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While the nose is the central cosmetic anchor of the face, the eyes are critical as a feminine attribute. The ability to properly highlight the eyes with makeup is important for any woman. The eyes are an aesthetic connection of the upper face to the lower face. A necessary factor in evaluating the eyes is the position of the eyebrows. Eyes vary in their anatomy between different ethnic groups. As with all of the cosmetic surgeries that I perform, individualizing the surgery to the patient is critical.

From an anatomic standpoint, there is the degree of excess skin to determine, the amount of protruding fat, and such factors as the angle of the eyes, their symmetry, the position of the upper eyelid in relation to the pupil, and the laxity of the lower eyelid skin. When a person relaxes, the upper eyelid should fall two millimeters below the top edge of the iris. This is where the top of the colored ring and the white of the eye interface. Positions below this are referred to as “ptosis”. The repair of this is functional and is usually reimbursable by insurance. There is associated visual field impairment and at the end of the day the eyes feel very heavy with this condition. If you do not correct the position of the muscle that holds open the eyes, then the outcome will be disappointing.

The outer edge of the eye should be elevated a few degrees above the neutral plane. This tilt is greater in the eye of Eastern Asians (i.e. Chinese, Japanese, Korean, etc…) and the angle of the eye cannot be changed without detaching the fibrous ligament from bone that holds the eye fixed at a specific angle. In any upper eyelid blepharoplasty, there is skin to excise, orbicularis muscle, and fat. There are two pockets of fat to remove. The incision in the upper eyelid is placed in the natural crease. One must be very precise in the skin markings to insure that enough skin is removed without compromising the ability to fully close the eye long term. One must be careful also not to damage the lacrimal gland which makes tears and is located on the upper outside edge of the eyelid. In Eastern Asians, there is an extra layer of fat in the upper eyelids and no attachment of the upper lid muscles to the skin. This accounts for the “heavier” upper eyelid which has no crease. In order to effectively westernize the Eastern Asian eyelid, one must be able to reconstruct this attachment and be able to remove extra layers of fat in a proper anatomic configuration.

In the lower eyelid, there is the traditional incisional approach that removes skin and muscle either together as one flap, or separated as separate skin and muscle flaps. There are three pockets of fat to remove. The incision is placed below the eyelashes. Care must be taken to insure good support to the lower eyelid in order to prevent a turning out and pulling down of the skin (ectropian). If needed, the lower lid must be reinforced to prevent this from happening. If the skin excess is not too great and fat bulging is the greater concern, a transconjunctival approach can be used. This leaves no visible outside incision as the cut is placed inside the lower eyelid. Often this is combined with a light chemical peel or laser resurfacing in order to tighten the outside skin, soften wrinkles, and get rid of dark circles. This is a great technique in younger women. Getting rid of drooping skin, bulging fat, and insuring the proper eyelid positions and angles will allow one to highlight the eyes in a youthful and seductive fashion.

The eyelid skin is very thin and concerns with excessive scarring are minimal. Recovery is five to seven days depending upon how extensive the procedure is. Bruising and swelling can range from minimal, to the eyes becoming completely swollen and shut at two days post-op. There are lubricants that I ask my patients to use for the first few weeks since normal swelling does not allow one to blink as much, and the eyes do not close completely. This provides added lubrication when it is needed most. Ice packs in the first twenty-four hours, and a steroid dose pack, help to reduce swelling. The eyes can be light sensitive for a few weeks. Sometimes it can take up to three months before the minor swelling goes out of the eyes and they return to a perfectly symmetrical state. However, to the average eye, the recovery is quick and makeup can be applied after five days to achieve a refreshed, more youthful, and feminine, look.