below the eyelashes, best seen when smiling. The fat pads are below this and just above the lower eye socket, and are best seen when pressing the eyeball.

The lower eyelid incision also allows for tightening the relaxed eyelid and for fat grafting or fat repositioning. There are different ways to treat the fat under the lower eyelid. This depends on if a tear trough is present, the eyelid skin thickness, cheek skin thickness, and the amount and distribution of the fat. Fat is then excised or repositioned and turned down over the cheek. The removal of fat needs be done extremely carefully—it is easy to remove too much fat and create a sunken eyeball look. If fat is repositioned, it is pulled out then down to fill in the crease between the eyelid and cheek, and enhances the lower eyelid and upper cheekbone. Some physicians insert cheek implants through this lower eyelid skin incision.

At the same time, the tendon at the outer edge of the eyelid can be moved up and connected higher on the bony rim to correct sagging or “hound dog” eyes. This is canthopexy, a corner eye lift, and it is different from canthoplasty. The slant of the eyes and the lower eyelid curvature is controlled with a corner lift. This lift also can tighten loose lids, but mainly it is done to change the eye shape from round to more almond, or change a sad, bowed lower eyelid to a more cheerful, snug, and pleasant look. This procedure also treats clients with too much white of the lower eyes showing, especially in the outer half, and improves lower eyelid bowing and excess tearing.

The surgery is done by grasping the tendon where the upper and lower eyelid fuse, and then sewing it up higher onto the bony eye socket edge. This is all done through the eyelid incisions, and no new incisions need to be made or are visible. Corner lifts are meant to give a tiny, graceful lift and won’t produce cat eyes unless the lift is intentionally overdone.

Bony Rim
The edge of the eye socket often can play a role in the upper eyelid aesthetics. The appearance of fullness of the upper outer eyelids may be due not only to eyelid and brow fat, but also to a prominent bony orbital rim. Excessive bone on the orbital rim can be removed through the upper eyelid incision. This softens the upper outer eye socket.

Cheeks
The anatomy of the cheeks and upper middle face has an impact on lower eyelid anatomy and esthetics. If the cheekbone is very small or flat, implants can improve this. These usually are placed through an incision on the inside of the mouth. The implants are made of various materials, but most often silicone is used. They are safe and “anatomic,” which means they are shaped to follow the size, shape, and contour of the cheekbone they are intended to increase. Working through the small incision above the gum line inside the mouth, a space is made exactly to fit the dimensions of the implant. This is put in place, and the incision sewn up. The implants are soft and pliable, do not move, and give increased width and more prominence to the cheeks.

Complications
Incisions inside the hairline can risk hair loss or wide healing incisions, but both of these are rare. Too much pull on the forehead lift can create the surprised look. Clients should be able to close their eyes almost immediately after surgery. There may be a small gap for several days or weeks, but this should progress to full closure in time. Until this closes, there can be some discomfort from dryness and irritation. Occasional massage, under the direction of a physician, is helpful to loosen the tissues. Clients who have had prior surgery and tight skin are at greatest risk. White showing between the eyelid and the pigmented portion of the eye in the lower eyelid is called “scleral show,” and is due to lack of elasticity and too much relaxation of the tissues after surgery. Hollowing out and the sunken eye look can be related to too much fat removal. Clients may want a lot of fat and puffiness removed, but care must be taken to leave enough to preserve the natural padding between the eyeball and the bone for a smooth skin surface. Too much lift at the corners will create a cat-eye look. Laser resurfacing of the lower eyelids can cause pulling and bowing if the eyelids are loose and not much elasticity is present.

Recovery from Surgery
Every client wants to know how long it will take to recover and when they can attend a party, go back to work, or meet with others at the office. Every client heals differently. There is no way to compare healing from one client to the next, just as you cannot compare technique from one physician to the next.

There is a lot of preparation that you, as an esthetician, can do before surgery that will accelerate the client’s recovery. This makes a dramatic difference in decreasing the healing time, bruising and swelling. The combination of dietary recommendations, supplements, reduced activity levels, skincare products, and telling the client which drugs to avoid can make a huge difference in the healing. Vision is blurry for several days due to the eye ointment and some swelling. Some redness, swelling, and discoloration can occur.

Instruct your clients to keep their head elevated 45 to 60 degrees while healing. Ice is helpful. No bending, stooping, heavy lifting or vigorous activity should be performed for one to two weeks. Makeup is allowed after three to four days when the stitches are removed. Green-colored base will help conceal the redness. The client should avoid mascara for about two weeks. Often, clients can return to work within a week.

Longevity
Any cosmetic surgery has the potential to last a long time depending on the elasticity of the tissue, and will be long-lasting in the sense that it will always look better than if it were not done. There is no limit as to how many times these procedures can be repeated as long there is ample excess tissue, and not too much is removed on any one occasion.

Your Role
So through all of this, do not underestimate your value to your client and the powerful and important role you play, not only in pre-operative and post-operative care, but also in evaluation, counseling and educating your clients about what they need to know about eyelid, eyebrow, forehead and cheek surgery.

  1. Botox is a trade name of The Allergan Corporation, Irvine, CA.
  2. Retin-A is a registered trademark of Ortho-McNeil Pharmaceutical, Raritan, NJ.
  3. Perlane is a trade name of Q-Med Esthetics, Uppsala, Sweden.
  4. Restylene is a trade name of Q-Med Esthetics, Uppsala, Sweden.
  5. Artecoll is a trade name of Artes Medical, Inc., San Diego, CA.

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