All About Aesthetics
Cosmetic Surgery
Raleigh NC
(919)-845-0333

Eyelid & Brow Surgeries

Many people are referred for evaluation and management of “droopy” or”heavy” lids. This is an area that Dr. Hudak can claim expertise in, as she has had extensive training and experience in Oculoplastics (plastic surgery of the eyelids, eye socket, brows, and mid-face) under the tutelage of some of our country’s best eyelid surgeons, including John Holds, MD (in St. Louis, MO), Guy Massry, MD (in Beverly Hills, CA), Robert Goldberg, MD (in Los Angeles, CA), and Henry Baylis, MD (in Newport Beach, CA ). Her Instructors of the mid-face surgeries include Joe Niamtu, DMD (in Midlothian, VA), Angelo Cuzalino, MD (in Tulsa, OK), and Drake Vincent, MD, DMD (Ogden, UT).

The eyelid surgery called Blepharoplasty is the most sought-after facial cosmetic surgery, since eyes with redundant amounts of skin and/or bulging fat tend to make the person appear tired and old. The eye area is looked to for much of our facial expression. The skin of the eyelids is different than the skin elsewhere on the face, and needs a surgeon who understands the anatomy of the lids intimately in order to keep any complications to an absolute minimum.

The function of the eyelids is to protect the eyes. Improperly done eyelid surgery can prevent lids from doing their job, and lead to eye disease. It is for this reason that the American Medical Association, representing all fields of medicine, recommends that those interested in eyelid surgery seek the attention of a specialist in this, ie. an Oculoplastics doctor, or at least an Ophthalmology-trained surgeon.

Droopy/ Heavy upper eyelids may be due to several different causes, and are best corrected by addressing the root cause.

Causes:

  • excessive skin (dermatochalasis)
  • excessive skin with redundant, protruding fat pads (blepharochalasis)
  • low eyebrows (brow ptosis)
  • due to aging and atrophy of the forehead skin and/or frontalis muscle
  • due to Bell’s Palsy, a Cranial Nerve VII Palsy
  • due to a lower-than-normal eyelid margin (ie. a true ptosis); in this,the edge of the upper eyelid is displaced lower on the eye than is normal, often covering part of the pupil
  • due to thinning or damage of the tendon of the muscle that lifts the lid (ie. dehiscense and/or disinsertion of the levator aponeurosis)
  • due to a disorder of the Mueller’s muscles, which are responsible for the first 2-3mm of lid lift,
  • eg. as seen in a Horner’s Pupil and Syndrome, which can be due to a disorder in the eye socket (orbit), in the neck, in the top (apex) of the lung (such as a tumor), or with migraine
  • due to a disorder of the levator muscle, which is responsible for the majority of eyelid lifting
  • eg. as seen in Myasthenia Gravis, the Chronic Progressive External Ophthalmoplegias, and Myotonic Dystrophy
  • eg. as seen in some cases of Congenital (ie.”born with”) Ptosis
  • due to a disorder of Cranial Nerve III (ie. the nerve to the levator muscle)
  • eg. a disorder causing a Cranial Nerve III Palsy, such as a brain aneurysm, stroke, or tumor
  • due to high blood pressure, diabetes, collagen vascular disease, congenital (ie.“born with”) blood vessel defect, or acquired problem (as is true with most tumors)
  • eg. as seen in some cases of Congenital Ptosis
  • -due to a “pseudo-ptosis”, a false, untrue ptosis; ie. it looks like a ptosis of the lid, but upon closer inspection, it is not a true ptosis
  • due to a spasm of the orbicularis oculi, the muscle group responsible for closure of the eyelids, called a blepharospasm
  • eg. as seen in Benign Essential Blepharospasm and Hemifacial Spasm
  • due to a movement disorder of the orbicularis oculi muscles
  • eg. as seen in Lid Apraxias and Lid Dystonias
  • due to a smaller eye (microphthalmos)
  • due to an eye that has been displaced downward or toward the back of the head
  • eg. as seen in trauma to the bones of the eye socket
  • eg. as seen in some tumors of the eye socket
  • due to an outward bulging of the other eye
  • eg. as seen in thyroid diseases, like Graves’ Disease

Treatments

Depending on the root cause of the droopy lid(s), different options may be recommended. They include observation, Botox® injections, pills, eyedrops, laser procedures, eyecreams and surgery.

  • Botox® can temporarily paralyze and stop spasming orbicularis oculi muscles (that close the lids) and help lift the inner brow (by temporarily paralyzing the glabellar muscles that pull our brows into a downward frown). The result is less draping of skin over the lashes or in the crease line of the upper lid.
  • Pills can occasionally help reduce the ptosis of a patient with Myasthenia Gravis, or the pseudo-ptosis of a patient with thyroid disease/ thyroid-associated-orbitopathy.
  • Eyedrops that lubricate can help the patient who has blepharospasm from dry eyes or who has a disorder of the cornea (windowshield of the eye) in which there is breakdown of its surface cells.
  • Laser skin tightening of the lids can reduce mildly redundant dermatochalasis
  • Eyecreams our Esthetician can choose for you can help replenish elastin, collagen, and moisture to the dry, mildly redundant skin

Common Surgeries

Upper Eyelid Surgeries

  • Blepharoplasty - a procedure in which excess skin and/or fat is removed, being careful not to remove much, if any, orbicularis oculi muscle
  • Levator Aponeurosis Resection- a procedure in which the tendon of the muscle that lifts the lid is shortened
  • Silastin Sling Procedure- a procedure in which an elastic-like piece of sterile tubing is threaded through the brows and lids, and attached to the tight tissue covering over the forehead bone, the periosteum

Brow Surgeries

  • Coronal Brow Lift - a procedure in which skin and/or fat is removed in the forehead, usually high in an area hidden by hair
  • Endoscopic Brow Lift - a procedure in which the forehead tissues are lifted by going to the level deep to the periosteum, the tight tissue covering over the forehead bone, and loosening its attachments to the bone, and then anchoring the tissue by way of sutures, screws, or staples to the bones of the top of the head
  • Direct Brow Lift - a procedure reserved for people with bushy brows and very high hair lines, in which skin and fat is removed immediately above the brows
  • Eyelid Retraction is a condition in which there is too much sclera (the white of the eye) showing, often resulting in an abnormal and/or incomplete lid closure (lagophthalmos).

Causes: It is most often associated with Graves’ Disease, or Thyroid-Associated Orbitopathy. It may also be seen in patients with a history of eyelid trauma, a “botched eyelid surgery”, or congenital (born-with) disorders associated with a shallow orbit.

  • Lid Retraction Repair- a procedure in which the lid is vertically elongated, because too much sclera—the white of the eye—is showing, and there is subsequent incomplete lid closure.
  • Mucous Membrane Graft Insertion- a procedure in which a piece of cartilage-like tissue with adherent mucous membrane, such as from the opposite upper eyelid tarsus or from the hard-palate of the inside of the roof of the mouth, is removed and transferred to the lid retraction site and sutured into place, attaching it to the inner lid’s tarsus.
  • Full-Thickness Skin Graft Insertion- a procedure in which a piece of skin is transferred from another site, such as from the opposite upper lid or from just behind the ear, to be inserted within an incision in the lid crease of the eyelid with retraction.
  • Muellerectomy- a procedure in which there is a cutting and partial removal of the Mueller’s muscles in the lids, which are responsible for the first 2-3 mm of upper lid lift.
  • Lower Lid Retractor Release- a procedure in which there is a cutting of the condensed tissues responsible for lower lid retraction.

Droopy/ heavy lower lids may, like upper lids, be due to various different causes.  The repair options are aimed at correcting the cause, whenever possible. Following are some of the more common causes.

Causes:

  • excessive skin (dermatochalasis)
  • excessive skin and/or protruding fat pads (blepharochalasis)
  • laxity of the tendon(s) that supports the lower lid (by way of attachments from the tarsal strip--that gives the lower lid a stiffness and shape at its edge--to the periosteum that covers the eye socket bones, providing a great place to anchor muscles and tendons). This results in an unstable lower lid, which can show as an outward turning of the lower lid (ectropion), or inward turning of the lower lid (entropion).
  • an obstructive mass of the eyelid or eye
  • eg. an eyelid skin or conjunctival or tear-drainage-system infection
  • eg. a chalazion, abscess, stye, canaliculitis, or tear sac infection (called a dacryocystitis)
  • eg. an eyelid skin or eye tumor
  • eg. a papilloma, skin cancer, lymphoma, or squamous cell cancer
  • a vertical shortening of the skin of the lower lid, causing an ectropion
  • eg. due to too much skin being removed during a blepharoplasty
  • eg. due to certain collagen vascular disorders, like scleroderma
  • a vertical shortening of the mucous membrane of the lower lid, causing an entropion
  • eg. due to severe inflammation of mucous membranes, as seen in Ocular Cicatricial Pemphigoid and Stevens-Johnson Syndrome

Treatments

Most lower lid disorders require surgical intervention to correct.

Common Lower Lid Surgeries:

  • blepharoplasty- a procedure to remove excess skin and/or fat
  • lateral tarsal strip procedure (aka Kuhntszymanowski procedure)- a procedure in which the horizontal length of the lower lid is shortened at the outer corner of the eyelid by removing a piece of the tarsal strip, and reattaching the end of the tarsal strip to the periosteum of the eye socket
  • pentagonal wedge resection- a procedure to remove a skin tumor that is growing on the lid margin, or in which a horizontal lid shortening is desirable, but a lateral tarsal strip won’t help sufficiently
  • mucous membrane grafts and skin grafts- procedures to supplement an inadequate amount of either in order to restore the lid to normal function
  • tarsorraphy - a procedure to bring the upper and lower lid margins closer together

For questions, see Frequently Asked Questions

If you would like to have me evaluate your lids and brows, please call for a consultation. I can assure you I will be thorough in my examination and evaluation, show you many before-and-after photos of my work, and answer all your questions.