One of the common concerns amongst many patients considering facial rejuvenation procedures is that they don’t want to look ‘done’, ‘surgical’ or otherwise unnatural. They would prefer that people do not see them as having had plastic surgery. On the flip side of that concern is that they also want to have some visible improvement and get good value for their investment.

For fear of being overdone, some patients will stay with less invasive procedures like Botox, injectable fillers and light and laser skin treatments. While they don’t produce surgical results, there is no fear of having too significant a facial change.

A recent study published in the February issue of the Achives of Facial Plastic Surgery reports an interesting and perhaps not unexpected finding…the more procedures patients have done, the younger they look. This study looked at sixty patients between the ages of 45 and 72 years old, 90% of whom were females. They were divided into three types of facial rejuvenation procedures. The first group had lower facial rejuvenation of facelifts/necklifts. The second group also had facelifts but also had eyelid work or blepharoplasties done. The third group had more total facial rejuvenation which also included browlifts with blepharoplasty and facelifts. The ages of the patients were then estimated by non-surgeons. (medical students)

The students rated patients in the first group as appearing 5.7 years younger but the second and third groups were rated 7.5 and 8.4 years younger respectively. In essence, the more procedures a patient had done the younger they look. Or, more relevantly, the more parts of the aging face you treat the better or more rejuvenated the entire face becomes.

But the real importance of this study, and something I tell my patients all the time, is that work done around the eyes always produces the most rejuvenated appearance. Periorbital rejuvenation, blepharoplasties and browlifts, creates the most visible evidence of improvement to both the patient and particularly to others. This has to do with a basic element of human interaction and communication…we spend most of our time looking at each other’s eyes. That is actually how most people recognize another’s face. It is also how people perceive, right or wrong, our physical state and emotions. For example, everyone’s been told (numerous times no doubt) that we look tired. It is our eyes that carry that impression.

Cleaning up loose and redundant eyelid skin, getting rid of eyelid bags by fat removal and even lifting sagging brows can make the whole eye area look less tired and aged. The eyes are the first area that begins to show age and often shows it the worst even as the rest of the face ages. For this reason, blepharoplasty in particular is almost always the best value of any facial rejuvenation procedure. It has the greatest anti-aging effect for the money as its benefits will be guaranteed to be seen by all.

Dr. Barry Eppley

Indianapolis, Indiana

Background:  When a man presents for facial rejuvenation it frequently is driven by someone (or many) telling them they look tired. With enough repeated comments and in looking in the mirror, it eventually becomes evident that they in fact are looking tired. This most commonly is due to changes in the eye area.

A man’s eyelids begin to sag and excess skin and fat develop in both of them. The upper eyelid skin hangs down onto the lashes making them feel heavy and obliterating any evidence of a supratarsal fold. The lower eyelid becomes very puffy  and develops a sagging appearance. Dark circles often develop under the eyes which draws extra attention to their changed and aging appearance. Also, the eyebrows may begin to sag and hang below the browbone, creating a ‘hangdog’ or an angry expression. Crow’s feet and other wrinkles develop outside of the actual eyelids.

Blepharoplasty or eyelid surgery is the well known antidote to a man’s aging eyes.While eyelid surgery may seem similar between men and women, there are some subtle and important differences. Men often seek a less obvious and an absolutely natural look compared to women. Eyelid scars are also a major concern, particularly in the lower eyelid as men do not have the option of scar camouflage with cosmetics. (they can use them but usually don’t want to) Men also desire to avoid any periorbital change that would make them look in any way feminine. These include such concerns about too high of an upper eyelid crease/scar, an upward flare to the eyebrow or too tight of a sweep to the tail of the lower eyelid or alteration of the corner of the eye. It is also important to realize that men are not usually interested in getting rid of every single wrinkle around \their eyes, they just want to less less tired and more refreshed.

Case Study: This 52 year-old man from Indianapolis Indiana was tired of being told he looked tired. He was bothered by skin that hung down onto his upper eyelids and eyelashes and the bags under his eyes. His lower eyelid bags were usually fairly swollen in the morning and it took all day until some of the puffiness went down. It took him several years to come to the realization that surgery was the answer.  

Under general anesthesia, he had both upper and lower eyelids treated. The excess skin of the upper eyelid was removed creating a visible supratarsal fold and upper eyelid crease. A skin-muscle flap lower blepahroplasty technique was used removing a significant amount of herniated fat. Minimal lower eyelid skin was removed and the corner of the eye was tightened with the skin closure.

He had the usual amount of swelling and bruising after surgery that took about ten days to look ‘passable’. By three weeks after surgery, he looked non-surgical and was clearly in the benefits phase of the procedure. He did have some mild tearing issues of the left eye which took six weeks to completely resolve due to a slight amount of temporary lower eyelid retraction in the corner. He ended up with a less tired look around his eyes but with an unchanged appearance.  

Case Highlights:

1)      Facial aging in men disproportionately affects the eye area with extra skin, protruding fat, wrinkles and brow sagging.

2)      Blepharoplasty surgery in men must avoid overresection and tightening of eyelid tissues that can look unnatural and more feminine.

3)      Eyelid surgery in men creates a refreshed look but an overall unchanged facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Aging around the eyes, as evidenced by wrinkles and dark circles, will occur to some degree in everyone. It is a perpetual process that starts to become evident after the age of 35. While formal eyelid surgery (blepharoplasty) may ultimately be needed, some may desire to consider non-surgical treatment options. While there are thousands of eye creams and potions, none can really make a significant periorbital rejuvenation change.

Laser resurfacing is the bridge between creams and blepharoplasty surgery. Traditionally, laser skin treatments have been avoided on the eyelids because the skin is very thin and the risk of causing a burn injury is very real. But laser resurfacing has changed over the past ten years with the use of more accurate depth control and fractional spacing of the laser pulses. Both approaches produce less skin damage and can virtually eliminate any risk of burns and scarring.

While there are advocates for every type of laser resurfacing device out there, there is not solid scientific evidence that fractional laser treatment produces a better or longer-lasting result than traditional non-fractional ablation. Fractional laser is certainly more popular currently but optimal laser energies and devices remain in a state of perpetual development and evolution.

Non-surgical eyelifts are currently done in my practice using the Sciton microlaser and fractional laser resurfacing peel. Typical treatment time is done in less than 10 minutes for both upper and lower eyelids. The laser is used to treat the entire upper and lower eyelids, going right up to the lashline.The eyelid skin is first treated by a topical anesthetic for 15 minutes and the eye is protected with a metal shield. The eyelid skin can be treated from a 4 to 15 micron depth. It is then treated with the fractional laser at 80 microns at 22% density.  This results in some mild redness and swelling for several days. Whether it is two days or four or five days is depth dependent. How much downtime a patient can tolerate determines the best depth. Ideally, a series of laser treatments are done to get the best skin tightening and some wrinkle reduction. Treating a patient every 6 to 8 weeks over  a 6 month period for a total of four treatment sessions is our current protocol.

Laser resurfacing of the eyelids is not new and has even been given branding names by certain practices. It has been touted that it achieves significant skin tightening with results that are comparable to a surgical eyelid lift…without any risks. The minimal to no risk part is true but comparing it to what can be accomplished with a blepharoplasty is an overstatement. It is a good compliment for the younger patient who does not yet need surgery and works well in conjunction with Botox injections. For the older patient with more skin excess, it provides some improvement but should clearly be viewed as a bridge to blepharoplasty and not a replacement for it.

Dr. Barry Eppley

Indianapolis, Indiana