However, eyelids are only a part of the entire area called the orbital region of the face—upper and lower eyelids, forehead and brow, and upper regions of the nose. After medical and esthetic assessment and discussion with the surgeon, the patient and surgeon may agree on the need for additional procedures in order to meet the patient's esthetic goals—for example, a forehead/brow lift if severe "frown lines" accentuate the appearance of aging .

The dermatologic surgeon's assessment of the eyelids will include medical history and examination to assure that changes in eyelid tissue are age-related and not due to an underlying medical condition. The dermatologic surgeon may recommend an examination of the eyes by an ophthalmologist to detect any eye conditions such as glaucoma or retinal detachment that could rule out or postpone blepharoplasty.

Alterations in the eyelid associated with aging vary from person to person, depending on such factors as heredity, smoking history, habits of facial expression, and general health. Age-associated changes in the eyelids occur as early as age 30 to 40 years in some persons:

• The skin and underlying tissue thins and loses elasticity

• The muscle responsible for voluntary and involuntary "blink" relaxes, loses tone, and descends to cause a "sleepy" look

• Supporting structures of the aging eyelid relax and become less supportive;

• Fat tissue in the eyelids which is normally a "shock absorber" for the eye prolapses (falls down) from normal position into pockets in upper and lower eyelids, giving eyelids a "baggy" appearance

• In some instances a displaced lacrimal (tear) gland may add to puffiness of the upper eyelid

Gravitational aging changes can occur in the upper eyelid, lower eyelid, or both. It is very important for the patient to explain what changes in the eyelid(s) he/she feels should be corrected, and to discuss these with the dermatologic surgeon in both medical and esthetic aspects. In some instances a patient may initially want a correction that should probably not be carried out—for example, crinkles that appear in lower eyelids when the patient smiles may be a personality-enhancing trait that should be retained rather than removed.

After the patient and dermatologic surgeon agree on the details of blepharoplasty, the surgeon will plan the procedure. Blepharoplasty is performed in an outpatient setting using local anesthesia. Depending upon the agreed-upon outcome the blepharoplasty may include any combination of:

• Removal or revised placement of fat in the eyelid(s);

• Removal of redundant or sagging skin;

• Surgery at the angle of the eyelids (canthopexy) to restore shape and tone; and.

• Surgical removal or reshaping of muscles to restore muscle tone.

The rejuvenating effects of blepharoplasty tend to be long-lasting. The procedure can have the effect of literally restoring a patient's personality.

Gravitational Aging and the Forehead/BrowA forehead/brow lift may be considered for forehead/brow ptosis (relaxed or falling tissue). While the procedure may be carried out alone, it is frequently done in combination with blepharoplasty when blepharoplasty alone cannot improve age-associated changes in the eyelid-forehead/brow region. Upper brow positioning can be a major factor in accomplishing the full positive effects of blepharoplasty. A forehead-brow lift also helps correct forehead creases in the triangular area between eyebrows and root of the nose, folds at the root of the nose, and even may correct drooping of the tip of the nose. The dermatologic surgeon will recommend the procedure(s) best suited to the individual; the dermatologic surgeon and the patient must agree upon the procedures to be performed and goals to be achieved.