Brow lift can be carried out either from the temple area (with or without endoscopic assistance) or by removing an ellipse of skin from above the brow (direct brow lift).
Excess upper eyelid skin can also be removed from below the brow, hiding the scar along the lower border of the brow. This is called a sub-brow lift. There is less bruising and swelling as compared to a conventional upper blepharoplasty and recovery is generally faster. The brow can then be stabilised using sutures during this surgery.
These are day surgery procedures and can be done under local anaesthesia with or without sedation. Recovery is generally fast although some bruising and swelling can be expected.
The ideal brow position is slightly above the bony orbital rim in women and at the level of the rim in men. It can droop with age due to loss of volume around the brow, with the deflation causing loss of soft tissue support. Conversely, some patients notice their brows rising higher with age. This is usually because of excess upper eyelid or levator ptosis, obscuring vision. The forehead muscles then become overactive, in an attempt to lift the brows to improve the field of vision.
The shape of the brow also plays a vital role in facial expression, for example, an unnaturally arched brow can give an impression of fierceness or surprise. The brow shape should fit the facial shape, for example, in a long face, a flat eyebrow shape will make the long face appear shorter.
Non-invasive ways of raising the brow include Botox injection to relax opposing muscles such as orbicularis oculi and depressor supercili. This results in less downward pull on the brow and a lifting effect. When the brow is uneven in shape between both sides, judicious placement of Botox can help adjust the shape and reduce the asymmetry.
Hyaluronic acid fillers can also be injected to augment the retro-orbicularis fat pad to increase brow support. Injecting filler under the brow can also help certain patients with sunken, hollow upper eyelids.
Ultraformer HIFU or Morpheus8 treatment can be used to tighten the skin and subcutaneous tissues of the area.
The suture technique is simpler yet potentially reversible should you change your mind. Several stitches are sewn into the upper eyelid between skin and deeper structures to create a natural looking fold. Recovery is somewhat quicker than the incisional technique. Younger patients in their 20s or 30s have minimal excess skin and fat hence are more suitable for this technique. The fold can come down after a few years and the procedure may need to be repeated. In addition, in eyes that are more asymmetrical to begin with, it may not be possible to correct this with suture technique.
Incisional technique is commonly preferred in older patients as it allows removal of a significant amount of excess skin. At the same time, some fat can be removed to reduce puffiness. The crease is then created by suturing the cut edge of the skin to more rigid structures below. With proper management and massage, the scars are usually not noticeable after a few months.
Many Asians have a prominent epicanthal fold. This is a little fold of skin over the inner corner of the eye. As discussed above, one’s anatomy, which is the presence of an epicanthal fold, will prevent formation of a parallel double eyelid crease.
Medial epicanthoplasty is needed to open up the inner corner of the eye and expose the caruncle. The double crease is no longer pulled downwards nasally. A parallel fold can then be created, resulting in a more Caucasian or Pan-asian appearance if desired.
Almost half of Asians are born without a double eyelid crease. Having double eyelids makes the eyes “open up” and look brighter. Double eyelid creases can be parallel to the eye margin (outfold) or tapered downwards towards the nose (infold).
Not infrequently, the crease shape may differ between both eyes. For the patient born without a crease, one’s own anatomy may then determine the type of fold that can be achieved. This can be decided during physical examination. Regardless of what is chosen, the current trend seems to favor a subtle, natural appearance.
Eyelid ptosis (pronounced toh-sis) is a medical condition whereby the upper eyelids appear droopy. The most common cause is when the eye opening mechanism (Levator aponeurosis) is detached from the cartilage plate of the eye, making it hard to open the eyes effectively.
It can cause an individual to appear tired and lead to functional issues such as obstruction of vision. In such instances, insurance and Medisave may be used for the surgery, subject to approval.
The aim of surgery is to improve the field of vision such that less effort is required to keep the eyes open. The eyes will also appear bigger and brighter.
The excess skin of the upper eyelid is removed. Depending on the severity of the ptosis, the levator aponeurosis is advanced or resected to lift the upper eyelid. Sutures are used to secure the repair. The final incisions are within the crease of the upper eyelid, hence they are typically inconspicuous.
Intraoperative swelling can affect the judgement of the eyelid levels. In a few patients, this may need to be re-adjusted post-operatively in the clinic, as needed.
The tear trough is the groove between the lower eyelid and the cheek, extending outwards to form a ring around the eye in many patients. Anatomically this is due to a ligament (supporting structure) at this location. As the cheek sags and loses volume with age, the lid-cheek junction is further unmasked. Eyebags protruding above this line also contribute to the illusion of shadowing.
As this tear trough groove gives a “sad and aged” look, much focus has been given to effacing it. Fillers are very useful to “fill up” the depression and camouflage the lid-cheek junction.
Eyebags are caused by protruding fat. They can be removed using hidden incisions inside the lower lid or just below the lashes (lower blepharoplasty procedure). Some of the removed fat can be placed back in small pieces over the rim, to reduce the visibility of the lid-cheek junction.
Some patients have more advanced mid-cheek aging, that is their cheeks sag and hang down over the nasolabial crease (which is the smile line between nose and corner of mouth).
A convenient and minimally invasive way to improve cheek sagging and lower eyelid appearance is the use of soft tissue fillers in the clinic. These are composed of hyaluronic acid, which is a component of our body’s own tissues. Therefore they integrate well and do not cause any long-term complications.
Fat grafting to the cheeks is another good method of restoring volume that has been lost with age. Fat can also be injected into the lips, temporal area or wherever required for total facial rejuvenation. Wrinkles and creases of the face can also be reduced with refined fat, further improving the skin quality. This is only injected where it is needed to improve facial contour and definitely not to make the face look fat. Liposuction through mini-incisions is used to harvest the fat from wherever is desired, resulting in simultaneous contouring of the area.
Conversely, some patients have more than sufficient cheek tissue; however, this has drooped downwards with time. The focus of treatment then changes to anatomic repositioning of the cheek tissue that has descended. A midcheek lift may be required, wherein the cheek tissue is mobilized and suspended upwards with sutures.
Common lower eyelid problems include the presence of dark eye circles, prominent tear trough/hollowing, eyebags and skin wrinkling.
The degree of swelling and bruising varies according to the patient, but 80% of the swelling typically resolves by 2 weeks. In some patients, it may take a few weeks more for complete resolution of mild swelling. There may be temporary minor side effects such as watery eyes and blurry vision.
During the recovery process, the patient is instructed on how to clean the eyelids and apply antibiotic ointment. Rubbing the eyes should be avoided and patients may need to wear sunglasses when out and about. Ice-packs are used for the first 3 days to reduce swelling, followed by warm compresses as needed from day 4-7. Sutures are usually removed at 5-7 days and periodic follow-up is essential to ensure proper recovery.
