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Windows to the Soul

By Dianna Sanchez
Posted On Jan 21, 2010

They say the eyes are the gateway to our souls, and few things are as revealing when it comes to the appearance of youth. They are also one of the key areas that can quickly be brought back to life by cosmetic surgeons.

Words Barbara Perkins

If you happened to catch Madonna’s “Sticky & Sweet” tour last summer, chances are you were instantly spellbound. Not by her song, dance or risqué new fashion, but by her eyes, literally shimmering beneath upper lids sprinkled with crushed, flawless diamonds. As the fifty-something diva knows so well, the eye area is the first place people focus on when they look at you.

Because the skin surrounding the eyes is the thinnest and most delicate in our bodies, it’s typically the first place to show signs of aging. Whereas the Material Girl can easily pick up the tab for bejeweled eyes, however, for others the reality eventually hits you: There is no cream, lotion or magic potion that can completely reverse the signs of aging around the eyes. That’s when prevention tips, tricks and techniques morph into “procedures.”

Seeing Eye to Eye

When it comes to the eye area, looking old can mean many things: drooping eyebrows, sagging upper lids, baggy lower lids, dark circles, sunspots, fine lines, deep wrinkles and more.

“It’s such a rich palette of issues that can make patients unhappy about the eyes,” says ocular facial plastic surgeon, Dr. Robert Goldberg, chief of the Orbital and Ophthalmic Plastic Surgery Division at UCLA’s Jules Stein Eye Institute. “We do teaching here at UCLA,” says Dr. Goldberg. “In one course, I give an hour long lecture just on the different anatomical problems that can make the eyes look [tired and old].” And that, he says, “is simplified.”

Moreover, if you think for a minute about how different everybody’s eyes are, it becomes easy to see how wide the spectrum of solutions must be. And today, says Dr. Goldberg, when it comes to cosmetic eye procedures, people are much more sophisticated, expecting far more natural results.

Fillers: They’re Not Just for Lips Anymore

It used to be that most surgeons saw the aging eye area as a problem of “excess” skin. Not anymore. “We don’t really grow extra skin,” says Dr. Goldberg. Instead, as we age the face deflates and loses volume, and what most of us perceive as an “old” face really has to do with loss of fullness. So, plumping up the eye area to fill in wrinkles and hollows is one of the treatment du jour.

Fortunately, there are numerous fillers on the market today. But it’s the natural ones—particularly the hyaluronic acid fillers, like Restylane and Juvéderm—that are the darlings of the filler-up-in-the-eye-area revolution. Hyaluronic acid gels are made of sugar molecules that are produced naturally by the body and bind with water to plump the skin. Because it’s a natural substance, the risks of allergic reactions are rare. The gel is injected with fine needles and can be shaped and sculpted in the tissues for instant results. And since it’s a clear gel, putting it under thinner skin means less concern about exposure.

“I like the hyaluronic acid gels,” says Dr. Goldberg. “They’re versatile and in the very delicate eye area these fillers are the easiest to work with.” They tend to last about a year—which can actually be a good thing. “If they had permanent fillers which were safe I still wouldn’t want to use them,” says Dr. Goldberg. “The face changes over time, and this way you can gradually adapt to the ongoing changes that occur in the face.”

The latest in vogue treatment options for pumping up volume in the eye area is fat transfer. “It’s almost the perfect thing.” — Dr. Susan Hughes

Dr. Susan Hughes, a facial cosmetic surgeon with a private practice in Cherry Hill, New Jersey, is another big proponent of injectables. “Filler is very effective around the eyes,” says Dr. Hughes—and not just for crow’s feet or deep wrinkles. Under-eye hollows, too, are often the result of volume loss. “It’s funny, when people come in and say they want me to take bags out of their lower eyelid, for about eighty percent of them I add fat or filler—definitely not what they thought they were coming in for,” says Dr. Hughes. If there’s only a small bulge you can raise the skin, fill in the valley between the cheek and the lower eyelid, and the bulge is hidden. With fillers the procedure is fairly quick and relatively painless. Most of the time a numbing cream is used at the injection site, and patients are in and out in about half hour to forty-five minutes. “The numbing itself usually takes longer than the procedure,” says Dr. Hughes.

Fat is Where It’s At

The latest in vogue treatment options for pumping up volume in the eye area is fat transfer. “It’s almost the perfect thing,” says Dr. Hughes, who has undergone fat transfer treatments herself. The way it works: Fat is harvested from an area of the body where it’s not needed (can you say spare tire?) through liposuction, then processed and injected into eye areas where the skin is sagging or hollow. It’s unique in that it’s your own tissue, and some of the harvested fat contains stem cells, which can help the fat survive. The harvesting procedure takes about thirty minutes and injections about the same amount of time. What’s really great about it, according to Hughes and other doctors, is that it lasts.

The downside? The downtime. It’s a “stay out of sight for about ten days procedure,” says Dr. Hughes. After ten days you can camouflage it and put your glasses on and go back to work. You will be swollen for up to six weeks but after that you’ll know how much has lasted. About fifty percent of the people who go the fat transfer route do need a touch up within a month or two. Many choose to have their harvested fat kept “on ice” and ready for the second round.

Special FX

When it comes to lasers and eye treatments, there are two distinctly different applications. With one, the lasers are used for surgical cutting, taking the place of a scalpel. For the other, using a laser is a process to resurface facial skin. Years ago, carbon dioxide (CO2) lasers were used to completely ablate (which means: obliterate) the surface of the skin. “They left you looking like a burn victim, but the skin would grow back and you would have minimal lines and look fantastic,” says Dr. Lisa Chipps, a dermatologist at the Moy-Fincher medical group in Los Angeles who specializes in dermatological surgery. The difficulty was recovery—about three weeks to heal—and occasionally patients were left with pigment demarcations.

Today’s lasers are more technologically advanced, says Dr. Chipps, with immediate benefits for her clients. “The newest, most popular thing we’re doing is fractional CO2 resurfacing. The machine, called the Deep FX, is fantastic for fine lines,” she says. “We’ve been doing it for just under a year and we’re doing a lot of it. So far, our patients really like their results.”

The fractional CO2 laser destroys the skin on the surface and causes tightening of the deeper layers, so that it gets rid of most brown spots on the surface as well as the more entrenched wrinkles and lines. The ‘fractional’ aspect of the laser makes thousands of tiny little holes in the skin, so you have thousands of tiny wounds to heal, much quicker than if the entire skin surface had to heal. Now, instead of three weeks down time, it’s about a week, and pigment problems are much less common.

“The procedure takes maybe 15 minutes and it can make the [eyes] look five to ten years younger.” — Dr. Lisa Chipps

Still, for many people it’s not easy to carve out a week for down time, but Dr. Chipps says the results are so good it’s worth it—especially for the majority of her clients, who are concerned with their aging eyes. “To treat the eye area the procedure takes maybe fifteen minutes and it can make the area look five to ten years younger,” says Dr. Chipps. Nonetheless, even though it’s a procedure that’s not going to wear off, the aging process does continue. So how long it “lasts” will depend on how well you are aging, says Dr. Chipps. Dr. Hughes also cautions that while recovery time is significantly reduced, the results are less pronounced than with the fully ablative resurfacing technique.

Freeze Right There

By now almost everyone knows what Botox is, and how it works: as a neurotoxin it blocks the nerve impulses of the injected muscles, causing a temporary paralysis so the muscles are unable to contract. The skin begins smoothing out as the treated facial muscles—including those around the eyes—relax. Since its introduction a few years back, however, there have been a few advances. When Botox was first used for forehead wrinkles, people complained about getting that “frozen look”; today doctors are more site selective with the injections, so results look more natural. Plus, there’s a new kid on the block.

In July of 2009, Dysport became the first drug of its type approved by the U.S. Food and Drug Administration (FDA) to compete with Botox. It’s the same neurotoxin as Botox with a slightly different carrier molecule, and they also work the same way in the eye area. “They’re pretty equivalent,” says Dr. Chipps, whose group participated in the clinical trials to get the FDA approval. Both are minimally invasive, 15-minute office procedures; a needle is used for the injection, which is directly over the muscle area to be treated. “We’ve treated several hundred patients, and now we’re using it just as frequently as Botox,” she says. The differences between the two neurotoxins are subtle, says Dr. Chipps, with Dysport a little less expensive and, in some patients, a little quicker to take effect. Both achieve the same results, unraveling telltale worry lines, like the so-called ‘elevens’ that some people have between their eyebrows.

Cut to the Chase

While non-invasive procedures help some put off surgery and others avoid the knife altogether, for many, non-surgical options are just not quite enough. “There are people who are fearful of the knife, but I’m not,” says Dr. Jeff Popp, a cosmetic surgeon based in Omaha, Nebraska. While there is always hope that sagging skin can someday be corrected without surgery, for now Dr. Popp, with 26 years of experience, remains keen on the time-tested methods like blepharoplasty. Blepharoplasty is the technical term for an eyelid lift or eyelid surgery. It is one of the most common cosmetic procedures performed in the U.S., creating a youthful look by removing fat, skin, and/or muscle from the eyelids.

For the upper eyelids, skin and fat are removed through an incision hidden in the natural eyelid crease. The surgery takes anywhere from one to three hours (less if only upper lids are being treated), and it’s frequently done under local anesthesia. The bruising lasts up to three weeks, while swelling can last up to six months. But, says Dr. Popp, “My goal is to improve what issue bothers the patient.” And this surgery he says, comes with a guarantee: “That upper lid skin will never grow back.”

As for the lower lids and its ancillary issues, Madison, Wisconsin-based Dr. Brad Lemke—a board-certified facial cosmetic surgeon with an active practice for close to 30 years—has seen his share. “A big part of my practice is eyes,” says Dr. Lemke.

Lashing Out:…read more»

While often treated at the same time as the uppers, the under eye area presents unique issues including drooping, puffiness, and dark circles, with a variety of treatment options. Traditional blepharoplasty for the lower lid requires an incision made just below the lashes. Fat can be removed or repositioned through this incision; the skin is then tightened and closed. Another technique when there is very little saggy skin is a procedure called transconjunctival blepharoplasty. Here the incision is made on the inner surface of the lower eyelid, leaving no external scarring.

Sometimes dark circles under the eyes are the result of rich blood vessels close to the surface, casting a dark shadow on skin so thin it can appear bluish. Blepharoplasty cannot remedy this problem, but in other cases the dark circles are due to fat that is herniated forward and accentuated by light casting a shadow. In this case a surgeon can perform a lower lid blepharoplasty to remove a small amount of fat. Technically it’s easy to remove fat, but artistically it’s not easy to remove just the right amount, says Dr. Lemke. You’ve got to be careful not to take too much out, he says, and that is what separates the artist/surgeon from the technician.

Brow Now

No discussion of the eyes, especially the upper eyelids, is complete without talking about the eyebrows. Because drooping eyebrows can compound the look of sagging lids, some people may appear to have drooping upper lids but in actuality it’s simply drooping brows. In this and certain other situations, elevating the brow is recommended and postpones the need for upper eyelid surgery.

Dr. Arthur Perry, who literally wrote a book on cosmetic surgery (Straight Talk About Cosmetic Surgery) and co-hosts the nationally syndicated radio talk show “YOU: The Owner’s Manual,” is a big proponent of eyebrow lifts for the sake of improving the appearance of the eyes. “We have to think of the brow as part of the eye, and start by looking at the position of the brow. We then design the procedure based on that,” says Dr. Perry who, in addition to his media ventures, sees patients in his private practice. Most brow lifts are performed under local anesthesia and/or I.V. sedation. The procedure can take anywhere from 30 minutes to two hours depending on the technique, of which there are many. Traditionally a long incision was made inside the hairline (from ear to ear) and the skin of the forehead lifted to raise the brows. An endoscopic brow lift, on the other hand, allows for small incisions in the forehead and scalp. The brow is then lifted and suspended with stitches.

These days Dr. Perry, who has gone through an evolution with brow lifts, favors a technique called the browpexy. “I do the brow lift through the upper-eyelid—lifting the entire forehead through the eyelid then sewing the eyebrow to the connective tissue that sits on the bone.” This allows Dr. Perry to position the brow higher on the forehead without making an incision in the hairline. The procedure takes about forty minutes, and says Dr. Perry; the stitches dissolve in six months. Other approaches incline at the hairline or just inside it. As with all solutions, there are plusses and minuses with each technique.

Another procedure that Dr. Perry performs on more than half of his patients is called the canthopexy. “It’s like a belt tightening procedure,” says Dr. Perry, with your lower lid acting like a pair of pants. You can pull forever on these ‘pants’ if the belt is tight, but if it’s loose, “down they go.” Consequently, Dr. Perry makes sure the belt is tight. “I lift the position of the lid slightly toward the ear and slightly up in very small movements,” he says. The procedure is not new but has caught on in the past few years, says Dr. Perry.

“Every time I do a lower lid lift I do the canthopexy, or lid tightening,” says Dr. Robert Dryden, a fulltime clinical professor at the University of Arizona School of Medicine, who also runs a private practice based in Tucson, Arizona. “It’s a great procedure. By tightening the lower lids and attaching the muscle of the lower lid to a higher position, it actually helps a fair amount with the bulging fat.”

Dryden also uses surgery to treat drooping upper eyelids, a condition that is caused by any number of things including disease, trauma, or simply the aging process. With this condition, called ptosis, patients can experience difficulty keeping their eyelids open. It can also obstruct the pupil and reduce the patients’ field of vision. “It’s a muscle malfunction,” says Dr. Dryden, and can be corrected by tightening the muscle responsible for elevating the upper eyelid. The procedure takes anywhere from thirty to sixty minutes.

Both invasive and non-invasive procedures and treatments for the aging of the eye area continue to be refined, developed and perfected. But until we reach that holy grail of restoring elasticity to skin, cosmetic surgeons continue to advise you to protect your skin from the sun, especially the area around the eye. It’s important to be using a sunscreen of SPF 30 or higher, every day, even in the winter. And make sure it blocks UVA as well as UVB rays, because it’s the UVA rays that contribute to fine lines. Of course do not smoke and try to deal in a constructive, self-loving way with stress, since both heavily contribute to aging of the eyes.

The Eye Treatment Tools

Today’s cosmetic surgeons are equipped with an ever more sophisticated array of techniques to make your eyes look more youthful. The most effective include:



  • Fractional CO2

Muscle Relaxers:

Cosmetic Surgery:

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