Upper and Lower Eyelid

Los Angeles Upper and Lower Eyelid Plastic Surgeon

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In the past many blepharoplasty patients would have the excess skin of their upper eyelid removed along with some muscle and fat tissue.  In most cases these patients had visual fields performed showing that they were losing 15%, 20%, or 25% of their upper field vision.  The visual field was a very easy test to fake and make it appear that you were getting your upper eyelids done to improve your vision.  In truth, very few patients have visual field problems from heavy upper eyelids and I would even go so far as to say that most patients who had confirmatory visual field tests did not need the surgery for better vision in the upper plane field of vision but did it for insurance reimbursement.   

Consequently, eyelid surgery previously was removing skin and muscle from the upper lid, and fat, to make the eyelid deeper.  However, if you look at every major actress today, from Jennifer Lawrence to Megan Fox to Mila Cunis to Charlize Theron to Anne Hathaway to Natalie Portman, etc., all of them have heavier Asian-type eyes.  In fact, the next time you are in a group of young women, look at their upper eyelids, none of them have deep upper eyelids.  It is just not something that is very prevalent in our youth.  The continued use of the operation for vision has fallen by the wayside with this realization that deep eyes and hollow eyes look old.  A woman who is 60 will have no fat around her eyes creating deep hollow eyes. Fat will start disappearing in the middle 30s until it is gone in her 70s. Surgeons have actually been accelerating the aging process.

Consequently, the great reversal of upper blepharoplasty is filling with fat grafting rather than cutting of has. The experienced and artistically inclined plastic surgeon, realized that the heavy upper eyelid is a sign of youth.  Early folds and wrinkles in the upper eyelid, rather than being excised, should be filled up with the patient’s own fat.  Many patients have this done with filler, but then again filler is a temporary form and in many cases the Tyndall effect is seen when using filler in the upper eyelids, a bluish tinge forms over the eyelids.  Fortunately most filler can be reversed and dissolved.  Making the upper eyelids heavier as they were in youth with fat is a difficult process.  The fat has to be processed properly and placed directly over the orbital rim, thus lowering it and creating a tarsal crease from about 5-7 mm. Symmetry is vital.

Of interest, many patients who come to the plastic surgeon desirous of forehead lift or eyebrow lift realize, when shown on the computer that filling in this depth of the upper eyelid actually raises the eyebrow, both optical illusion wise and in actuality.  The medial eyebrow can be lifted a number of millimeters without the much more dramatic forehead lift, which in many cases gives an unnatural or staring  appearance .  The lateral eyebrow can also be raised using fat on the orbital rim.  Generally about 3 cc of fat is used in each upper eyelid in order to create this heavier, more youthful eyelid.

The lower eyelid treatment has changed significantly over the years. Many dermatologists and other doctors not familiar with orbital fat herniation attempt to hide it with fillers.  The results are less than successful and create a bluish tint under the skin and, all in all the herniated fat pockets are still visible under the skin.  Lower lid bags or herniations of the orbital fat should be removed from inside the eye (trans-conjunctivally).  This, in most cases, allows the skin and muscle, which was present over a convexity, to re-drape over the new concavity.  Care must be taken to remove all 3 of the fat pockets evenly to create the proper contour.  In some cases, particularly in older patients, it is necessary after the removal of the 3 fat pockets to place some fat over the rim to prevent the hollowness which may be present in an older face.  In lower blepharoplasty most ophthalmic plastic surgeons recommend a canthopexy, holding the lateral eyelid to the orbital bone and preventing a pulling down of the eyelid.  I think in many cases it creates an unnatural look in the lower eyelid and is an operation which is overdone and should be done only if necessary, reserving it for the older patient with a severely lax lower lid.  Removing skin in the lower eyelid in the proper patient is a very dramatic operation.  In fact in some cases lower eyelids removing skin and placing fat to fill out the area which has hollowed somewhat, as done in the upper eyelid, creates an extraordinarily youthful, natural look. 

Similarly, everything needs to be done within the proper framework.  Too much skin or muscle removed from the lower eyelid may cause ectropion or just a strange shape of the lower lid, which catches the eye as being unnatural.  All things that are done in plastic surgery are operations that need an expert with a good visual artistic eye to know when there is too much and when there is too little.

Forehead lifts, at one time, were one of the most popular operations and were performed with almost every facelift.  I rarely, if ever, perform a forehead lift any more.  I feel that the propensity toward hair loss, irregular hairline, unnatural movement of the eyebrows, and paresthesias, numbness, and itching postoperatively make me really evaluate whether a patient needs a forehead lift or if I can create the same eyebrow elevation with fat injections to the supraorbital rim.  This is something which has been a major change in my practice.  Rarely a patient who had a facelift would leave my office without a concurrent forehead lift, but with the advance of fat grafting and its use in the hollowed and the aged eye, the forehead lift is now a rarity instead of something which is used universally. 

Fat grafting is also utilized in the temples when the temples are deep.  Frequently the hollowed out look in the eyes is also there in the temples and in the face.  After fat grafting the upper and lower eyelids, a few cc’s of fat is almost routinely placed in the temple to create a natural, youthful, buoyant look around the eyes which are still windows of the soul. 

In conclusion, the heavier eyelid in almost all cases is more youthful than the deeper eyelid.  In fact, creating a deeper eyelid, in many cases, prematurely ages the upper eyelid and the forehead. 

Men are different than women in what they want out of eyelid surgery.  Men do not wear makeup, use false eyelashes, or eyebrow pencil.  Consequently, the surgery in a man has to be masculine and precise.  The heavier eyelid is present in almost all male actors from Clint Eastwood to Tom Cruise to Colin Furth to Ryan Reynolds.  Basically it is the style of eyelid that men should have if they have a hollow eye.  The eyelid can be made heavier with the same technique of adding fat to the orbital rim and the lateral eyebrow can be raised by putting fat underneath this area.  Frequently, in doing the lower eyelid of men we get the problem of the nasojugal fold, now called the tear trough.  In order to correct the tear trough most people feel that it can be filled with fat to eliminate it and that through the lower eyelid incision, the release of the arcus marginalis, which is the connection of the orbicularis oculi muscle to the bone at the orbital rim must be released and almost immediately the nasojugal fold becomes blended in.  In many cases, both the release of the arcus marginalis and fat in the nasojugal fold is necessary to create a smooth contour in both men and women. 

Many of the older eyelid operations done many years ago resulted in ectropion requiring a canthopexy repair.  Similarly, many eyelid surgeries done years ago created deep hollow eyes, which also require repair.  The correction for the ectropion is similar to that for the canthopexy.  In all cases of lower eyelid surgery, the minimum amount of skin should be removed to avoid a different shape of the eye.  Women refer to their eyes as round or almond-shaped and sometimes it is difficult for the physician to understand the relationship to the word almond or round, but much of this relates to makeup techniques that women have used over the years to shape the eyes properly and make them appear youthful. 

Eyebrow positioning and shape is very important in the expression that the eyes denote.  When the medial brow is too low a certain angriness or possibly age expression is transmitted.  The highest part of the brow should be the outside of the corner of the pupil and not the highest point at the lateral canthus of the brow.  Many women like to create an exotic look of the eyebrow but in many cases this exotic look with the high lateral eyebrow and low medial eyebrow creates an angry, unpleasant appearance.  The mouth and the eyebrows denote 90% of the facial expression and drawing an imaginary line from the corner of the nose to the corner of the eye, extending that line upward and using a plucker or a pencil the brow should not come any more toward the center than that.  The same is done for the outer part of the brow and the same is done for the highest part of the brow, which is aligned from the outside of the color of the eye directly toward the top of the head.  Adhering to these 3 different points, the neutral brow which is used from the days of the divas to the days of the rock stars, creating a pleasant appearance allowing the mouth to create the smile. Eyes are, indeed, the windows of the soul and of all make-ups made for over 50% are for the eyes, the eyelids, and the eyebrows. 

Latisse has been used in a number of patients to grow their eyelashes longer.  Many have been very pleased with it and some have been somewhat disappointed that it is basically a treatment that is necessary for life.  Some have noticed their light colored eyes have turned somewhat darker using the Latisse and for that reason many people do not use the Latisse at all to avoid this problem. 

In conclusion, eyelids need to look youthful without bags and without obvious wrinkling.

Botox has been used for the crows feet, the laugh lines outside of the eyelids, as well as the wrinkles between the eyebrows and in the forehead.  Great care has to be utilized in performing Botox to the forehead, that it does not drop the brow, immobilize the brow to expression, or run down into the eyelid and cause paralysis of the levator muscle and lower the eyelids which can be minimized by using Iopidine, but keeping a finger inferior to the injections will prevent it from passing within the tissue planes to the levator muscles of the eyes.  I do not recommend  Botox under the eyes or anyplace else in the face.  The problem with paralysis or a strange look is very possible.  Whereas many uses of Botox in the forehead and the laugh lines has proven to be with the lowest complication rate imaginable. 

This has nothing to do with actual eyelid surgery, but the most important fashion accessory that a woman has are her glasses.  The improper glasses can make a woman look older or even more like a schoolmarm than like a model.  Glasses that are inappropriately too large or too wide for the face are fine for sunglasses, which are somewhat like costume jewelry; but actual glasses for reading and seeing distances must be matched very carefully to the eyes and the face.  The glasses must not be wider than the face and the glasses should show the eyebrows and be comfortable upon the nose.  Certain nose pads of glasses have been associated with skin cancers in the past.  I assume that most of these types of plastics are no longer used in the nose pads of glasses. 

In closing, the style of eyes has changed thanks to numerous actresses who have heavy upper eyes and patients’ desires to look like them.  Just as it has been in the past for patients wishing to simulate other famous people in the body, now it is very common to want to have the eyelids of a particular celebrity and most different styles of eyelids are created by an artistic plastic surgeon.

Meet Dr. Ellenbogen

Dr. Richard Ellenbogen began his medical career at the University of Florida, where he showed advanced skills in both pre-medicine and art courses...


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