Fat Grafting Eyelid Series Part 1 of 2:  Rethinking Aging of the Upper Eyelid and Brow

Traditionally, we have looked at the aging of the upper eyelid and brow through a gravitational model, i.e., we believe that the aging of the upper eyelid and brow sag over time.  This is not always the case.  In fact, it is rarely the case.  We have to see completely differently to understand this new paradigm of aging, which looks at deflation of the upper eyelid and brow rather than their falling down.  Yes, I know when you take two fingers on the corner of your brow and lift gently you like the look.  But that does not mean necessarily that you need to have a browlift or upper-eyelid surgery.  In order to learn this new paradigm, we have to unlearn what we already know about aging of the upper eyelid and brow area.

The best way to start to understand aging is to go back to your own photos when you were much younger.  Invariably when I show a patient their old photograph in their teens, twenties, and early thirties, they are flabbergasted that their brows were not much higher if at all and their skin hung over their eyes almost the same if not sometimes more.  When I point to how their eyes were much fuller in youth, they see that is actually the principal difference in aging.  Most plastic surgeons never bother to look at old photographs to determine how a patient used to look.  When I used to perform browlifts, I remember countless times when I gently picked up the corners of the brow and the patient responds that looked good but they never looked that way.  After investigating the aging process through a meticulous review of patients through their years of aging I realized that the principal mechanism of aging in the upper eyelid is fat loss and not sagging.

Instead of removing skin from the upper eyelid and brow area, this individual underwent fat transfer there as well as in the rest of the face to provide a more global rejuvenation. (She did not have any eyelid skin removal or browlifting.)

Another good way to understand this principle is to take a look at photographs of young, attractive models.  You will see that they all have relatively full upper eyelids and brows that are not necessarily always high.  Now, there are two types of eyelid shapes:  one that is full and round covering the eye and one that is relatively skeletonized only with modest soft tissue fullness over the bony rim.  It is important for a surgeon who is interested in replacing the lost fat of the brow to look at these old photographs to ensure that he does not place too much or too little fat in there that would otherwise make the patient look different.  By examining magazines like Glamour, Allure, and Vogue, a prospective patient can truly understand better what defines youthfulness.  That is why a woman who has had a browlift looks less sagging but she really does not look that much more youthful in her countenance.

An easier model to understand why the upper eyelid looks like it is sagging with aging is that of a balloon that undergoes gradual deflation.  If you suck the air out of a balloon it looks like it is hanging or it does slightly hang.  But instead of cutting out the “extra skin”, the balloon of the brow should be reinflated.  This is a very hard concept because the upper eyelid and brow already “feel or look heavy” and to suggest putting more “weight” there is almost insane until one reviews photographs of brows and upper eyelids filled aesthetically with fat.  In those cases, one can see that the brow and upper eyelid actually look less heavy with volume filling rather than heavier.  This paradigm shift is perhaps my most difficult “sell” to a patient because it is so radically counterintuitive.

Do I ever remove skin from the upper eyelid then? Yes, in about 1 in 10 patients, a combination with a conservative skin removal of the upper eyelid is warranted.  This combined procedure is only really beneficial in those whose eyelids are actually hanging over their eyelashes.  By removing 2 to 3 millimeters of skin in combination with a fat transfer (which still remains the principal way to rejuvenate the upper eyelid) then the individual has the best chance at a rejuvenated appearance that looks seamlessly natural.  It is a crime when I see patients who cannot close their eyes when they are asleep.  I have never seen this with my patients because I remove so little skin.  When combined with fat transfer very little skin needs to be removed.

What I always like to say is that is important to see “negative space” i.e., the hollowness, rather than the “positive space”, which is the apparent extra skin, hanging brow, etc.  However, it is difficult to see what is not there, so to speak.  When one can see the negative space, the breakthrough is there in perception so that one can see the value of a fat transfer to the eyelids over traditional lifting and cutting procedures.

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