Wrinkles, loose skin, and bulges occur as a result of hereditary factors and the aging process. Pouches or bags of the upper and lower lids are generally due to weakening of the tissues of the orbital septum and protrusions of intraorbital fat (Fig. 18.1). In some cases edema in the periorbital tissues contribute to the condition. In my practice, fat bulges are generally removed. When conservatism is exercised, I have not found an indication for fat repositioning (the sub-orbicularis oculi fat [SOOF]). A good rule to follow is to not remove fat that lies deep to the infraorbital rim. only that which protrudes beyond it.
Fatty pouches are sometimes seen in the 20- to 30-year age group, occasionally younger, and can often be corrected at that time. After addressing possible medical reasons for these bulges (allergies, kidney and thyroid disease), there is little rationale to wait for some arbitrary age before having surgery. When the problem exists, it should be corrected (Fig. 18.2).
Upper lid surgery is usually performed at the same time as the lower lid surgery, but either can be done as an isolated procedure. Upper and lower eyelid plastic surgery may also be performed with a facelift, browlift, or other surgery. When a skin-muscle technique is used in the lower lids, a level II chemical peel may be performed at the same time, as long as the peel solution does not extend to the incision site.
It is not the intent of this chapter, or others, to describe details of my surgical techniques. They are provided in other publications and video demonstrations. Rather, the purpose of this book is to discuss the art of practice development and management, skills not generally learned through traditional training methods.
In upper lid blepharoplasty a preoperative determination is made about the excess or overlapping skin that frequently obliterates the natural crease above the lashes. The excess skin and fat are removed, and the incision sites are closed with delicate sutures. Magnification often assists the surgeon in absolute approximation of the skin edges, for better postoperative scars.
Fig. 18.1 Drooping, heavy tissues around the eyes can be removed with the upper and lower lid plastic surgery procedure blepharoplasty to remove the “tired look.”
Fig. 18.2 (a) A 17-year-old patient with excessive upper lid skin. (b) A 70-plus-year-old patient with excessive skin of her upper lids and drooping brows.
■ Transconjunctival Blepharoplasty
In some patients the herniated fat producing “bags” or bulges in the lower lid can be removed without making an incision in the skin. The incision is made behind the lower lid, thereby eliminating a visible scar.
It is not possible to remove loose skin or sagging wrinkles when this method is used, unless an external incision is also made in the eyelid skin, usually at the level of the lower border of the tarsus. In most cases this anatomical landmark coincides with the first rhytid in the lower eyelid skin.
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