Published in Oculoplastics

Introduction to Surgical Periocular Rejuvenation

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7 min read
Discover surgical periocular rejuvenation techniques that, with communication and an experienced surgeon, can lead to increased patient confidence.
Introduction to Surgical Periocular Rejuvenation
There are several procedures that oculofacial plastic surgeons are trained to do which may improve the patient’s periocular appearance. We know that humans spend most of their time interacting with others by looking them in the eyes.
The tired appearance that may occur from drooping eyelids, baggy eyelids, or simply sad-appearing eyes can lead to a loss of confidence in social interactions for our patients. Fortunately, we have several evidence-based surgical techniques that may help reverse those signs of aging.

Blepharoplasty

An oculofacial plastic surgeon's most frequently performed procedure is the upper and/or lower eyelid blepharoplasty. Upper blepharoplasty is often done to improve vision. However, it can also be a rejuvenating procedure. In contrast, lower eyelid blepharoplasty is almost exclusively done to improve cosmetic appearance.1

Upper blepharoplasty

In some cases, the upper blepharoplasty may be done with insurance coverage, but this is typically only in cases where three essential conditions are met:
  1. The eyelids must affect the patient’s activities. For example, the patient may have reduced peripheral vision, making driving difficult. The doctor must write a note explaining how the vision is affected.
  2. Visual field testing must be completed and show a significant improvement with lifting the eyelids.
  3. Full-face photos must be taken in standardized views, demonstrating excess skin rolling over the lashes and blocking the pupil from an oblique and frontal view. These photos must also be submitted to insurance companies to verify the excess eyelid skin.
Upper eyelid blepharoplasty is typically done by removing excess upper eyelid skin with a scalpel, electrocautery, or CO2 laser. The advantage of laser blepharoplasty is that it has been shown to reduce postoperative bleeding and bruising.2
Excess skin is removed, and approximately 20mm of skin is left behind, measured from the inferior border of the brow to the eyelid margin in approximately the plane of the pupil. This ensures that the patient can easily close their eyes after surgery. Typically, only skin is removed, but at times orbital fat transposition or sculpting may be performed.
Figure 1 features a patient before and after receiving an upper eyelid blepharoplasty.
Upper Blepharoplasty
Figure 1: Image provided by Paul Phelps, MD, FACS.

Lower blepharoplasty

Lower blepharoplasty is more challenging and, in most patients, is best addressed with multiple modalities. Oculofacial plastic surgeons most frequently use a transconjunctival approach below the level of the tarsus to address the lower lid fat pads.3 Depending on the approach and the patient, it is more challenging to get a patient perfectly comfortable for lower eyelid blepharoplasty with local anesthesia alone, unlike upper eyelid blepharoplasty.
Many oculofacial plastic surgeons will recommend that lower blepharoplasty be done with MAC or general anesthesia to improve patient comfort.

However, deeper sedation may be an unwarranted risk in certain patients, and lower eyelid blepharoplasty carries a much higher risk of retrobulbar hematoma, which may lead to blinding compartment syndrome if not quickly identified and treated with a lateral canthotomy and cantholysis.

With the correct patient selection, fat excision alone can improve the lower eyelid bags. This approach has relatively low rates of lower eyelid retraction compared to subciliary skin excision blepharoplasty.4
Fat transposition may be undertaken in cases of a prominent medial tear trough or as an alternative to fat excision alone. CO2 laser resurfacing is frequently combined with lower eyelid blepharoplasty to improve fine lines and wrinkles, as well as reduce the risk of postinflammatory hyperpigmentation which can occur after surgery.

Ptosis repair

Upper blepharoplasty can be combined with an internal ptosis repair to correct mild asymmetries, which may be bothersome to the patient interested in periocular rejuvenation.
By taking a photo of a patient in the primary position before a phenylephrine drop is placed, then again after a phenylephrine drop is placed in the affected eye, the clinician can demonstrate to the patient the expected outcome of an internal ptosis repair. As worsening dry eyes and asymmetry are common findings in patients who undergo ptosis repair, patients should be carefully selected.
Figure 2 shows a patient before and after right ptosis repair.
Right Ptosis Repair
Figure 2: Image provided by Paul Phelps, MD, FACS

Browpexy

When considering upper blepharoplasty, the surgeon should also evaluate the brow position. The lateral brow will often descend somewhat after excess upper eyelid skin is removed.
To address this, a permanent suture may be placed between the sub-brow fat pad and the periosteum of the frontal bone approximately 10mm above the orbital rim at the level of the lateral 1/3 of the brow. This ancillary operation can greatly enhance upper blepharoplasty results.5

CO2 laser resurfacing

When excess fat from the lower lid is removed, it can deflate like a balloon. This is best addressed with laser resurfacing for two main reasons:
  1. The alternative of removing excess lower eyelid skin from below the tarsus can leave a scar and result in lower eyelid retraction.
  2. By resurfacing the lower eyelid with a laser, the texture and quality of the skin can be improved while also tightening and reducing wrinkles.
Laser treatments stimulate collagen production and are one of the most effective treatments for dark circles around the eyes. The main downside to laser resurfacing is prolonged redness, which may occur. Also, special care must be taken to avoid UV light for 3 months after surgery to avoid hyperpigmentation.
Oftentimes antivirals will be prescribed to patients undergoing laser resurfacing to help minimize the chance of a postoperative herpetic infection, which is rare but can be devastating if it occurs. Chemical peels may be a reasonable alternative in patients with darker skin color.

Fat grafting

Perhaps the most controversial aspect of periocular rejuvenation is fat grafting. This technique utilizes the harvesting of fat from other sites, such as the abdomen or flank, to add volume to the face. Fat is typically purified with a centrifuge or gravity and then passed through “fat sizers” to reduce the size of the collected fat from larger particles into micro fat.
The micro fat particles can then be injected with a cannula into the mid-face, tear trough, and other areas which require volumization. The value of this approach is that grafted fat may help to add volume where needed. Also, the stem cells within the fat have been shown to improve skin quality.6

Alternatively, the amount of fat that survives grafting is variable and, therefore, several touch-up procedures may be required.

Fat grafting is more frequently associated with the ophthalmic artery's embolization than hyaluronic acid fillers or triamcinolone, which are also both associated with this risk.7

Conclusions

As evident from the discussion above, many techniques exist that are reproducible in experienced hands and can lead to greatly improved patient confidence and self-esteem. The mastery of periocular rejuvenation requires a holistic approach to evaluating the patient and letting the patient guide you in their goals and aims. Most importantly, the surgeon must be capable of mixing and matching the right combination of treatments for the aging eyelids of their specific patient.
Surgery is best avoided in patients with unrealistic expectations. Even in the best hands and with the most compliant patients, the possibility of complications should be discussed thoroughly before surgery.
  1. Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, Mawn LA. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011 Dec;118(12):2510-7. doi: 10.1016/j.ophtha.2011.09.029. Epub 2011 Oct 22. PMID: 22019388.
  2. Morrow DM, Morrow LB. CO2 laser blepharoplasty. A comparison with cold-steel surgery. J Dermatol Surg Oncol. 1992 Apr;18(4):307-13. doi: 10.1111/j.1524-4725.1992.tb03676.x. PMID: 1560155.
  3. Murri, Michael, et al. "An update on lower lid blepharoplasty." Seminars in Plastic Surgery. Vol. 31. No. 01. Thieme Medical Publishers, 2017.
  4. Zarem, Harvey A., and Jeffrey I. Resnick. "Minimizing deformity in lower blepharoplasty: The transconjunctival approach." Clinics in Plastic Surgery 20.2 (1993): 317-321
  5. Zandi, Alireza, Behzad Ranjbar‐Omidi, and Mohsen Pourazizi. "Temporal brow lift vs internal browpexy in females undergoing upper blepharoplasty: Effects on lateral brow lifting." Journal of Cosmetic Dermatology 17.5 (2018): 855-861.
  6. Mojallal, Ali, et al. "Improvement of skin quality after fat grafting: clinical observation and an animal study." Plastic and reconstructive surgery 124.3 (2009): 765-774.
  7. Xing L, Almeida DR, Belliveau MJ, Hollands H, Devenyi RG, Berger A, Gale J. Ophthalmic artery occlusion secondary to fat emboli after cosmetic nasal injection of autologous fat. Retina. 2012 Nov-Dec;32(10):2175-6. doi: 10.1097/IAE.0b013e31826a6897. PMID: 23064430.
Paul Phelps, MD, FACS
About Paul Phelps, MD, FACS

Dr. Paul Phelps, MD, FACS, is a native of the Midwest, the son of an electrical engineer and a primary school teacher. He completed his undergraduate degrees in Chemistry and Neuroscience at the University of Minnesota in Minneapolis. With a strong interest in world cultures, Dr. Phelps spent his junior year abroad at the University of Lancaster, England, studying physical chemistry and history. After graduation, he worked for two years as a Research Associate at MIT.

Dr. Phelps attended medical school at Drexel University College of Medicine. He then spent another year studying abroad, this time as a Fulbright Scholar at the world’s most productive eye hospital in Madurai, India. It was at this time that Dr. Phelps was first exposed to Ophthalmic Plastic and Reconstructive Surgery. This experience resulted in his first case report describing a new entity within oculofacial plastic surgery.

Dr. Phelps completed his residency at the John H. Stroger, Jr. Hospital of Cook County, gaining significant surgical experience within ophthalmology and oculofacial plastic surgery. After residency, Dr. Phelps completed a fellowship with Daniel M. Albert at the University of Madison, Wisconsin, in Ophthalmic Pathology. Dr. Phelps then completed a two-year Oculofacial Plastic Surgery Fellowship (ASOPRS) with Dr. Dale Meyer in Albany, New York. During his fellowship, he was awarded an EyeWiki Contest Award from the American Academy of Ophthalmology (AAO) for his publication on Canalicular Trauma.

In his four years as an Attending Surgeon at NorthShore University HealthSystem, Dr. Phelps was honored to teach both ophthalmology and plastic surgery residents of The University of Chicago. He was awarded two grants to teach a simulation lab course on Functional and Cosmetic Oculofacial Plastic Surgery and received a Physician Excellence Award by the operating nursing staff. Dr. Phelps was also promoted from Clinical Assistant Professor to Clinical Associate Professor and authored numerous publications during his tenure at NorthShore.

As the founder of Chicago Oculofacial Plastic Surgery, Dr. Phelps is excited to provide the highest quality for his patients and continue his service and academic missions in Chicagoland. He spends his free time exploring the excellent restaurants and sights in the city and spending time with his wife and son. In addition, Dr. Phelps is an avid skier and lover of travel and reading.

Paul Phelps, MD, FACS
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