Eyelid Surgery- From the eye of the beholder…

Here's looking at you kid (with my natural haircolor)!

Here's looking at you kid (with my natural haircolor)!




The first thing that I notice about a person is their eyes.  Many people do not know that there are oculoplastic surgeons such as myself who are trained specifically to perform cosmetic surgeries on the delicate eyelid structures.  Unlike many surgeons, when I operate on the eyelids I do not use a scalpel, but a precision Ellman Surgitron Radiosurgical device that emits radiowaves to make my incisions and to minimize recovery time and complications.  As a surgeon, I like to operate, but surgery is not the only means to recapture the look of youth.  In fact, the majority of my patients want to improve their appearance without the downtime associated with surgery.  For these patients, I have designed a regimen of nonsurgical therapies using injectable treatments, lasers and light sources, and Thermage skin tightening to improve the quality, texture, and resilience of their skin.  When used in proper combinations these treatments not only postpone the need for surgery, but actually improve the surgical result when the time comes for a procedure in the future.  But, for those who do need a little help from a surgical procedure, these are the things that I look at from a surgeon’s perspective:





Vertical Palpebral Aperture [distance between the upper & lower eyelids]

Twiggy versus mere mortals:

This is what makes the difference between having wide-open, “doe-eyed” appearance of supermodels (Twiggy), versus us mere mortals.  I once had an oculoplastic surgeon tell me that he knew that I was Czech by my “narrow vertical aperture”- I wonder how many times THAT pickup line worked?  Measuring the distance between the upper and lower lid margins will reveal the presence of a true drooping eyelid [ptosis].  The average vertical palpebral aperture is 10 mm, with the upper lid margin 1 to 2 mm below the superior limbus [“limbus” - point where the white part of the eye (sclera) and the colored part of the eye (iris) meets] and the lower lid margin at the level of the inferior limbus. 


Horizontal Palpebral Aperture [distance between the temporal eyelid and the nose]

Kate Moss

Ever do the trick to determine whether your eyes are too far apart or not?  You know, the one in all of the beauty magazines that say to measure one eye between your thumb and forefinger, then shift it to on top of your nose- if this is equidistant to the other eye then you are perfect- no?  Guess you didn’t grow up in the 80’s then (count your blessings). The average horizontal palpebral aperture is 30 to 34 mm. Kate Moss has a broad horizontal palpebral apeture, but a narrow vertical palpebral aperture, and the last that  I checked in, she was doing just fine.


Inferior Scleral Show [too much white showing when looking straight ahead]

Marty Feldman

The idealized lower lid rests at the level of the inferior limbus.  Inferior scleral show is the distance from the inferior limbus to the lower lid margin.  It may occur normally as an anatomic variant (large eyeballs from severe nearsightedness, shallow orbits) or as the result of underlying medical problems (overactive thyroid- Marty Feldman).  These patients require specialized reconstructive techniques for the best outcome.  [Don’t worry, we are pretty clever as surgeons…]. 


Superior Sulcus (New York versus “so L.A.”)

Nancy Pelosi

Below the eyebrow, the superior sulcus is tucked directly underneath the brow-bone. In young patients, the superior sulcus is a flat or concave surface.  Recontouring the superior sulcus is often the primary objective of eyelid surgery (blepharoplasty).  It’s funny, but in this era of economic crisis, I have had a lot of people hold up their hands to me and say “whatever you do, don’t make me look like Nancy Pelosi!...what did she have done anyway?”   (The answer is that too much fat was removed from the upper eyebrow region. I don’t do that look- it’s old school). The superior sulcus in men should be treated differently than women!  The male superior sulcus which is full, has a flat contour and a low flat lid fold with minimal central arching (Brad Pitt- just right, don’t touch it)! The female superior sulcus exhibits a high, arched lid crease and a delicate lid fold (Sophia Loren- gorgeous).  Oversculpting of the male superior sulcus can give a feminized appearance (Burt Reynolds- too much)!  Patients with droopy eyelids because of a slipped eyelid muscle [levator aponeurotic disinsertion] may have deep, flat superior sulci (Forrest Whitaker- on the right eyelid but still an awesome actor). They might find their droopy eyelid objectionable, but like their superior sulcus contours. These cases require special techniques. Fixing the droopy eyelid will change their superior sulcus contour, usually to their dissatisfaction.       


Lateral Canthal Angle [where the eyelid attaches to the temple]

Johhny Depp

I always liked guys with “tilt-tipped eyes.”  For some reason, a slightly upward sweep of the lower eyelid on a man seemed attractive to me.  This is determined by the lateral canthal angle (the point where the tendon holding the lower eyelid inserts onto the temporal bone) The lateral canthus is normally 2 mm higher than the medial canthus [where the eyelid meets the nose- “hello nose”].  In general, the lateral canthal angle is more angular than the medial canthal angle which is round.  Any rounding or inferior displacement of the lateral canthus will be cosmetically significant.  Bilaterally rounded lateral canthi alerts the surgeon (me) that previous cosmetic surgery may have been performed. 


Hypertrophic Orbicularis Muscle (bunched up lower lid when smiling)

Jackie Chan

The pretarsal orbicularis muscle holds the lower eyelid in place.  In some people, this bunches up into a little sausage when they smile.  This doesn’t bother me, but it seems to bother half of Hollywood and Broadway.  It’s caused by a strong pretarsal orbicularis muscle (I don’t know if Jackie Chan works this one out- but he does kick some serious butt and is constantly smiling- he truly enjoys his work, as do I).  Personally, I think it gives a cute look of character, but if it really bothers somebody, it can be softened with a little Botox injection to the lower eyelid (but leave it alone, please)!



Inferior Orbital Rim (Lower eyelid region)

Walter Matthau looks great now!

Correcting “bags” beneath the lower eyelids is the number one surgery requested in the eyelid region.  When you look at a human skull, there are dark sockets where the eyes used to be.  The eyes don’t just sit in empty space, if they did, the eyeball itself would be injured every time that we shook our heads “yes” or “no.” Instead, the eyeballs are protected by a surrounding cushion of fat inside the eye socket.  This cushion of fat is held back by a “girdle-like” tissue called the orbital septum.  In some people (through no fault of their own) this girdle becomes a little stretched, and the fat herniates forwards, giving the appearance of baggy lower eyelids.  No big deal.  We go into the operating room, you get a little intravenous sedation (Pina Colada cocktail), I make a small incision on the inside of the eyelid, the fat pops up, I skillfully sculpt it, and you are on the road to recovery, which takes about a week.


Lid Margin and Punctal Malpositions, Canthal Tendon Laxity

Basset Hounds and Blood Hounds

Ever notice how the lower eyelids of Basset Hounds and Blood Hounds just don’t seem right?  That’s because they aren’t.  The lower eyelids are not firmly attached to the skull, the tendons have been stretched, and some of the lower eyelid is folded outwards looking all red and irritated.  It’s just an aspect of the breed.  Well, this happens to people too, only usually not to that extent.  That’s okay; I can fix this as well. I’m like the McGuiver of eyelid surgery… lid margin laxity is determined by grasping the eyelid and pulling it away from the eyeball (globe).  If it can be retracted 6 mm or more from the globe, it is deemed to be lax (distraction test).   Lower lid laxity left unaddressed during blepharoplasty may predispose the lid to turning outwards like a blood hound (cute on a Hush Puppy, but not on you)!    



So, that’s it.  I know that this was a very technical subject, but I hope that I made it fun by throwing in some celebrity examples to demonstrate the ideals and extremes of what I am looking for during a surgical consultation in my office.


Have a Beautiful Day!

Dr. Lisa

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