Throughout history, the eyes have held us in captivation for their indications of emotion, yourh and health. Gemma Garkut spoke to some of the experts from the recent Masters' Symposium for Blepharoplasty and Upper Facial Rejuvenation about how surgical and non-surgical procedures can rejuvenate the eyes to help defy the ageing process.

We've been mesmerised by Sophia Loren's, Elizabeth Taylor's, Angelina Jolie's, Scarlett Johansen's and even the Mona Lisa's - our fascination with beautiful eyes has been a primary point of reference for beauty, both throughout history and in our contemporary beauty culture.

But with the effects of ageing taking their toll, the anatomy that frames the eyes experiences a series of changes that can make recapturing a transfixing gaze difficult without a helping hand. A blepharoplasty procedure seeks to rejuvenate the appearance of the eyes using both surgical and non-surgical treatment options to brighten and illuminate the face.

Dr Angelo Tsirbas, convenor of the recent Masters' Symposium for Blepharoplasty and Upper Facial Rejuvenation held in Darling Harbour, Sydney, says a blepharoplasty procedure can be an extremely satisfying surgery when performed well. ‘As the saying goes, the eyes are the windows to the soul and often an improvement in this area can magnify a patient's overall rejuvenative effect,' he says. However, as an ophthalmic, orbital and ocular plastic surgeon he notes that the procedure requires meticulous accuracy, as any imperfection can be very obvious to the human eye. As a result, the treatment process calls for an emphasis on correct patient selection and individualised surgical approach according to each individual patient.

The ageing process

From skin laxity and thinning to fat depletion and decent, there are many different processes occurring as the eyes age. When describing these processes to his patients, Western Australian facial plastic surgeon Dr Jayson Oates explains there are four categories of ageing that occur.

‘In general, there are four things going on that make a person look older: photoageing, dynamic lines, gravity and volume,' he says. ‘Photoageing can be treated using laser treatments and peels; dynamic lines can be reduced using muscle relaxants such as Botox; gravity causes the decent of skin and fat which can be corrected with a surgical "lift". Volume disappears from where you want it, and accumulates where you don't want it. Unfortunately these processes are all acting together around eye area and are also affected by genetics and lifestyle.'

When these categories are more specifically applied to the eyes, very specific and delicate changes can be seen to occur during the ageing process. Ophthalmic plastic surgeon Dr Michael J. Groth from the US says the muscle layer beneath the skin starts to lose its tone with age, the fat of the eyelid bulges forward to cause a dark shadow, the cheeks begin to shrink, leaving a groove-like valley known as the tear trough, and the brows descend. ‘These changes often lead people to mention that you look tired when you are not, and make you look like your parents long before you thought you would,' says Dr Groth.

Furthermore, Dr Tsirbas explains that crow's feet and fine wrinkles under the eye are a direct result of sun and smoke damage - something which the former is especially common in Australians. ‘In this country this occurs at a much younger age due to the high levels of UV radiation. It is vital to appreciate that the loss of skin elasticity and turgor that occur in ageing contribute significantly to periocular and facial ageing,' he says.

Because of this complex ageing process, there are many important aspects in ensuring the right blepharoplasty options are chosen to create the best results according to each individual.

Patient selection

Despite the somewhat uniform ageing processes occurring around the eyes, the different ways in which these processes behave in each person means not everyone is suitable for a blepharoplasty procedure. Because of this, experts note that to avoid unsatisfactory results, patient selection process is crucial.

‘Patients often have an idea of what type of blepharoplasty, be it upper or lower, they want when they walk through the door. This is not always what they need or where the true opportunity for improvement may lie,' explains Dr Groth. ‘I ask them to bring photos of themselves as young adults. With this, a thorough consultation and an assessment of the patient's anatomy and the corresponding surgical possibilities are discussed.'

Sydney ENT and facial plastic surgeon Dr George Marcells agrees: ‘If they were happy with their lower eyebrows in their youth and want to restore their youthful appearance, then I pay attention and am careful not to "over correct",' he says. ‘It's important to create results that the person can live with, so this initial research is essential in helping outline a treatment plan. I examine the eyes in the context of the whole face. Sometimes apparent excess skin of the upper eyelid is due to a drooping eyebrow and in this case a brow lift may be indicated instead of or as well as limited skin removal through blepharoplasty.'

This consultation process typically involves a thorough assessment of the patient's facial features, which Newcastle specialist cosmetic oculoplastic surgeon Dr Eugene Hollenbach says is an essential part of the treatment process. ‘There are several aspects I analyse in the eye before I'll diagnose what surgery or adjunctive treatments may work best for a patient,' he says. ‘I look at the symmetry of the eyes and measure any asymmetries between the upper and lower lid, the lid height and redundant skin. There are three factors of the ratio to look at - between the brow, lashes and lid crease - and to take into account. I look at the distance between the eyebrow height and eyelashes, the lashes and lid crease and the lid crease to lowest brow hair.'

Surgical techniques

Dr Groth says the approaches to upper and lower eyelid surgery need to be individualised to each patient. ‘Although an aesthetic sense and expert technique are first and foremost in all surgeries, each patient requires an
individualised approach. Skin quality, ethnic features, as well as anatomical differences will dictate the proper approach for each patient. We try to preserve the orbital septum and orbicularis muscle tone and innervations whenever possible in order to maintain a natural look, function and movement to the eyes.'

One of the most important aspects of achieving this is an understanding of how the upper and lower lids differ in their aesthetic and function, and whether altering one or both is the appropriate surgical approach.

Dr Tsirbas says an extensive understanding of the anatomy of the upper and lower lids is vital to undertaking the correct rejuvenative procedure. ‘It is important to preserve volume and not over-resect the lid, otherwise a "skeletonised" ageing look can be created,' he says. ‘In the upper lid an appreciation of the role of the brow fat pad is critical to sculpting a beautiful upper lid. Ultimately, the incisions must reflect differences in the individual and be specific to male and female faces.'

However, Dr Hollenbach says sometimes procedures that target other areas of the face can be better suited to rejuvenating the appearance of the eyes. ‘Often an upper lid blepharoplasty alone will suffice in rejuvenating the face in a younger patient. If there's redundant skin and bags we may also perform a transconjunctival lower lid blepharoplasty. Sometimes a blepharoplasty isn't the best option for a patient; we may be better to pursue a brow lift or fat sculpturing.'

Upper blepharoplasty

Upper eyelid surgery is known among surgeons to be more straightforward than lower eyelid surgery and is well suited to those with excess skin that creates a hooded effect over the eyes. Typically, the procedure involves surgically removing this excess skin to create a more ‘open' appearance in the eye area, revealing the contour of the brow and inner eyelid crease. In some cases the fat pockets around the eye need to be repositioned during surgery, but this is dependant on the patient.

‘Upper eyelid surgery is usually approached from the skin crease in the outer surface of the eyelid - five to 10mm above the lash line,' explains Dr George Marcells. ‘Rejuvenation of the upper eyelid may often involve lifting or supporting the brow at the same time. This can be performed by incisions around the hairline. As well, the brow can be supported more directly by using the same incision as used for the upper lid blepharoplasty.'

Dr Hollenbach says upper blepharoplasty procedures can produce dramatic results for those suited to the procedure, providing a very noticeable improvement to the face overall. ‘I would consider upper lid blepharoplasty the least invasive surgical procedure for the face if no fat removal is required,' he says. Dr Oates agrees, noting that upper blepharoplasty patients are those who typically experience the most satisfactory results.

Lower blepharoplasty

Dr Oates says there are much bigger differences in approaches to the lower eyelid than there are to the upper. ‘Approaches to the lower lid are more likely to require a combination of surgery, filler and laser to give the best result,' he says. ‘Most surgeons agree that restoring volume to the tear trough area has made the biggest difference to lower blepharoplasty techniques in recent years.'

A transconjunctival blepharoplasty involves making an incision on the inside of the lower eyelid to access the tissues of the eyelid, Dr Groth explains. ‘The orbital fat can be repositioned or removed from this approach. When the fat is repositioned we move it into the area of the orbital rim depression to reduce the fullness of the lid and the depth of the orbital rim groove. This technique improves the appearance of the dark circle around the eye, with minimal effect on the shape of the eye while maintaining a naturallooking appearance,' he says.

Additionally, the supporting structures surrounding the lower lids play a pivotal role in their appearance, which Dr Tsirbas explains requires an intimate understanding of the periocular anatomy.

‘The role of muscle, skin and ligaments in keeping the lid in a normal position is critical, and damage to any of these structures can lead to complications of a scarred and droopy lid,' he says. ‘The preservation of the lids' blinking mechanism is paramount in blepharoplasty in order to avoid problems with eye irritation after the surgery.'

Brows

The eyebrow area can be especially influential in the appearance of ageing eyes, which sometimes calls for the surgeon to consider both surgical and non-surgical options to enhance the brow to rejuvenate the eyes.

‘The brows frame the eyes and when they are drooping and deflated they can make a person tired and older than they are,' says Dr Groth. ‘The brows also convey expression, so when the brows droop they can make you look angry, sad or even sinister involuntarily. Something as simple as botulinum injections can safely and effectively alter an angry or heavy brow appearance, and filler injections strategically placed in a sagging eyebrow or hollow temples can also enhance the eye area.'

Dr Oates says brow descent can be managed with a variety of surgical interventions, from minor procedures such as thread lifting to more substantial surgery such as an endoscopic brow lift (keyhole surgery to lift the brow) or bicoronal lift (surgical repositioning of the scalp). Surgical brow lifting procedures provide a permanent option for those with excessive brow descent and can work to provide total upper facial rejuvenation.

Interestingly, many patients seeking a blepharoplasty procedure are often more suited to a surgical brow lift because of anatomical limitations that might prevent satisfactory results from a blepharoplasty procedure. Dr Marcells specialises in a new technique which is designed to lift the brow area via a small blepharoplasty incision. ‘I have been using a new technique to support the eyebrow and give it a subtle, natural-looking lift, where the incision is the same as used for the upper lid blepharoplasty,' he explains. ‘This is suitable for certain patients and may obviate the need for more extensive brow lift procedures and extra surgical incisions around the hairline.'

Periocular volumisation

Sydney ENT and facial plastic surgeon Dr Michael Zacharia says volumisation is a key factor in restoring youthfullooking eyes. ‘More often than not, loss of volume in the cheeks and mid-face area is the source of why people
look aged. Adding volume here can "lift" the mid face and subsequently define the youthful curves of the face, enhancing the appearance of the eyes.'

With this approach, Dr Zacharia says it's important to judge every eye on its own merits. ‘Non-surgically, we can concentrate on improving the quality of the skin as thin, rough textured skin surrounding the eyes can make the eyes look dull and aged. Chemical peels and laser resurfacing treatments in this area can work well to improve skin texture and illuminate the natural radiance of the eyes,' Dr Tsirbas agrees, noting that the role of facial volume augmentation and stem sell regeneration provides an exciting horizon that may well be realised in the coming years.

‘On some occasions the "bags" the patient complains of are actually due to bone and fat changes, and require a re-inflation of tissues,' he says. ‘This is especially common in the tear trough and brow fat-pad area. It's vital to understand this, as surgery is often not the solution for these patients. The use of hyaluronic acid (HA) gel fillers has improved management of these areas in the past five years but it's important to not go overboard with facial fillers as they can sometimes give an artificial look.'

Experts agree that approaches to eye surgery and non-surgical eye rejuvenation have evolved to include the entire upper and mid face areas, resulting in a more holistic approach to blepharoplasty procedures.

‘Over the past decade there has been a shift away from creating an overly resected eyelid that suggests obvious surgery,' notes Dr Tsirbas. ‘As our understanding of facial ageing improves, we come to appreciate that the loss of facial volume and skin turgor is often critical in the face. We often mask this by cutting and lifting, but techniques aimed at regeneration and reinflation, as well as preservation of normal tissues, are coming to the forefront.'

What do your eyes say about you?

Several studies show the eyes are the most important facial feature that other people use to determine your age, level of fatigue and even overall health, says Dr Groth. Such studies have shown the eyes are most focused on
during conversations on first meeting, revealing that factors such as the degree of wrinkling, poor skin texture and upper eyelid "hooding" indicate poor health and lifestyle to the beholder.

Similarly, recent research published in US journal Ethology has found that people with bloodshot eyes are considered sadder, unhealthier and less attractive than people whose eye whites are unstained in colour - an indicator which research website Science Daily describes as a uniquely human cue for emotion and health among other animals.

Combination rejuvenation

More often than not, the source of dull, tired-looking eyes is the quality of the skin around them. A chemical peel or laser resurfacing treatment is often combined with surgical and non-surgical options to restore the skin underneath the eyes, targeting pigmentation, sun-damage and poor textured skin. Safety precautions are employed to ensure the eye is not damaged during such treatments, typically with the use of protective contact lenses.

Thread lifting can also be used in combination with non-surgical eye rejuvenation treatments and involves the insertion of tiny barbs which adhere to the skin from underneath to lift and tighten the skin. Modern thread lifting procedures involve the use of reabsorbable threads, which dissolve over time and leave a framework of collagen fibres to secure the lifted effect.

Sydney ENT and facial plastic surgeon Dr George Marcells says he uses muscle relaxants such as Botox to ease the appearance of wrinkles and relax muscles that pull the brows downwards.

‘I assess whether patients will benefit from surgery first or whether a non-surgical procedure will be best for them. For example, a young person in their late 20s may have hereditary fatty bags under the eyelids which can be addressed with surgery, or they may have droopy eyebrows which could benefit from Botox injections first,' he concludes.

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