Q: Dr. Eppley, I understand if this is an upper blepharopasty question you cannot answer online, but I was wondering if I could get your honest opinion regarding my eyelids. Although I’m young, I’ve always felt they are unusually droopy and asymmetric. In particular, I do not like the excess skin of my left eyelid. I understand that my case is a little weird and subtle, so I would appreciate your honest opinion whether surgery would actually benefit me or not. Thank you very much for any information!
A: In looking at your pictures, you do have an extra skin roll on both upper eyelids of which the left side has the greatest amount. A limited upper blepharoplasty of either just the left upper eyelid or both eyelids would be beneficial and a very straightforward procedure to go through with a very short recovery. One’s age really does not matter, what counts is what is the anatomic problem and is it correctable. This is your natural eyelid anatomy and if it bothers you this is a very minimal to no risk procedure to undergo. Upper blepharoplasty scars are very minute and usually not visible even with the eyelids closed.
Dr. Barry Eppley
Q: Dr. Eppley, I have very heavy looking eyelids. Would I be a good candidate for an endoscopic browlift or an eyelid lift? I have some concerns about making my forehead higher.
A: Your question is not an uncommon one as many people with ‘heavy’ upper eyes do have a combination of some degree of brow ptosis and redundant upper eyelid skin. In looking at your pictures, I think your heavy upper eyelids do fall into this ‘combo’ category and are caused by a combination of slightly low brows and upper eyelids that have too much fat and just a touch of extra skin. The question is whether a browlift alone (pretrichial not endoscopic so your hairline will not only not get longer but can even be lowered if desired), some upper eyelid skin removal and defatting or both would be optimally beneficial.
This type of periorbital decision can be difficult as you do not want to over operate but, by the same token, you do not want to under treat either.
Dr. Barry Eppley
Q: Dr. Eppley, I have had an upper blepharoplasty where a lot of skin was removed. This caused my eyebrows to lower ( about 5 or more mm). I want to restore my eyebrow position but I don’t want my eyes to appear any more wide open than they are and for too much of my upper eyelid to show. Is it possible to perform an upper eyelid skin graft to assist in my situation?
A: The first question is how long has it been since the initial blepharoplasty procedure? If it was 6 months or more afterward then it is reasonable to consider some management strategy.
If it is less than six months there is still some possibility of upper eyelid skin stretch that may lessen the overresection effect.
A skin graft can certainly be done to the upper for an over-resected blepharoplasty problem and it will take very well. It is the definitive answer to your present concerns. But there are some trade-offs. First a skin graft will often appear as a small patch because it will be virtually impossible to have a perfect skin color and thickness match. Secondly there has to be a donor site for the graft and it needs to skin that is very thin and with as little pigment as possible. This usually means it has to come from the back of the ear. In older patients it could come from the lower eyelids but this opportunity is very rare.
Dr. Barry Eppley
Q: Dr. Eppley, I would like to improve the appearance of my eyes. My upper eyelids (just below my brow) have excess skin that hangs down, often pushing against my eyelashes. Also, I would like the canthopexy in order to make my eyes look more feminine. My eyes are very round, showing a significant amount of my sclera, and are angled down slightly at the outer corners.
A: The description of upper lid skin pushing on the eyelashes certainly indicates that an upper blepharoplasty would be needed to recreate an upper lid sulcus again. That is very straightforward and a standard periorbital rejuvenation procedure. Changing the position of the lateral canthus at the corners of the eyes can be done at the same time as the upper blepharoplasty. This is better known as a lateral canthoplasty as opposed to a canthopexy. In a canthopexy procedure the existing tendon is tightened by maintains its current position on the inner aspect of the lateral orbital wall. As a result, it tightens the lid margins but will not change their vertical orientation. Thus a lateral canthopexy will not correct a downward eye slant. A lateral canthoplasty, which relocates the insertion of the lateral canthal tendon up into a higher position on the bone is what you actually need to achieve your eyelid reshaping goals. That is done through the tail end of the upper blepharoplasty incision.
Dr. Barry Eppley
Q: Dr. Eppley. Five years ago, I had surgery on the right upper eyelid to reduce the size of my eye opening. My right eye used to be larger than the left one. Some times for a few seconds my right eyelid seems relatively normal but as I blink, it seems like the skin detaches from the muscle and the eyelid goes back to a droopy appearance. Unfortunately, it seems like the scar didn’t heal well or the stitches weren’t placed correctly. If the inner crease or fold would stay inside it would have a normal look. I wouldn’t want my right eye to end up larger or deformed compared to the left side again.
A: In looking at your pictures, one can see that with the eye open there is a fold of skin that hangs down onto the lashes of the upper eyelid. However, when the upper eyelid closes completely that fold of skin disappears. That dynamic piece of information is critical in selecting the right blepharoplasty procedure.
Trying to correct this problem by only removing all the extra skin may cause exactly the problem you are trying to avoid. Rather, a very conservative amount of upper eyelid skin should be removed and the dermis then sutured down to the tarsus or levator muscle. This is very similar to the classic ‘double eyelid’ operation done in Asians where they lack an upper eyelid fold. Your problem is conceptually similar.
Because it is only one one eyelid, the procedure can comfortably done under local anesthesia. This would also be helpful in that you would be awake and the dynamic action of the eyelid can be observed as the blepharoplasty repair is being performed.
Dr. Barry Eppley