EyeNet Magazine

The Aesthetic Facial Exam
By Marianne Doran, Contributing Writer
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Successful surgeries, beautiful results and happy patients start here.

With their intimate knowledge of ocular and upper facial anatomy, ophthalmologists have an instinctive appreciation of facial aesthetics. Not surprisingly, eye surgeons’ interest in enhancing their patients’ appearance has grown over time, from the eyelids to the surrounding facial structures. Today, with new products and a growing understanding of facial anatomy, the entire face has become the realm of oculoplastic specialists.

“Historically, ophthalmologists were safe and effective surgeons for the upper and lower eyelids,” said Jill A. Foster, MD, associate clinical professor of ophthalmology at Ohio State University in Columbus. “But as aesthetic surgery developed greater levels of sophistication, it became apparent that ophthalmologists could do a beautiful job on the eyelids and the area around the eye, but if they ignored the lower face, the result would not be harmonious because the two parts just don’t fit. For example, if you have someone whose lids and brows are in the position of a 30- or 40-year-old, but the volumetrics of the lower face are those of a 60-year-old, the upper face might look nice, but it would not be the desirable result you were looking for,” she said. “As a natural progression, we are focusing more and more on comprehensive facial aesthetic plastic surgery.”

Today, oculoplastic specialists have an impressive array of procedures and products to correct or improve facial asymmetries, address functional issues such as ptosis and restore a youthful appearance to an aging face. But overall facial harmony is the key to a natural-looking result—and a thorough, meticulous facial exam is where it all begins.



Oculoplastic facial examinations are multidimensional and encompass the area from the collarbones up. One valuable approach is evaluating from the superficial to the deeper layers. Dr. Foster said, “From the physician’s aspect, when you go from superficial to deeper layers, you think about the skin as being the wallpaper—and even if you fix everything beneath the skin, if the skin still has issues that detract from the overall result, you have not accomplished your goal. As a result, you have to look at the intrinsic and environmental age-related changes of the skin.” These changes may include fine lines, wrinkles and pigmentary irregularities; dermal atrophy; and loss of elasticity.

From the outside in. Moving inward from the skin, the oculoplastic surgeon assesses gravitational changes that cause downward descent and laxity of facial ligaments affecting the position and relationships of the brow, the midface and the jowls.

At the deeper tissue levels, it is important to consider the effects of volumetric loss, which may include thinning of the skin, loss of underlying fatty tissue, muscle atrophy and bone loss, said Dr. Foster. These changes can lead to flattening of the projection of the brow and malar eminence, caving in of the lips, and hollowing of the temporal fossa and the superior sulcus.

Dr. Foster said that, as she completes her survey from superficial to deep layers, she considers how each of these components relates to her patient’s concerns. “After I internally synthesize that evaluation, I talk to the patient about my assessment of the skin and facial wrinkles, discussing changes that come from sun damage, like pigmentary variability and loss of elasticity; changes that come from repeated muscle contraction, like the glabellar lines and crow’s-feet; and redundant wrinkles that are magnified by volume loss, like the sleep creases in the cheek.”

From the top down. Many surgeons find it useful to describe their findings from the top down, starting with the forehead and brow region. Dr. Foster said she talks about tissue descent and how the position of the brow and the fat pad beneath the brow affect the appearance of the eyelid. She pointed out that, often, when surgeons talk about doing a brow-lift, they really mean recontouring the brow. “It’s not so much about moving the eyebrow cilia up as it is about making the upper eyelid look better by changing the position of the brow fat pad and the overhang into the upper lid.”

Eyelids and cheeks. Changes in the upper lid may include conditions such as laxity of the skin, protrusion or malposition of the fat in the lid or tendinous laxity with an actual ptosis or droop in the lid. Lower eyelid problems include gravitational issues such as laxity, elasticity issues in the skin and orbicularis, and protrusion or malposition of the fat. Dr. Foster said that the location and herniation of the lower eyelid fat disrupt the smooth contour of the junction between the lower eyelid and cheek. She said that she talks to the patient about “how the positioning of the cheek fat can affect the look of the lower lid or the tear trough area—the indentation between the protrusion of the lower eyelid fat and the bulge of the malar area in the cheek. Transitioning from the lower eyelid to the cheek, we cover midface deflation and descent and how it influences both the lower eyelid and nasolabial fold.”

Lower face and neck. “Next, we discuss the nasolabial folds, the marionette lines and the area around the mouth, talking about volumetric loss and how it affects the shape of the lips and the amount of visible pink lip. We move on to the jowl area, the neck and the chin—pointing out gravitational issues that will need surgical intervention with face-lifting, neck liposuction or neck-lifting techniques—and the importance of volume loss in the anterior projection of the chin to the shape of the neck.”

Only after discussing these features with the patient does Dr. Foster focus on possible therapeutic interventions for the specific concerns of the patient. “Although the patient may choose to intervene for only some of the concerns that I have described, I think it’s important to share a comprehensive overview with the patient prior to honing in on specific procedures.”



Evan H. Black, MD, associate professor of ophthalmology at Wayne State University in Detroit and director of the oculoplastic service at Kresge Eye Institute, underscores Dr. Foster’s key point, saying, “It’s important for ophthalmologists to realize that the eyelids, brows and cheeks are all part of a continuum.”

Dr. Black added further pointers on what to watch for in a facial exam. For example, he noted that what looks like upper eyelid skin may actually be brow skin. “It’s important to differentiate true dermatochalasis from actual brow and forehead ptosis. When we examine the upper eyelids, we are looking at brow position, the demarcation between the eyelid and the brow, and subcutaneous fat that is present in the brow but not in the eyelid. Then we determine the position of the brow relative to the bony orbit.”

A similar situation exists in the lower lids, Dr. Black said. “The lower eyelids and the cheek are obviously connected, so you want to check lower eyelid tension and laxity, look for true herniated orbital fat versus inferior displacement or descent of the cheek fat pad, and assess for fat atrophy at the orbital rim, which can cause a tear trough deformity or a nasojugal crease. While addressing these issues, you want to determine whether you will be dealing with fat repositioning, midface-lifting, tightening of the septum or, in some cases, removal of herniated orbital fat. Your examination of how the eyelid and cheek orient to one another will help determine what type of surgical procedure is best suited to that patient.”



Tanuj Nakra, MD, an oculoplastic surgeon and partner in Texas Oculoplastic Consultants in Austin, said, “Patients often come to the office with preconceived notions from the media or from their friends about what they think they need cosmetically; however, that’s not always what they actually need. I try to analyze the patient’s goals and then determine what treatment they really do need. Part of the initial examination is just gaining an understanding of the patient and being able to suggest something that is positive and useful.”

Educating the patient. “I spend quite a bit of time educating patients about the normal aging process,” Dr. Nakra continued. “Using pictorial examples, I show them the three principal changes of aging: skin changes from the sun; volume loss in the entire face, which affects the eye region in a major way; and gravitational descent. Most patients are focusing on the skin changes and the gravity changes, but they don’t appreciate the volume changes. So I explain how the volume loss affects the eye region. It’s actually quite striking. When you point it out to patients in photographs, then it clicks for them.”

The importance of volume. Dr. Nakra added that significant age-related volume changes occur in the brow fat pad. “You often see the brow hanging low in an older person, or extra skin in the upper eyelid. We are tempted to think that we need to cut that skin out, but the reality is that the volume loss in the brow and forehead causes the descent. Adding volume to the brow is often a much more natural way to rejuvenate the upper eyelid than surgically resecting the ‘extra skin.’ I’m doing a lot less blepharoplasty and brow-lifting in my practice since I started focusing on volume rejuvenation. Options for volume augmentation include both nonsurgical fillers and autologous fat.”


VOLUME: An Enduring Standard of Beauty

Dr. Nakra points out pictures of beautiful women in magazines to illustrate the importance of tissue volume to patients who are seeking cosmetic improvement.

“Women in Vogue and other fashion magazines have so much volume around the eyes,” he said. “And women throughout different ages and in different cultures have applied eye shadow to the lateral eyelid and eyebrow region and blush to the lateral malar area to make these areas look more rounded and sculpted.”

He points to the concept of three-dimensional shading in art, in which you can make a two-dimensional surface look more volumized and have more shape if you shade down below, where the shadow would be. “I believe this is a common denominator in the concept of beauty, and the makeup patterns of different societies illustrate this. It’s sort of an unconscious desire for everyone to want to have more volume in the eye region. That is something that I spend a lot of time explaining to patients.”



John B. Holds, MD, clinical professor of ophthalmology and otolaryngology/head and neck surgery at Saint Louis University, said, “The goal of the initial exam is twofold: to rule out comorbidities that could interfere with surgery and to listen carefully to patients to identify what’s bothering them—the emotional aspects of their concerns—and whether there is a suitable intersection between my capabilities and those concerns.”

Start with the basics. Dr. Holds takes a standard medical history and performs an eye examination, including vision, slit-lamp exam, ocular motility and measures of tear production. Next, he assesses eyelid position and makes specific notes on brow position, prominence of the eyes, degree of upper and lower eyelid fat prolapse, relative excesses of skin and other features.

“Areas of facial lipoatrophy, such as a prominent malar groove, are important, as are facial asymmetries, which I discuss with the patient. Skin examination is essential, as the patient’s pigment type, degree of sun damage and amount of wrinkling will determine treatment options, including topical medications or cosmeceuticals, tretinoin (Retin-A) products, peels of varying depths or various laser treatments.”

Dr. Holds routinely notes features relating to jowling, loss of the cervicomental angle, and other features that would need to be corrected with face-lift surgery. However, he does not perform face-lifts but refers patients to a surgeon who does.

Customizing care. His approach to recommendations is highly individualized and depends on the suitability of the patient for surgery, skin care, botulinum toxin type A (Botox) or fillers and how those align with the patient’s specific desires.  

“Some patients are very focused on one feature, such as sagging upper eyelid skin,” said Dr. Holds. “Often, one must discuss brow-lift surgery in addition to upper blepharoplasty in such a situation. Likewise, it is important to point out prominent fat pseudoherniation in the lower eyelids or other features, even if the patient declines the treatment and seems to otherwise be a good candidate for surgery. Sometimes, treating age-related changes in only one area will create an inharmonious appearance that accentuates the untreated area.

“Working from above downward, I generally consider the advisability of a brow-lift and, if recommended, determine the most suitable approach (endoscopic, pretrichial, mid-forehead or direct), depending on the patient’s hairline, hairstyle and other needs. Upper blepharoplasty surgery may be advisable, and I will assess and discuss the need for treatment of specific fat pads, most frequently the medial, or other concomitant procedures such as a ptosis repair.

“In the lower eyelid, the configuration of the eyelid, lid tone, skin type and a variety of nuances determine whether the patient needs treatment of the skin alone, a dermal filler injection into the tear trough or surgery. Lower eyelid blepharoplasty is the most complex routine cosmetic procedure in this area, with the most variations, subtleties and potential pitfalls.”

Fat transfer techniques. Dr. Holds said that he is increasingly using autologous fat transfer techniques, primarily to the midface but also to the pre-jowl sulcus, forehead and brow to reinflate a sunken midface. Fat transfer involves performing a manual aspiration of fat from the abdomen or thigh, separating the fat from other fluids and lysed cell components, and carefully reinjecting the fat into the desired area.

In suitable patients, this procedure creates a better foundation and a smoother, less aged appearance in the midface. Disadvantages include variable resorption and cases of under- or overcorrection.  Such patients usually need a bit of dermal filler, such as Juvéderm or Restylane, postoperatively, but they will achieve a much better result with only a small amount of filler.


The Keys to Achieving a Natural Look

Dr. Black offers a few simple tips for achieving a natural look.

Never overdo things. For example, if you are thinking about removing fat, consider repositioning the fat and tightening up the septum with an orbicularis-septum sling instead. And if you do remove some fat, be sure not to take too much—you don’t want to hollow out the patient’s eye socket and create a “double-circle” appearance, in which the eyeball appears to sit in a bony orbital rim because not enough fat remains.

Watch the brow in forehead-lifting. You want to keep a natural contour to the brow. In a woman, the nose curves up into the brow in a smooth C shape. A man’s brow is straighter, forming more of a T shape. Be careful not to inadvertently masculinize or feminize the forehead, depending on the gender. Dr. Black prefers to use a brow fixation device that provides broad fixation with a smooth contour rather than devices that rely on screws or one-point fixation.

Ensure a good temporal lift. It is important to get a subtle temporal lift of the brow because brow descent results in crow’s-feet and even some drop-down in the lateral canthus and upper cheek area. “With the lower lids, I either remove fat if the orbital fat is excessive or do a skin-orbicularis-septum sling procedure, in which the structures that keep the fat in the eye socket are just tightened up, and some skin may be removed. It is always important to think about lower eyelid laxity when you are doing lower lid procedures because it is very disturbing when lower lid surgery causes lateral scleral show or retraction of the eyelid, creating a “had too much surgery” appearance. The lid margins should still remain in the appropriate position while the wrinkles and fat are tightened.

Fillers and Botox: less is more. Be careful not to overcorrect or overfill lips or creases. You certainly do not want to paralyze someone’s face with Botox and give him or her a complete absence of facial expression. The goal is to soften and relax the wrinkles with Botox and efface the wrinkles with filler.



Many general ophthalmologists are already performing blepharoplasty, as their patients are not interested in extensive procedures but are bothered by overhanging eyelid skin. And if the lid causes functional problems, Medicare will reimburse for the procedure.

For ophthalmologists who are tempted to expand further into cosmetic procedures, Dr. Foster encourages them to get the appropriate training and begin with whatever they feel most comfortable. “Ophthalmologists should be as comprehensive as possible in taking care of their patients as long as they have the appropriate background, training and skills to accomplish this.”



EVAN H. BLACK, MD Associate professor of ophthalmology at Wayne State University and director of the oculoplastic service at Kresge Eye Institute in Detroit and partner at Consultants in Ophthalmic and Facial Plastic Surgery in Southfield, Mich. Financial disclosure: None.

JILL A. FOSTER, MD Associate clinical professor of ophthalmology at Ohio State University in Columbus. Financial disclosure: Consults for Allergan, Medicis and Merz.

JOHN B. HOLDS, MD Clinical professor of ophthalmology and otolaryngology/head and neck surgery at Saint Louis University in St. Louis, Mo. Financial disclosure: Consults for QLT Phototherapeutics.

TANUJ NAKRA, MD Oculoplastic surgeon and partner at Texas Oculoplastic Consultants in Austin. Financial disclosure: None.


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