History

Rejuvenation of the upper third of the face involves surgery of the brows and upper and lower eyelids. BLEPHAROPLASTY is a term that was coined in 1818 as ‘surgical modification of the eyelid’ and was used at that time to repair deformities caused by cancer of the eyelids. It wasn’t until the 1920’s that these techniques started to be used for cosmetic purposes. In the upper eyelids removing excess skin is the mainstay of treatment. While originally it was thought this was necessary in the lower eyelid as well, we now know caution must be taken to avoid pulling the lower lid margin down away from the eye. Often the skin under the eye can be tightened with chemical peels without the need for surgery. A tightening of the lid margin itself is sometimes also necessary to avoid a saggy lower lid margin. In the mid 1900’s it was discovered that the puffiness around the eyes was caused by fat ‘herniating’ (pseudoherniation) through a weakened support system. While sometimes this fat is resected, we have realized that ‘skeletonizing’ the eyelids is not attractive and a conservative amount of fat should be removed, and sometimes fat from other parts of the body can be added to the area around the eye providing a more youthful fullness. In the early 1990’s we realized that we can take the fat in the lower lid and reposition it over the hollow bony orbital rim providing a smoother and more youthful contour. In modern times, it is estimated that 100,000 people have this cosmetic procedure done every year.

The brow often also needs to be restored along with surgery of the eyelids. As we age, the brow often descends, especially laterally (towards the outside) resulting in compensatory brow raising and forehead lines and an unaesthetic brow shape. The first brow lift was done in the 1930’s and was performed using an incision in a wrinkle in the mid forehead and, shortly after that, directly above the brow. Other approaches have also described including a ‘coronal lift’ requiring an incision behind the hair line from ear to ear. This lifted the brow but caused significant numbness of the forehead and scalp and raised the hairline. A modification of this approach, called the pre-trichial approach, can be used to lower the hairline and is still sometimes used today for patients with high hairlines. The endoscopic brow lift was first described in 1992 and is the preferred technique used today by many surgeons because of the limited incisions hidden within the hairline and low risk of forehead numbness. We now understand that it is not just the height of the brow that matters, but also--and sometimes more importantly--the shape. As the shape of the brow changes, so does our expression. Because of this realization, sometimes the brows don’t need to be lifted, but rather contoured. Hair transplantation which has more commonly been performed since the late 1990’s can restore youthful appearing full and shapely eyebrows.