Neither between our eyelids and eyebrows nor between our eyebrows and forehead is there a definitive anatomical boundary. Each of these structures is a smooth continuation of the other, and the change in one affects the other closely. Therefore, when evaluating periorbital aging around the eyes, it is required to consider the forehead/temple/eyebrows/upper eyelids as a whole and to plan the treatment accordingly.

The aging face, forehead, temples and eyebrows both lose volume and sag a little. With the sagging of the forehead/temple/eyebrow, the skin that normally covers a full and soft contour is piled on the eyelid.

When untrained eyes look at an aging face, they see only the excess skin on the eyelids, and when this excess skin is removed, they have an error of perception as if everything will be alright.

Indeed, interfering with this excess skin on the upper eyelid is one of the most common surgical procedures we perform around the eyes.

In this post, I want to underline some key elements for both my patients and my younger colleagues.

When the forehead/temple/eyebrows droop on an aging face, some weight occurs on the eyelid. The eyelid is disturbed by this weight and it sends a signal to the brain, asking for help from the muscle on the forehead called the frontalis, which looks like a roller blind. The frontalis muscle constantly contracts, keeping the eyebrows up. When the eyebrows rise, the eyelid relaxes a little. As the frontalis muscle contracts, horizontal wrinkles form on the forehead, and these wrinkles become permanent and gradually deepen over time. When you look at a patient with a sagging forehead/temple/eyebrow unit or if you are the patient and you look at yourself in the mirror, you will see the following:

1. There are fixed horizontal wrinkles on the forehead.

2. The eyebrows appear falsely and deceptively higher than their normal resting position. So the actual level of the eyebrows is lower than what you see in the mirror.

3. When the patient closes his eyes and rests for 2-3 minutes while standing, the muscle on the forehead relaxes, the wrinkles decrease and the eyebrows go down to their normal position. This position is the actual position of the eyebrows.

While treating the eye region, we pursue the following path:

If the patient has a low forehead/eyebrow/temple as I described above and is satisfied with the eyebrow position they see in the mirror, we combine both forehead/temple lift and eyelid surgery in the same session. This allows us to maintain brow position while restoring the aesthetic appearance of the eyelid, all the while treating the forehead and temple area harmoniously. The result is a beautiful upper eyelid, a relaxed forehead with reduced wrinkles, and a pair of eyebrows at the ideal height.

If the patient's eyebrows are already high and the patient prefers these eyebrows to be a few millimeters lower, we only do extended upper eyelid surgery. During this surgery, we not only optimize the eyelid anatomy but also weaken the muscles that pull the eyebrow down. Following the operation, the eyebrows droop a little as we expect. The result is a beautiful eyelid and eyebrows that are slightly lower than before the surgery but still at the ideal height.

 

 

Now focus your attention: If there is one single take-home message I want to give you, it is coming now!

If only an upper eyelid surgery is performed in a patient who has low forehead/temple/eyebrow and is satisfied with the eyebrow height they see in the mirror, the weight on the eyelid will decrease after the surgery, the forehead muscle that holds the eyebrows up will relax and the eyebrows will droop. With the drooping of the eyebrows, the appearance of "excess skin" on the upper eyelid of the patient will recur. The result is an incompletely-healed upper eyelid, low eyebrows and an unhappy patient.

My advice to patients who complain of periorbital aging is to act on the knowledge that this is not an eyelid problem but rather a periorbital problem. In the evaluation of upper eyelid complaints, forehead, eyebrows, temples, muscle mechanisms that open and close the eyelids, and tear mechanism must be included in the assessment. In terms of the aesthetic surgery of the eyelids, the ability to incise and suture the skin on the eyelid is not sufficient. Do not act without consulting a plastic surgeon who has full knowledge of the anatomy of this region as well as all surgical procedures around the eyes.

Periorbital surgery around the eyes is not “simple”. If there is a claim otherwise, take a step back and think.

The same principles apply to the relationship between the lower eyelid and the cheek and midface area. I will address this issue in my future posts.

Until then, take good care of yourself and your beauty.