Dr. Little’s Techniques
Surgical Techniques for the Eyes
Even before the age when patients first consider facelifting, most have lost considerable volume from around their upper and lower eyelids. Dr. Little has found that the replacement of this lost volume is more important in most patients than conventional eyelid surgery (blepharoplasty) in restoring a youthful, rested look. Thus he has found it necessary to perform upper or lower eyelid surgery in only a minority of his patients. Some manipulation of eyebrow position, however, is almost always desirable, typically a tasteful suspension of the outer tail of the brow, with maintenance or even lowering of the inner eyebrow position.
Temporoplasty (outer eyebrow “kick”)
Dr. Little doesn’t use the term “brow lift,” as he feels that lifting of the central and inner eyebrow is usually inappropriate (although he will do so occasionally for specific patients, as can be seen in a handful of cases within the photographic Eye Results and Face and Neck Results sections). He does lift or “kick” the outer, temporal or “tail” portion of the brow in most patients, however, alleviating the “hooding” of the upper orbital space to the side. This is accomplished through a limited one-inch incision within the temporal scalp behind the hairline and is seen as a continuation of the basic vertical lifting maneuver of the XJ facelift. Here a buried (2-0 nylon) suture is utilized to maintain correction. Neither hair nor scalp is removed in this brief maneuver.
Upper Eyelid Surgery (upper “blepharoplasty”)
In the few of Dr. Little’s patients that require upper lid surgery, the procedure remains especially conservative, consisting of a modest removal of eyelid skin that nevertheless retains an eyelid fold similar to the one present in almost all early patient photographs. In still fewer patients, a limited amount of fat may be removed from the inner fat pocket near the nose, but almost no other eyelid fat is ever removed. Nor is eyelid muscle (orbicularis oculi) removed. And in the overwhelming majority of patients, fat is added back to the upper orbital hollowness under the eyebrow by micro structural fat grafting. Finally, the lid and brow skin is tightened and smoothed to a degree by conservative laser resurfacing. [view: Upper Orbitoplasty in diagrammatic form] [Dr. Little prefers “orbitoplasty” to the conventional term “blepharoplasty” (Gr. blepharon eyelid) because his approach involves so little direct surgery to the upper eyelid itself]. Most patients with upper eyelid concerns present to the office expecting that considerable skin, fat, and muscle will be removed from their upper lids (as in conventional blepharoplasty). But what first strikes them as counter-intuitive soon begins to make sense, as they review multiple results of Dr. Little’s approach to the brow and upper lid. Almost none of the patients in the photographic Eye Results and Face and Neck Results sections, for example, have had either skin, fat, or muscle removed from their upper eyelids, leaving them with full, healthy, natural, and youthful upper eyes (that remain closed during sleep).
Lower Eyelid Surgery (lower “blepharoplasty”)
Lower eyelid surgery often presents concerns for both the patient and the plastic surgeon as the single most notorious area in facial rejuvenation surgery with respect to complications and unnatural outcomes. While Dr. Little finds such lower-lid surgery unnecessary in the majority of his patients, he continues to recommend it for those with significant descent of their lower eyelid muscle (orbicularis oculi) and a heavy skin load. His remedy for such aging muscle descent with loose skin is a simple, single-stitch (5-0 nylon) resuspension of the fallen muscle coat that he calls “orbicularis hitch,” a less invasive technique that removes no eyelid muscle and that he considers especially safe for the lower lid. [view: Orbicularis Hitch in diagrammatic form]
Of particular note, he almost never finds it necessary to perform manipulations at the outer corner of the eyelid (canthopexy or canthoplasty), that may in turn create subtle (or not-so-subtle) changes in eyelid shape. As with the upper lid, he removes fat only rarely, preferring instead to camouflage eyelid bags by blending them away with fat grafted below them. And he never removes eyelid muscle. [view: Lower Orbitoplasty in diagrammatic form] [Dr. Little prefers “orbitoplasty” to the conventional term “blepharoplasty” (Gr. blepharon eyelid) because his approach involves so little direct surgery to the lower eyelid itself]. Almost none of the patients in the photographic Eye Results and Face and Neck Results sections, for example, have had either fat or muscle removed from their lower eyelids. And a significant amount of volume is added back to almost all lower lids by structural fat grafting. Similarly, almost all lower lids receive a conservative laser resurfacing with low energy.
Micro Fat Grafting
In Dr. Little’s opinion, nearly all eyelids with a tired, aged appearance require significant volume restoration, which he feels is best accomplished by micro structural fat grafting. And in the majority of cases, that may be all that is required. Most of the eyelids in the photographic Eye Results section have had no direct surgery or scars, but have benefited instead from micro structural fat grafting alone (with low-energy laser resurfacing). Among patients consulting Dr. Little because of disappointment after prior upper or lower eyelid surgery, the most common complaint remains emptiness, with hollow upper or lower eyelids, either left uncorrected by the prior surgery or, worse still, actually created by the surgery itself. [view: Fat Grafting to Orbit in diagrammatic form] A note of caution is appropriate here, however. Among all the fat grafting sites within the face, the most challenging by far remains the thin tissues of the lower eyelid region, where the incidence of irregularity runs notoriously high (and remains notoriously difficult to correct). Seeking out proven expertise in structural fat grafting (whether with Dr. Little or others) is the best strategy to avoid such problems. Finally, fat grafting to the orbit presents a uniquely effective tool for the relief of the “buggy” or “pop” eye, as well as the “staring” eye (conditions which may be associated with thyroid disease, which must therefore be ruled out). A number of examples are revealed throughout the photographic Eye Results and Face and Neck Results sections (wherein a disturbing look around the eyes is rendered entirely natural). Alternative treatments, if effective at all, would have been far more complex.
Dr. Little has found that conservative laser resurfacing of the eyelids (with an ablative CO² laser) adds an element of rejuvenation that is worthwhile in almost everyone. The key to such success, he has found, is the strict limitation of the energy used, which minimizes the risks of atrophy (thinning) and decoloration (whitening). Aggressive laser resurfacing, on the other hand, he finds misguided, as it may bring an appearance of thinness, whiteness, and overall atrophy of the skin that is unnatural, untreatable, and anything but young. He cites eyelid laser as an example of many applications in facial cosmetic surgery wherein: “if a little is good (which it is), more is not better…and a lot may be dreadful.”
Illustration: detail from Leonardo da Vinci, “Anatomical Studies for the Proportions of the Face and Eyes,” ca. 1490, Biblioteca Reale, Turin