I often see patients who say I feel completely fresh, it is 9 o’clock in the morning, but I look tired and something about my eyes are my eyelids. And on examination what they will often have is extra skin, redundant skin on their upper eyelids. Sometimes they will have a little bulging of the fat pads on the upper eyelids, in the inside or the middle and often with the lower eyelids, they will have a lot of puffiness along here which is protrusion of the fat pads inside under what is called the orbital septum that sort of bulges out as you get older, so you will see people that have fullness in through here. And one can improve the appearance of both the upper lids and the lower lids. With the upper eyelids, the primary improvement is removing the excess skin and trimming the extra fat. If people have a lot of extra skin it can also improve their peripheral vision that can hang down in people in their 60s and 70s, it can be a functional operation as well. For the lower lids, you need to cautious, you need to be conservative. If there is a lot of extra fat, the fat can be trimmed. If there is excess skin that can be very carefully trimmed and lifted up and back to smooth out the contour. At the same time, you do not want to over resect fat because than later in life you can get a hollowed-out look and the youthful eye usually is fairly full. So what we also do sometimes is just to transpose the fat from its current position down into this tear trough groove. Sometimes we will add fillers of flat or different injectables to try to fill out the area to give you a more youthful eyelid, so that again there are several options. We do not have one standard procedure that we do for everybody. We need to talk about the options.
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