December 20, 2018
The eyes are often referred to as the “windows to the soul.” If, however, the eyes appear “tired” as a result of age-related changes to their aesthetic architecture — the dermatologist should feel comfortable in addressing these concerns and directing patients regarding the available solutions.
Changes to the upper eyelid in older males generally fall into 1 of 3 categories. The first and most common is excess or redundant upper eyelid skin (dermatochalasis). A second more subtle influence to this appearance may involve laxity or hypertrophy of the underlying muscle. Finally, weakening of the orbital septum with bulging of the underlying fat (pseudoherniation) may also be a factor contributing to a “tired” appearance.
Concerning rejuvenation of the upper eyelid, just as in women, many options exist that a dermatologist may present for men to consider. Over the last several decades, surgical and laser techniques to enhance the aesthetics of the upper lid region have been optimized to benefit a broad range of patient concerns. These modalities now offer men the ability to successfully restore a more youthful rested appearance to their eyes.
The Male Brow
The approach to upper eyelid blepharoplasty in men must take into account gender specific variations in the anatomy of this region. Females, for example, have a well-formed arch to their brow that rises above the orbital rim peaking laterally. Men, on the other hand, have a flatter brow that arches more subtly. The supratarsal crease is well-defined in females and found at 9-10 mm above the lash line. In males, these landmarks are more muted and the supratarsal crease is only about 8 mm above the upper lid margin.1 In both genders, the medial canthus is generally 1-2 mm caudal to the lateral canthus. This gives the eyes a slight inward tilt in both genders. This angle, however, is also more accentuated in females (3-4 degrees) than in males (1-2 degrees).2
It has been expressed that males seeking blepharoplasty do so more for age-related functional changes such as the restriction of superior and/or temporal visual fields.2 It is our experience, however, that male patients are now more commonly requesting the procedure for aesthetic concerns.
Upper Eyelid Blepharoplasty
In patients with dermatochalasis, gentle grasping of obviously redundant upper eyelid skin with forceps often allows the rapid assessment of the degree of excess skin that needs to be excised. The first incision is commonly placed along the supratarsal crease. Surgical incision begins medially above the punctum and is continued laterally, generally ending above the lateral canthus. If necessitated by extensive lateral hooding, the incision may be extended further beyond the lateral canthus. In this case, the extended incision is directed upward at an angle of 30-45 degrees to a point just beyond the extent of any hooding identified.3 A second superior surgical incision can then be placed at the determined height above the first that still Ensures that both eyelids can be fully closed. This second incision connects distally at both extremes with the first to completely define the skin of the upper lid that can then be excised.
Resection of orbicularis oculi has traditionally been an integral part of upper eyelid blepharoplasty procedures, particularly when concerns go beyond simple dermatochalasis. Removal of a small central strip of this thin muscle, parallel to the inferior skin incision, can reduce bulk if the muscle is redundant or hypertrophied. More importantly, however, resection helps to better define the palpebral crease in this area and provides access to the septum for reduction of orbital fat.4 Resection of orbicularis oculi should generally not extend to the edge of the skin incision to prevent a step down or exaggerated crease. Conservative resection also prevents the development of an overly cachectic or hallowed appearance to this area following the blepharoplasty.
Once the septum is exposed, any laxity that contributes to pseudoherniation (bulging) of the upper lid can be addressed. Two orbital fat pad compartments are in the upper lid. The preaponeurotic fat pad is situated centrally and the nasal fat pad is located more medially. Independent of a patients overall weight status, the nasal fat pad tends to gain bulk as a part of the aging process.3 Pseudoherniation of this nasal fat is addressed with a small incision made through the medial septum. A portion of the nasal fat pad is gently delivered out of the incision, with mild pressure on the closed eye and/or additional blunt dissection. This fat is clamped and excised. Bipolar cautery is utilized with meticulous attention to hemostasis to prevent hematoma. Lastly, the cutaneous incision is closed with running or simple interrupted non-absorbable sutures.
With a balanced approach the post-operative appearance of upper eyelid hooding, as evident in this case (Figures 1-4), can be improved significantly.
Figure 1. Pre-operative: lateral view
Figure 2: Post-operative: lateral view.
Figure 3. Pre-operative: frontal view.
Figure 4. Post-operative: frontal view.
Figures 1-4. MALE UPPER BLEPHAROPLASTY
Post-operatively there is a significant improvement in lateral hooding evident. Relative conservation of orbital fat results in a very natural, but more refreshed appearing upper eyelid in this older male patient.
Fortunately, complications following upper eyelid blepharoplasties are uncommon and some appear less frequent than with similar procedures on the lower lids.5 Early post-operative concerns may include wound dehiscence or infection. Post-operative dry eye symptoms may also be noted. Such symptoms are generally transient often resulting from intraoperative corneal exposure, but lagopthalmos should be ruled out as a contributor.6 Most patients are prescribed lubricating ointment for nocturnal use until eyelid edema resolves and normal lid function returns. Prolonged dry eye may be secondary to inadvertent resection of the lacrimal gland, which can be mistaken for orbital fat by the novice surgeon. Less common concerns are the development of ptosis or diplopia.
The most serious complication is retro-orbital hematoma, which can threaten vision if not relieved within 2 hours of symptom development. Symptoms may include orbital pain, a tense globe with elevated intraocular pressure, proptosis and chemosis. In this situation, immediate consultation with ophthalmology should be sought. Treatment including surgical evacuation of the hematoma and administration of agents to reduce ocular pressure and local swelling (eg, mannitol, acetazolamide and methylprednisone) can be administered. Finally, lateral canthotomy or even orbitotomy may be necessary in some patients.7 Again, the risk of this potential complication is diminished greatly by having patients avoid pre-operative use of anticoagulants and by providing meticulous intraoperative hemostasis.
Lasers and Upper Eyelid Rejuvenation
In recent years, laser therapy has become an essential part of a dermatologist’s armamentarium for rejuvenation of the eyelid region. This modality can be employed to address aesthetic concerns in men that are not necessarily improved by upper blepharoplasty alone, including creping of periorbital skin. Attempting to rectify creping surgically may result in overly aggressive resection that leaves the eyelid appearing excessively taut. This can result in a loss of the lids youthful fullness and increase the risk of exposure keratitis if there is concomitant difficulty in closing the eyelids completely. Laser resurfacing helps to restore eyelid texture, tightening the skin while simultaneously increasing collagen support.8 Actinic damage and dyspigmentation may also be improved by laser resurfacing.9
The appearance of lateral periorbital rhytides (crow’s feet) can be diminished with laser resurfacing. A study by Yamauchi et al demonstrated more significant efficacy when combining laser with botulinum toxin denervation.10
Fractional ablative laser treatment, which vaporizes tissue by targeting water, is commonly utilized. Fractional ablative carbon dioxide (CO2) laser provides concomitant thermal coagulation and this generally eliminates any associated bleeding. It may, however, be associated with a slightly higher risk of post-inflammatory pigmentation. Fractional ablative erbium YAG laser is generally considered safer in more pigmented skin types, but can be associated with more punctate bleeding. In our experience, CO2 laser appears to be more effective in rejuvenation of the upper lid than erbium YAG. One could speculate that this may be due to more effective thermally induced collagen tightening with the CO2 platform. Other side effects similar with both laser modalities can include hypopigmentation, post-laser erythema, infection, milia and scarring.
Non-ablative laser also targets water and utilizes thermal energy to heat the dermis, contract collagen bundles and stimulate new collagen formation with resultant skin tightening. Examples of non-ablative laser include Nd:YAG at 1064-nm and 1320-nm. The appearance of telangectasias on the upper lid and periorbital area can also be addressed by targeting hemoglobin with pulsed dye laser at 585-nm and 595-nm.
Ultimately, the approach to upper eyelid rejuvenation should be tailored to each individual patient.
Dr. Lortie is a procedural dermatology Mohs surgery fellow at Affiliated Dermatologists & Dematologist Surgeons in Morristown, NJ.
Dr. Torres is a practicing dermatologist at Affiliated Dermatologists & Dematologist Surgeons in Morristown, NJ, as well as a Mohs and cosmetic surgeon. He also teaches Mohs and cosmetic surgery in a Procedural Dermatology Fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Dr. Rogachefsky is a practicing dermatologist and the program director of the ACGME-approved Procedural Dermatology Fellowship at Affiliated Dermatologists & Dermatologist Surgeons in Morristown, NJ.
Disclosure: The authors disclose that they have no real or apparent conflicts of interest or financial interests or arrangements with any companies or products mentioned in this article.
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This article originally appeared on The Dermatologist.