In spite forehead and eyebrow lift is commonly requested and indicated in middle aged and older patients, there are cases in their 60s and even 70s which, due to aging factors, do naturally evolve with very droopy and low forehead and eyebrows, like the patient shown in this case; his eyes look sunken more due to forehead droopiness rather than eyebrow lowering, actually the tail of the eyebrow is only slightly droopy unlike other aging cases in which low eyebrows tail is the prevailing issue.
Considering the heavy forehead and the aims of the patient to obtain a refreshment in his upper facial third with a natural outcome and non detectable stigmata, he underwent a supraperiosteal lift of the upper two thirds of the face, covering an ambitious lift of the forehead, a subtle lift of the tail of the eyebrows, and a moderate but noticeable lift of the cheekbones, the cheeks and a remarkable smoothening of the nasolabial folds; all the former with undetectable and concealed short scars at the temporal fossa or temple.
Final result is a natural face of unnoticeable surgical signs, rejuvenated, not anymore looking chronically tired and quite refreshed.
In spite the scar less transconjunctival approach inside the eyelid is the recommended and clearly superior access to perform lower blepharoplasty in order to remove the protruding fat bags at the lower eyelid, there are cases with indication for the traditional open approach via subciliary incision practiced at the outer skin of the lower eyelid running along and parallel to the free margin of the lid and the eyelashes; such scenario is the one depicted in this case in a man requiring removal of the not excessively large fat bags of the lower eyelids but also the exuberant festoons and muscle and skin excess noticeable at the lower eyelids which was producing a severe aging effect, a goal unfeasible via transconjunctival approach; for such purpose a mini lift of the lower eyelid skin was performed prior to suturing the wound, subsequent to the fat bags excess removal.
The lower eyelids had also a double aesthetic and functional situation; there was a significant excess of skin and muscle but also an incipient grade of eyelid ectropion or droopiness of the lower eyelid edge; if not preventively treated such ectropion would have been severely aggravated by the tension and fibrosis of the aesthetic blepharoplasty, so a cautionary and minimally invasive prophylaxis was applied in the form of a tarsal cartilage vertical wedge resection so that the eyelid be horizontally shortened and tightened upwards, a second reason why the transconjunctival approach could not be used in this case; the aesthetic side involved a biplanar dissection so that more muscle than skin could be removed and thus treat the festoons and sagginess avoiding an excessive skin resection; the excess of the fat bags was also removed.
The upper eyelids also had a severe muscle and skin excess and a moderate fat bags protrusion, which was treated by means of an incision concealed within the upper tarsal crease.
It is remarkable how the eradication of the overweight burden at the upper eyelid leads to a more powerful and wider eyelid opening thanks to the release enjoyed by the already aging levator muscle, without any direct functional surgery on it.
The final result is a comprehensive rejuvenation of the eyes and eyelids without any noticeable stigma, plus a significant functional improvement.
Note how the upper eyelids had a significant grade of functional ptosis or droopiness which was causing visual field limitation and was aggravated by the low position of the eyebrows; this is corrected by the combination of the eyebrow lift and the aesthetic blepharoplasty, no functional blepharoplasty was applied.
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