Treatments: Blepharoplasty

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What is a blepharoplasty?

A blepharoplasty is a cosmetic surgery operation that removes excess loose folds of skin from the upper eyelids and eye bags from the lower eyelids. It is often referred to as an eye lift, an eyelid lift, cosmetic eye surgery, cosmetic eyelid surgery, or an eye bag removal operation.

What are the reasons for having a blepharoplasty?

An upper eyelid blepharoplasty is performed for people who have droopy, overhanging eyelids that impair vision, cause frequent blinking and eye fatigue or look unsightly causing a cosmetic problem. It can be combined with ptosis surgery if there is an associated droop of the upper eyelid. Often an eyebrow ptosis (drooping of the eyebrows) contributes to the problem and may need to be addressed separately or at the same time.

A lower eyelid blepharoplasty is also performed on people who have "puffy" lower eyelids or eye bags that may look unsightly and cause a cosmetic problem and affect self confidence. An ophthalmic consultation with an oculoplastic specialist can provide a comprehensive assessment of your cosmetic eyelid problem, and a discussion of the available treatment options. It is important that other potential problems are excluded as an underlying cause of the complaint e.g. an underactive thyroid gland can cause puffy eyelids.

	Preoperative appearance of a patient with "hooded" upper eyelids due to excess upper eyelid skin and a mild brow ptosis, and lower eyelid skin laxity.		Postoperative cosmetic appearance of the same patient 3 months following a bilateral upper eyelid blepharoplasty, internal brow lift and a bilateral lower eyelid blepharoplasty with orbicularis muscle suspension.

Preoperative appearance of patient with upper and lower eyelid skin excess

Postoperative cosmetic appearance 3 months after bilateral upper and lower eyelid
blepharoplasties with lower eyelid orbicularis muscle suspension

 

	Preoperative appearance of a patient with thyroid eye disease and eyelid "bags" and upper eyelid retraction		Postoperative appearance 3 months following bilateral upper and lower eyelid blepharoplasty and a bilateral upper lid retractor recession

Some patients with a tired look due to lower eyelid dark circles may not be suitable for cosmetic surgery to the lower eyelids. A new alternative approach is the use of Restylane injections to the lower lids. This is referred to a Tear Trough Restylane injections or Tear Trough Rejuvenation. This procedure is safe and very effective when performed by a surgeon who is both a skilled oculoplastic and cosmetic surgeon.

What happens at surgery?

Blepharoplasty surgery can be performed under local anaesthesia, local anaesthesia with sedation by an anaesthetist (“twilight anaesthesia”), or under general anaesthesia.

Upper lid blepharoplasty

When upper eyelid cosmetic surgery is undertaken, a curved incision is made through the upper eyelid crease above the eyelashes and a crescent-shaped piece of skin is removed. If necessary some underlying fatty tissue is also removed. Tiny dissolvable sutures are inserted to close the wound. An eyebrow lifting or stabilizing procedure is commonly performed at the same time to achieve the desired result and to prevent the brow from descending further following the removal of upper eyelid skin.

Preoperative marking of an upper lid blepharoplasty incision

Lower lid blepharoplasty

An emerging concept in cosmetic surgery holds that the face develops the characteristics of aging as a result not only of sagging but also soft tissue atrophy. The evolution of this concept is well illustrated in the field of lower lid blepharoplasty, in which the traditional approach to the cosmetic surgical improvement of lower eyelid "bags" or eye bags is to resect the herniating orbital fat. While this method can indeed remove eye bags, in many patients it may also eliminate the soft tissue that conceals the infraorbital rims, creating a hollowed, skeletonized appearance. This is in contrast to the appearance of the youthful face, in which soft tissue fullness creates a smooth transition from the cheek to the lower lid. The inferior bony orbital margin is concealed. The traditional approach of resecting orbital fat is therefore unlikely to produce a full, youthful lower lid contour and conflicts with the aforementioned concept that facial aging is partly a consequence of soft tissue atrophy. A number of surgical approaches have been devised to address this problem. One such technique that has gained prominence is the arcus marginalis release, in which orbital fat is advanced rather than resected to reconstruct the soft tissue of the lower lids. This technique is designed to conceal the underlying bony structure of the inferior orbit in an attempt to impart a more youthful contour to the periorbital area.

Bulging of fat through a weakened orbital septum with a secondary concavity
over the inferior orbital margin responsible for the complaint of "eyebags" and
for a "tear trough" deformity

The septum and fat are advanced over the inferiororbital margin and sutured to
the periosteum.

An orbicularis muscle suspension. The orbicularis muscle is sutured to the
orbital rim after passing it under a bridge of tissue.

An incision is made about 1-2 millimetres below the lower eyelashes if excess skin is to be removed or if the orbicularis muscle is to be resuspended. An orbicularis muscle suspension is performed to help to prevent retraction of the eyelid and to prevent excess skin being removed. This requires a separate incision in the upper eyelid and is often performed in conjunction with an upper eyelid blepharoplasty. Sometimes the surgeon will perform the procedure from inside the eyelid which leaves no visible scar on the skin (a transconjunctival blepharoplasty). Any associated skin laxity or wrinkling can be addressed by other methods at the same time or later e.g. by laser resurfacing using Fractional laser resurfacing or a mild chemical peel using TCA (trichloroacetic acid). The surgery is performed using a "Colorado needle" rather than a surgical blade and scissors which greatly reduces bleeding. This results in a faster recovery time.

	Preoperative appearance of patient with lower lid “bags” and "tear troughs". Postoperative cosmetic appearance 2 months after bilateral lower lid transcutaneous blepharoplasties with orbicularis suspension and fat repositioning.

	Preoperative appearance of patient with lower lid "bags" and "tear troughs". Postoperative appearance 2 months after bilateral lower lid transcutaneous blepharoplasties with orbicularis suspension and fat repositioning.

	Preoperative appearance of patient with lower lid "dark circles" and postoperative appearance 2 months after bilateral lower lid transcutaneous blepharoplasties with orbicularis resuspension and fat repositioning.

The procedure may be carried out as a day case or with an overnight stay in hospital depending on the patient's individual requirements. After surgery, the eyes are initially covered with pressure dressings to reduce postoperative swelling and treated with antibiotic ointment. These are then removed and replaced with cool packs and the eyes watched closely for any excessive bruising.

What happens before eyelid surgery?

You will visit the clinic to have a preoperative consultation with your cosmetic surgeon. He will ask you questions about your current and past health, about any previous eye surgery or treatments including refractive surgery or laser eye surgery, and will need to know about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin, nurofen or vitamin supplements), previous surgery, the previous use of fillers or botulinum toxin injections and whether you smoke. You will have your blood pressure checked by the nurses. You may also be required to have a physical examination of your heart and lungs by the anaesthetist to make sure it is safe for you to have an anaesthetic. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, or a blood cell count. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing is usually necessary, however, if you are in good health and younger than age 55.

Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your cosmetic surgery can be planned as carefully as possible. If you are unsure of the names of any medications, bring them with you. You will be told whether or not to stop any medications at this preoperative clinic visit. For example, if you are taking aspirin-containing medicines or anticoagulants, they may need to be temporarily withdrawn or reduced in dose for two weeks before the procedure. If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your eyes are examined carefully; your vision in each eye is measured, your tear film status is determined and the back of the eye (called the retina) is examined as well as the eyelids themselves. The surgeon examines the general state of your skin, for example the presence of acne or scars, and takes a photograph of your face and eyelids before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.

In some patients the appearance of "hooded" upper eyelids with overhanging skin is caused by a droop of the eyebrows rather than by excess upper eyelid skin. A blepharoplasty may then be inappropriate and may worsen the appearance. An operation to lift the eyebrows may be required instead or in addition. If appropriate in your own individual case this will be discussed with you. There are a number of different procedures which can be undertaken to raise eyebrows. The one most suited to the individual needs of the patient is selected.

What should I expect at the hospital?

The cosmetic surgery operation will be explained to you and you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any possible complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective. If you have any questions or worries, make sure they are answered, before you sign the consent form. You are quite free to go away and consider the options before committing yourself to any surgery. You can then write to us requesting further information if required.

What are the possible common complications of cosmetic eyelid surgery?

Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.©

Complications from cosmetic eyelid surgery include:

How long will I stay in hospital/in the clinic?

Most cosmetic eyelid surgery procedures are performed as day cases where you arrive at the hospital in the morning and leave the same evening after the operation. If your surgery is undertaken in our ambulatory surgical centre, Face & Eye, you will be able to leave within an hour after the completion of your surgery. Someone must be available to take you home and stay with you for up to 24 hours after the operation. Alternatively an overnight stay may be required if you live some distance from the hospital/clinic. Some patients like to stay in a local hotel close to the clinic rather than in hospital overnight.

What happens after a blepharoplasty?

You will be asked to clean the eyelids very gently using clean cotton wool and Normasol (sterile saline) or cooled boiled water and repeat the application of antibiotic ointment (usually Chloramphenicol or Soframycin) to the wounds 3 times a day for 2 weeks. The sutures used are dissolvable but are usually removed in clinic after 2 weeks. The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using protective sunglasses. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended. (The aesthetics nurses at Face & Eye can demonstrate this to you). Postoperative bruising usually takes at least 2-3 weeks to subside completely.  Swelling takes longer. Most of the swelling disappears within 4 weeks but the final result is not seen for at least 3 months. This should be taken into consideration when scheduling the operation. The scars gradually fade to fine white marks within a few months. Those in the upper eyelid are hidden within the skin crease. Those in the lower lids are barely visible beneath the eyelashes. The marks in the laughter lines at the outer corner of the eyelids can be hidden with make up. You will need to use frequent artificial tears for the first 2-3 weeks following surgery. These will be prescribed for you e.g. Hyabak drops, Systane eyedrops preservative free, or Viscotears preservative free, or Liquifilm tears preservative free, or Cellusvisc drops and Lacrilube ointment at bedtime.  It is often recommended that you use Lacrilube ointment to the eyes 2 hourly for the first 48 hours after surgery but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). These medications can be purchased across the counter at the chemist. You should not pull the lower eyelid down to put these drops or ointments in the eyes.

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