Understanding, creating a youthful upper eyelid

The best way to create a youthful upper eyelid is by understanding it, Nancy Swartz, M.D., told the audience during her presentation, “Understanding and creating the youthful upper eyelid,” at Vegas Cosmetic Surgery 2014. 

A youthful upper eyelid has three components that Dr. Swartz calls the “youthful triad:”

• A full, relaxed brow that transitions smoothly to;

• a full upper eyelid; and

• a well-defined eyelid crease that’s low.

“What we traditionally did surgically takes away from this triad,” Dr. Swartz says.

Surgeons in decades past would often perform a browlift to rejuvenate the upper eyelid, which frequently positioned the brow unnaturally high. Brow ptosis, she says, isn’t always an age-related change; it can be congenital, creating pseudo brow ptosis caused by deflation. In these cases, if you move the brow position, it can end up being in too high a position. Dr. Swartz admits that, once upon a time, both she and her patients achieved what they thought were good results using this method. She says now, however, it’s time to rethink this approach.

Aging changes what happens anatomically: Patients lose layers of fat in the eyelid and brow, which causes each to deflate. Dr. Swartz says she thinks of the eyelid as a compartment. Inside the eyelid is fat and muscle. When the compartment is full, the eye area has nice contours. When it’s not, it has craters and valleys. Maintaining volume in this area also maintains the aforementioned youthful triad.

Interestingly, Dr. Swartz believes one of the reasons the industry originally focused on lifting the brow was because older people tend to raise it. She says, however, it’s not necessarily due to the brow falling; instead drooping upper lids are caused by excess skin and the eyelid itself hanging down from the brow. It’s when this skin begins to obstruct vision that this population begins to regularly raise their brow in an effort to move that skin out of the way.

Dr. Swartz had this take-home message: For each patient, it’s important to evaluate whether they need surgery, volume or both to achieve successful, natural-looking upper eyelid rejuvenation, and to be aware of the possibility of a deflated brow and recognize it as pseudo brow ptosis. 

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