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To compound the problem, many patients have come to expect (and demand) aggressive upper eyelid surgery to raise the crease and create a high platform of exposed skin on which to apply cosmetics.
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Others may be dissatisfied if even the slightest remnant of noticeable fat remains after treatment of their lower eyelid bags and request a "touch-up".
Under such pressure, it is not surprising that many obliging surgeons are unwittingly contributing to an epidemic of post-blepharoplasty hollowness.
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• Fat
Some bulging of normal upper or lower orbital/eyelid fat develops in many people with advancing age. Judicious thinning of clearly excess fat by an experienced practitioner with a tender touch is unlikely to cause noticeable hollowing. Using newer techniques, it is possible to return bulging fat to the orbit by repairing a weak orbital septum.
Aggressively excising fat or repositioning fat into the tear trough, on the other hand, will almost predictably cause immediate or late-appearing depletion of orbital volume. Adequate eyelid inflation from deep orbital fat is a vital sign of youth. Take it away and the face radiates an aura of "illness" and "age."
Not uncommonly, the lower eyelid may undergo spontaneous "spotty" absorption of orbital fat accompanied by gradual thinning of the overlying skin, changes that serve to "unveil" any remaining islands of normal intact fat. Such eyelids demonstrate areas of apparent (but false) bulging. If this little remaining normal fat is misdiagnosed as excessive and removed during blepharoplasty, the eyelid will be hollowed even further. To view an example, see Video Case Study Two.
There seems to be some confusion regarding a "new" procedure employing electrical energy to melt away orbital fat. Fat melting during blepharoplasty was first described over twenty years ago. As with any method of fat removal, it, too, can result in significant eyelid hollowness. Whether too much fat is dissolved or excised doesn't matter; its effect on orbital volume is the same.
Recently, we have seen three patients in whom substantial orbital fat loss occurred shortly after the delivery of non-invasive energy (nitrogen plasma, radiofrequency) used to treat skin wrinkling and discoloration on and around the eyelids. Whether the use of such energy devices can cause fat loss is unproven, but correlation in each case was striking. Photos
• Skin
While it is not at all uncommon for patients to request aggressive upper skin and fat removal to create a higher eyelid crease, it is important to appreciate that most young people do not possess high creases. Too high a crease is a clear sign of either aging, bulging eyes, or overdone surgery. It is not a youthful feature.
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In patients with prominent eyes, a frequent but preventable surgical misstep is the removal of a tiny roll of upper eyelid skin that seems to develop with advancing age. In fact, this roll is not a sign of skin excess and removing it will not improve appearance.
For more, view a Video Commentary
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• Muscle
In years past (and present), it was not (and is not) uncommon for surgeons to excise large amounts of upper eyelid orbicularis muscle or perform incisions that compromise the nerve supply of the lower orbicularis muscle. In fact, no trimming of or incision into the eyelid's closing muscle is almost always preferable and will not only help to retain the natural fullness that is a sign of good health and youth but also prevent possible support, volume depletion, and closure problems with advancing age.
• Brows
If the upper eyelid is already naturally short on fat but the brow sits low and tends to camouflage this trait, undergoing brow lift will expose the hollowed area. More on hollowness and brow lift
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