This story has been medically reviewed for accuracy by Nashville, TN board-certified oculoplastic surgeon Dr. Brian Biesman on November 3, 2020.
Eyelid surgery is consistently ranked among the top five cosmetic surgical procedures in the country, with roughly three-quarters of partakers typically checking the over-50 box. As with every aspect of life, however, COVID-19 is reportedly upending standard stats by reshaping our surgical preferences and priorities. While we won’t see hard data reflecting the pandemic’s true influence on 2020 procedures until sometime next spring, surgeons’ social media posts and the candid conversations we’ve had with doctors provide a wealth of anecdotal insights.
“Since we came back after the coronavirus shutdowns, I’ve had a huge increase in the number of younger people I’m seeing [for eyelid surgery],” says Dr. Jessica Lattman, a board-certified oculoplastic surgeon in New York City. She estimates that 60% of the patients she’s treated for eyelid issues since reopening have been in their late 20s, 30s, or early 40s. With mandatory masks thrusting eyes into the spotlight and WFH stints doubling as downtime, there has, perhaps, never been a better time for blepharoplasty.
While some of the eye issues patients are aiming to improve have bugged them for as long as they can remember, others have only recently captured their attention. “I’m seeing teenagers and young adults in their 20s and 30s who are aware of asymmetries of their eyelids,” says Dr. Flora Levin, a board-certified oculoplastic surgeon in Westport, Connecticut. “While the vast majority of people’s faces are not symmetric, there can be obvious congenital asymmetries or smaller ones that are just bothersome.” Oftentimes, such imbalances are more striking in selfies and on video calls than in person, particularly when one is looking down at a device. “Relative to the past,” she adds, “we’re spending more time analyzing our faces and becoming more aware of things that we may not have otherwise noticed.”
Eyelid surgery will always be a gold-standard solution for the redundant skin, lax muscles, and sagging fat pads that come with age—but in our new normal, where being close-up ready is an unspoken job requirement, the procedure is proving to be a reliable fix for a slew of age-irrelevant eye-area concerns. Ahead, the top issues surgeons are tackling.
Hooded upper eyelids
Heavy upper lids aren’t always a consequence of age or gravity. Dr. Levin sees them in plenty of young folks who are simply “born with these facial features,” she says. Genetically low-set eyebrows often exacerbate the hooding.
Dr. Lattman notes the same: Patients are “coming in saying, ‘My eyes have always been like this, and I’ve always wanted a more open look.’” Beyond giving the eyes a sleepy feel, that bunchy skin fold dominates the top lid—the swath of skin doctors call the eyelid platform—leaving little space for makeup and disturbing whatever color does get applied. This is, in fact, what drives many young women to upper-lid surgery. “Eye-makeup smudging is a common complaint patients hope blepharoplasty will alleviate,” says Dr. Carolyn Chang, a board-certified plastic surgeon in San Francisco. And indeed, removing excess eyelid skin smoothes the canvas and obviates the rubbing and erasing of makeup.
Having a blepharoplasty earlier in life is also preventive, Dr. Chang adds, “enabling patients to notice less aging over the next decade.”
Under-eye bags
“On the lower lids, there are definitely a lot of patients who, since their teens, have had bags under their eyes,” notes Dr. Levin. “The way I describe it to patients is that the eyeball sits in a cushion of fat inside the orbit. A structure called the orbital septum holds the fat back, like a pair of Spanx.” Some folks are born with a small defect in the septum—think of it like a tear in the fabric or a split seam—which allows the fat to bulge through, forming the under-eye bag.
Compounding matters, the protruding fat oftentimes casts a shadow directly below it. Most often, dark circles are caused not by an actual darkening of the skin but “by shadows that exist because the light from above is lost in the valley of the eyelid contour issue,” explains Dr. Lattman. “The shadow can be caused primarily by a loss of volume, such as in a tear trough, or it can be caused by a bulge of fat, which makes the valley underneath it look dark.” Generally speaking, when dark circles are caused by bulging fat, “if we surgically correct the contour problem, the dark circles go away,” she adds.
When bags are small and accompanied by some degree of adjacent hollowing, hyaluronic acid filler can sometimes be injected around the puff, to help level out the area. “We can try to hide the bag by raising the valley to meet the peak, or bag,” says Dr. Levin. But if conditions aren’t ideal, she warns, “this can end up looking unnatural and obviously ‘done.’” Eyelid surgery, on the other hand, “corrects the actual problem by removing the bag and improving the hollowness via the use of the patient’s own fat, either from the eyelid or the abdomen.”
Droopy eyelids and asymmetries
“I see this all the time in twenty- and thirtysomethings, where someone is born with a little bit of droop, or ptosis, on one eye,” says Dr. Lattman. “It’s usually not bad enough to have required correction in childhood or to hinder their vision, but they’ll tell me it’s been driving them crazy their whole life.” In rare cases, the affected lid naturally carries a lot of extra heavy skin.
Ptosis is usually the result of a weakened eyelid muscle, explains Dr. Levin. It can be a congenital trait or occur following trauma or significant eyelid swelling. There also seems to be a link between ptosis and contact lens wear—albeit a somewhat nebulous one. “The truth is that we don’t know for sure [how contacts contribute],” she adds. “It may be the [repetitive] pulling on the eyelid, to put lenses in and take them out.” While ptosis is more common among lens wearers, she notes, it’s still a small percentage who experience the drooping.
Often performed at the same time as an upper blepharoplasty, which removes excess skin and possibly fat, “ptosis correction tightens the eyelid muscle, to lift the lid up and create a more open look to the actual eye, so you can see more of the iris,” Dr. Levin explains. Since ptosis commonly affects only one eye, it creates an inherent asymmetry. Moreover, “if someone is born with congenital ptosis, they often don’t have a lid crease on the side with the ptosis, because their levator muscle, which opens the eye and creates that crease, did not develop normally,” adds Dr. Lattman. In such cases, “the levator muscle is reattached to the top of the tarsus, which is kind of like the skeleton of the eyelid, and the lid crease resumes a normal position.”
Monolid eyes (no lid crease)
An absent eyelid crease isn’t always a developmental anomaly—for certain Asian groups, it’s a standard ancestral trait. The anatomy of the East Asian eyelid is unique from that of other ethnicities, notes Dr. Levin: “There may be no eyelid crease, or it may be very low, poorly defined, or incomplete,” leaving a short or imperceptible platform above the lashes.
In 2020, these differences are celebrated hallmarks of beauty and individuality—yet there are still some who want to tweak the proportions of their lids. “I see a lot of young Asian patients, mostly women, who want to create a double eyelid or a lid crease,” says Dr. Lattman.
Plastic surgeons aim to do this—while preserving the Asian character of the eyes—by modifying the lid-lifting levator muscle. Again, “that’s the muscle helping to create the lid crease,” says Dr. Lattman. “There are little fingers of that muscle that come out and attach to the skin, so when you open your eye, the muscle pulls the lid crease in.” In some Asian patients, however, the muscle doesn’t reach through to the skin. But by using sutures, surgeons can “make those little attachments to the muscle, to give what’s called a dynamic crease—meaning it’s there when the eyelid is open and disappears when the eyelid is closed,” she says.
Not every surgeon performs this procedure, it’s worth noting. “A double eyelid fold creation is designed to Westernize an Asian eye,” says Dr. Chang. “Patients ask me about it quite a bit—I guess because I’m Asian—but I don’t currently offer this routinely, because I generally stick to procedures that respect and enhance one’s natural anatomy and features.”
