Surgery of the gaze
Integral treatmentintegral

Expression of the face
When assessing the face, the gaze is considered to be very important; eye bags and excess of eyelid skin are not the unique responsible for tired looking gaze.

Many aspects can spoil and make the gaze, the expression of our face, old. For that reason, the shape and the position of the eyebrow are very important (dropping eyebrows and curved downward make them look sad), the space between the eyebrows (frown) with two deep vertical wrinkles (looking bad tempered), excess of skin in upper eyelid (giving tired looking appearance and complete opening of the eyes is interfered due to this blepharochalasia causing a sad looking gaze). The excess of fat (eye bags) in inferior eyelids shows lack of sleeping hours or too much nightlife. Half closed eye with a downward axe in association with wrinkles around the external canthus, radially distributed (crow’s feet), contribute to create that sadness and aging aspect.

New: Integral treatment of the gaze. For that reason, global treatment of this area is mandatory, analyzing each feature, but scheduling a treatment combining all these elements. We present our technique through one single incision in the upper eyelid, which is hidden within the eyelid fold. From this approach, we can treat dropping eyebrows, the wrinkling within the space between the eyebrows, eye bags, excess of eyelid skin, crow’s feet and the axe of the eye. The final goal is to achieve global rejuvenation of the area adding youth and lightness to the gaze.

The novelty of this integral treatment performed in our Institute is that through one single incision placed in upper eyelid, carefully hidden within the eyelid fold, and a second incision placed within the mucosa (conjuntiva) of inferior eyelids, we can treat properly all these features.

Surgical techniques
Every patient is assessed individually, establishing the personal needs in each case. More often used surgical techniques included in the surgery of the gaze are described herein.

Upper blepharoplasty
At this level, skin excess is removed in an elliptical shape, placing the scar coinciding with upper border of the tarsal plate of the upper eyelid. In this way, the scar coincides with eyelid fold becoming inconspicuous. Eye bags have to be removed when needed, the internal and middle fat pads, being very conservative when performing middle fat pad removal, considering that overresection leads to skeletonized eye.

Inferior blepharoplasty
We perform the inferior blepharoplasty through transconjuntival approach; it means through the mucosa lining the inferior eyelid avoiding skin incision. A contact lens is placed to protect the eye and the cornea, reaching the fat pads through the mucosa, always below the inferior border of the tarsal plate to avoid its injury. After identifying the three fat pads, they are removed. Sometimes the exceeding fat from the internal fat pad can be transposed to correct the tear trough (eyebath).

Any surgical procedure involving resection of lower eyelid and its orbicularis muscle is avoided which is crucial to avoid scleral show and round shape eye. When excess of skin is present within the lower eyelid, its resection is performed through a small incision below the eyelash preserving orbicularis muscle. It means that fat pads are removed through transconjuntival approach and the excess of skin is removed externally, being very conservative, only when a huge amount of skin is present.

Elevating the axe of the eye
In those patients with an axe of the eye forming a 0 degree or even negative angle with the horizontal plane, this axe may be elevated to rejuvenate the gaze performing what is called cantopexy. We perform conservative cantopexy through suspension of the lateral canthal ligament of the eye. We work on the superficial sheet of the ligament, which is lax, placing a stitch anchored into the lateral orbital rim periostium. This stitch is internal and cannot be seen from outside. All this procedure is performed through the upper blepharoplasty incision.

Corrugator and Procerus muscles
These muscles are managed from the upper eyelid incision during upper blepharoplasty. Very delicate dissection must be performed to avoid supratrochlear and supraorbital nerve injury. After being identified, a partial myectomy (removal of a portion) of the muscles is performed. Wrinkleless and clean space between the eyebrows is obtained, resulting in a more lightness in this area, just from an incision placed within the upper eyelid.

Crow’s feet
To treat the wrinkles in the lateral canthus of the eye, the best outcome is achieved with botulinum toxin (Vistabel) injected radially drawing a triangle with the base placed laterally, just 20 units in each side. We also inject 5 units in the tail of the eyebrow, resulting in a pulling effect of the tail as contraction of the orbicularis muscle is weakened at this level.

Every single element is explained in following sections, but taking in account that is the sum of them and not individually that makes up the general aspect of the gaze of any person:

Eyebrow
At this level, in women, we must consider its orientation and position related to orbital bony rim. Very especially, the outer third or also named tail of the eyebrow becomes important. Its ideal position in women is localized lightly above the lateral orbital rim. This eyebrow position is influenced by the antagonistic action of two muscles: frontal muscle elevates the external portion of the eyebrow and the contraction of orbicularis muscle of eyelids depresses the eyebrow.

The equilibrium between the forces generated by both muscles determines the position of the tail of the eyebrow; predominance of orbicularis muscle or lack of frontal muscle action results in a depression of the outer third of the eyebrow. When the external third of the eyebrow is depressed and does not appear slightly above the orbital rim, a sad appearing and old looking gaze is produced.

Space between the eyebrows (or frown)
Represents one of the most expressive areas of the face. This fact is due to the action of contraction and relaxation of corrugator and procerus muscles; its contraction produces frowning. The action along a lifetime and getting used to frown produces two vertical wrinkle lines in this space that can be permanent. The juvenile frown is free of wrinkles and plain, while the presence of wrinkles and maintained muscular contraction provides an old looking appearance.

The axe of the eye
We can trace an imaginary line from the internal canthus to the external canthus of the eye. This line constitutes the axe of the eye. This axe varies its angle in relation to the horizontal plane during our life evolving as follows: Axe elevated 10 degrees from the horizontal plane: this is characteristic of young people; Axe at 0 degrees: characteristic of middle age person; Axe –10 degrees: characteristic of old age.

According to this information we realize that a slightly elevated axe from the horizontal plane is characteristic of young people and provides lightness and youth to the gaze. On the other hand, if it is negative (depressed) produces an old looking appearance.

Variation of this axe with aging is due to anatomical structure of external canthus. This canthus keeps its position by the presence of a ligament called external canthal ligament; another internal canthal ligament exists. The external canthus ligament has a deep component, which is stiff, but its superficial component is lax. With aging, the superficial component weakens losing tension progressively and the axe of the eye varies its angle causing aging gaze. This depression comes along with excess of skin in the area and depression of the tail of the eyebrow as well.

Intraorbital fat pads
The eyeball is surrounded by fat tissue inside the orbit playing an important role protecting the eye and facilitating the function of muscles that mobilize the eyeball. This fat is contained inside the orbit by fibrous walls. With aging, these fibrous walls begin to lose their turgidity and the fat tends to protrude and becomes noticeable in the eyelids from outside. In upper eyelids, two bags called internal and middle bags appear while the lacrimal gland occupies the external corner, and in lower eyelids three bags appear, internal, middle and external ones.

Skin excess in upper eyelids
With aging, skin laxity develops in upper eyelids resulting in skin excess which is characteristic of aged faces, enhanced by the presence of fat pads (bags). Youthful eyelids present no skin redundancy nor fat pad protrusion.

Skin excess in lower eyelids
As time goes by, skin excess is present sometimes in lower eyelids, but at this level the presence of fat pads (bags) is more characteristic. Youthful eye presents a smooth and turgid lower eyelid without any noticeable fat pad.

External canthal wrinkles (crow’s feet)
The contraction of orbicularis muscle, which is a round shape muscle adhered to the skin, produces wrinkles that become deeper and permanent with aging. These wrinkles are called expression lines of crow’s feet.