Publications:
BRIGHT EYES
The eyes are the window to the soul.
Poets and romantics for as long as time can remember, have made eyes a portal to one's inner self and the defining characteristic of beauty and health. Youthful, smooth, wrinkle free eyes are often associated with alertness, good health and beauty. As the aging process advances, wide eyes become smaller and tired looking. The eyelid skin is the thinnest skin on the body and for this reason it shows the signs of aging usually before other areas. The aging of the eyelid area is determined mostly by heredity. People of Irish and English ancestry develop puffiness around the eyes at a very early age, commonly during the teenage years. Many people may develop dark circles around the eyes as a result of heredity as well. Allergies can also contribute to this condition. Sun exposure and repeated movement such as smiling or blinking can result in premature aging of the skin. Yes, these facial exercises, utilized by many to slow the aging process can actually accelerate it! This is because the muscles of the face insert directly into the skin, so every time the muscles contract they crease the skin resulting in wrinkles at the outer corners of the eyes called “crows feet”.
Whatever the cause, the eyelid area undergoes a series of changes, some of which have only recently been recognized. The upper eyelid skin begins to fold over on itself gradually working its way down to the eyelashes. Some people will develop hollowness in the upper eyelid area.
Some people will develop puffiness or bags under the eyes. The eye is surrounded with fat and over time the fat comes forward like a hernia. People who smile a lot can develop a thickening of the eye muscle and develop a bulge under the eye. This is very similar to working out with weights and developing more defined body muscles. Some people can develop a combination of both fat and thickened muscle, giving them a roller coaster of hills and valleys on their profile.
The eyelid skin, because it is so thin, shows the signs of aging first. As the skin loses its' tone, it becomes crêpe and may become dark. The lower eyelid tends to become longer as this tissue relaxes and as the cheek tissue falls. The end result of this inevitable process is tired, sad and aged eyes.
Procedures to remove excess eyelid skin date back over 1000 years. The term blepharoplasty was first used by von Graefe in 1818 to describe the removal of skin cancer from the eyelid area. Cosmetic eyelid techniques in the early nineteenth century involved the removal of skin only. As surgeons began to understand the eyelid anatomy, the blepharoplasty procedures began to remove fat and excess muscle.
The knowledge of the aging eyelid area has reached new heights. This new knowledge has resulted in a revolution of aging eyelid management. Old blepharoplasty techniques removed fat, which after a couple of years, could result in a hollow or gaunt look. This is because the eyeball sits in an ice cream cone shaped socket. The eye is surrounded by fat. As the membranes which hold the fat back begin to weaken the fat comes forward giving a bulge or bag under the eye. Traditional techniques remove the fat. Because there is less fat to support the eye over time the eye may become deep set. This process occurs naturally for many and for others may occur after surgery. The end result is a hollow looking eye.
The new and improved blepharoplasty involves no fat removal for most patients- instead there is repositioning of the fat and strengthening of the eyelid area. The following describes the management of the different aging eyelid conditions for the new millennium.
Wrinkles around the outer corners of the eyes are often best managed with botulinum toxin (Botox). Botox is a neurotoxin produced by Clostridium Botulinum, yes the same bacteria which can ruin your family picnic with food poisoning. However, when purified, it is wonderful for softening facial wrinkles and is very safe. Last year it was the number one cosmetic procedure performed, primarily because it is quick and easy for the patients with little to no recovery time. It is often combined with laser resurfacing around the eye.
When crepiness or a tissue paper appearance develops around the eyes, the carbon dioxide (CO2) laser may be a great treatment. It tightens and smoothes out wrinkles and even lightens dark circles for most patients. The carbon dioxide laser does involve a recovery period of ten to fourteen days for most patients. Non-resurfacing lasers such as Thermage, foto-facial, etc., pass a wavelength of light or energy through the outer layer of skin where it is absorbed in the supporting layer. This then stimulates a small amount of collagen rebuilding. These new lasers require multiple treatments. They may show promise for the younger patient with fine wrinkles or patients with darker skin who are concerned with pigment issues.
Once a youthful quality is restored to the skin the eyelid needs to be examined carefully beginning with the position of the eyebrows. As the eyebrows settle they flatten and not only make the eyes look smaller but can impart an angry look to the eyes. If the distance between the eyebrows and hairline is average or low, an endoscopic or minimal incision technique may be most appropriate. If the forehead is high, the eyebrows can be lifted and the hairline lowered by using a trichophytic brow lift.
There are two different paths people may follow as a result of the aging process with the upper eyelids. Many will develop a roll of upper eyelid skin and puffiness. These patients are best managed by removal of the excess skin and conservative management of the deeper structures such as fat and muscle. Patients with hollow or deep set upper eyelids are best managed by adding tissue such as their own fat. The majority of patients will experience long term benefits from the augmentation blepharoplasty; however because of the aging process patients may require more volume placed in the future.
The lower eyelid puffiness is usually accompanied with a groove between the bulge and the cheek skin. In men the lower eyelid fat is not removed but repositioned into the groove. This accomplishes several things. It helps to smooth out the lower eyelid-cheek contour, occasionally additional fillers such as cheek implants or Alloderm are necessary to recreate a youthful contour from the lower eyelid to the cheek. Women have thinner lower eyelid skin and therefore fat transfer is generally a better option. With this procedure, fat is harvested from the tummy or outer thigh area and carefully prepared separating the intact fat from the surrounding fluids. The fat is then carefully placed in the lower eyelid- upper cheek area to soften the hollow look.
The lower eyelid procedures can be carried out inside the eyelid if there is no extra skin to be removed or if Co2 laser resurfacing is being performed at the same time. When a patient has excess lower eyelid skin the outside through a small incision close to the eyelashes if there is extra lower eyelid skin or thickening of the lower eyelid muscle.
The procedures are performed under a twilight or general anesthesia for most patients. The post operative recovery is shortened by manual lymphatic drainage by trained aestheticians. The lymphatic drainage is initiated after forty eight hours (ice compresses are applied during this early period), after the swelling has reached a peak.
In conclusion keeping the eyelids looking young begins with sunscreen and skin care. The secret for the new millennium is preventative maintence. Starting early with small procedures delays more significant procedures. Yes keeping fat in our body (at least in the eyelid area) and not removing it is important to maintain a long lasting beautiful youthful eyes.
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