My approach to the upper and lower eyelids has changed dramatically in Beverly Hills from when I first began performing this surgery 22 years ago. At that time I was taught to remove as much excess fat, skin and muscle as possible in order to get rid of all the hanging “extra” tissue. Over the years it became clear that removing all the tissue surrounding the eye did not make things look younger or better: It made the eyes look older. Youthful eyes aren’t prominent and round and don’t have much visible lid or hollow sockets or the whites of the eyes showing on the lower lids. Youthful eyes are surrounded by skin that is taut with fat. The lids have crisp folds and the lower lids blend into the cheek such that there is no delineation between the orbit and the face. Double eyelid surgery, more than any other facial procedure, has the potential to alter the essence of someone’s appearance. Because of this I strive to be conservative with the eyes and to “restructure” rather than to remove the tissues.
While performing double eyelid surgery, for the upper lids I almost never take away any fat. If I find the fat has herniated from behind the eyeball to underneath the skin I will delicately replace it back to where is once was to get rid of an unsightly bulge but without creating any hollowing. Muscle might be tightened and skin will be judiciously excised. Occasionally the lid skin can benefit from being intrinsically tightened by treating it with laser or other like-minded technology. The lower lids are usually approached from inside the lid to avoid any scar and potential eversion or dragging down of the lash line. Fat is gently teased out from inside of the orbit (where there is often a “bag”) and advanced over the rim and secured where it is most needed to fill in a visible trough or hollow. By moving fat from the “bags” to fill in the “hollows” I create a smooth contour that improves any “tired look”. This technique maintains the exact shape of the eyes as they were preoperatively. Occasionally it is necessary to place an incision immediately under the lashes to allow for smoothing out a superficial bulge or removing some excess lower eyelid skin. Such an incision is only performed when the lower liddemonstrates good support or when other measures are being taken to reinforce it.
As an alternative to surgery I often inject Restylane, an injectable filler, to fill in hollows that exist under the eyes. I began doing this in 1997 and over the years I have become quite expert at it. While there is no cutting involved and the results can be quite remarkable, there always is a chance for bruising and swelling. Fortunately, excess product causing any lumps can be dissolved if need be.