Beauty Is In the Eye of the Beholder Radius- Summer 2007 by Basil A.Pakeman MD, FRCSC

SERVING MANHATTAN AND NEW YORK CITY

Baby boomers are the largest and fastest growing segment of the population, and they are very concerned about their appearance. They are alot more active than their preceding generation. Often, they are faced with the situation that their appearance does not match their youthful vigor. They feel young and they want to look young. This disconnect is often remedied by cosmetic surgery to the upper face. Cosmetic procedures to this small area can have dramatic impact on facial appearance. It is especially true with eyelid surgery (blepharoplasty). Some baby boomers also use non-invasive procedures, injectable fillers, to volumize and smooth the lower eyelids. Restylane is the most common filler used in this area. BOTOX® is often used to diminish the squint lines lateral to the eyelids, the crowfeet area.

The eyes are one of the first areas noticed by other people. This area most often defines beauty and attractiveness. It is also one of the first areas of the face to show the effects of aging. As these aging changes occur, people often complain that they look tired as if they were lacking sleep. For the vast majority of people even sufficient sleep does not correct these aging changes. The combination of loose skin, weakened muscle, tendon, and fat bags around the eyes can make you look tired, sad, or older than your age. Some of these changes are related to natural aging or genetics. The genetic related changes can affect individuals in their twenties and thirties and progress further with aging. as the years pass, the skin stretches and wrinkles around the eye even with proper care and sufficient sleep. The fat around the eyes prolapses forward leading to under eye bags, and in the upper lids, it leads to sad or sleepy eyes. Excessive exposure to the sun, alcohol, smoking, poor nutrition, and not using sunscreen can accelerate these signs of aging.

Not all eyelids are created equal, and they age at different rates; therefore, surgery around the eyes must be highly individualized according to each person's problem and goal. It is not one size fits all. Eyelid surgery is about creating natural aesthetic, pleasing eyelids and eyes. When we look at young women, they often have soft, full, defined upper lid crease that is low set, close to their eyelashes. As the aging process takes place, this eye area loses volume, which leads to a deflated look. The surgeon's job is to restore a youthful look in a natural fashion. He or she must pay close attention to the skin, muscle, eyelid crease, and surrounding fat. The appropriate amount of skin should be removed, and it is not about removing as much skin as possible. While one person may require fat removal, another may require fat re-distribution. Often, people who under go blepharoplasty look skeletonized, because too much fat, skin, and muscle were removed.

Like the procedure for the upper eyelid, surgery of the lower eyelid is a highly customized procedure as well. There are many different approaches to surgery in this area depending on the person’s needs, facial characteristics, and desired outcome. Here again, it is not just about removal of skin and fat. It is about creating smooth contour through meticulous attention to the underlying muscle, tendon, and skin re-suspension. The surgeon can approach this area through the skin or from the inside of the eyelid, trans-conjunctiva, leaving no incision on the skin. When there is visible excess of skin and muscle, an incision below the eyelash line is often used to remove excess skin, muscle, or even fat. Lashes hide the placement of this incision. Sometimes all that is necessary to treat the wrinkled skin is laser resurfacing or chemical peel.

Frequently, women may find themselves with dark circles or hollows below the lower eyelids. The hollowing effect can produce the illusion of darkening around the eyes secondary to shadows. This hollow is referred to as the tear trough deformity. Dark circles
under the eyes can also be the result of hyper-pigmentation, poor blood circulation (venous stasis), and having very thin skin which makes the superficial veins very visible, giving a blue to a dark appearance. When tear trough deformities are present without sagging skin, injectable filler can be used to correct them. The most common filler used in this area is Restylane. A synthetic hyaluronic acid attracts water to the surrounding collagen fibers resulting in tissue plumping. This effect can last from six months to a year, and then it is repeated to maintain the volume that led to a youthful appearance. Another newer hyaluronic acid is Juvederm, which was approved by the FDA in June 2006. Fat is sometimes harvested from other body areas and used as filler around the eyes. These fillers, used to
replace volume loss from prior surgery, can be used to enhance the eyes with little to no down time except when bruising occurs which can last up to a week. Minor swelling for 24 to 48 hours is common.

These are some of the many treatment options available to improve the appearance around the eyes and one’s outlook. It is advisable that you and your doctor evaluate the problem or problems, and choose the appropriate treatment option to achieve realistic goals or endpoints. Healthy skin and youthful appearance is worth protecting… and don’t forget the sunscreen.

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