Treatments: Blepharoplasty

Font Size:

Under Eye Bags or Blepharoplasty

What is a blepharoplasty?

A blepharoplasty is a cosmetic surgery operation that removes 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 medical 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

 

	Preoperative appearance of a patient with marked hooding of the upper eyelids		Postoperative appearance 6 weeks following a bilateral upper eyelid blepharoplasty

 

Some patients with a tired look due to lower eyelid dark circles (tear trough defects) may not be suitable for cosmetic surgery to the lower eyelids. A relatively new alternative approach for such patients is the use of Restylane or Juvéderm injections (dermal filler injections) to the lower eyelids. This is referred to as Tear Trough Restylane or Juvéderm injections or Tear Trough Rejuvenation. This procedure, which takes approximately 20 minutes to perform in clinic, is safe and effective for most patients (male and female) when performed by a surgeon who is both a skilled oculoplastic and cosmetic surgeon. Some patients with lower lid dark circles or tear trough defects also have a soft tissue hollowing in the upper cheek area. This soft tissue hollowing can often be improved either with the additional use of Restylane Sub-Q or Juvéderm injections or, for a more lasting effect, with the use of fat injections (Coleman fat injections or structural fat grafting).

What happens at surgery?

Blepharoplasty surgery can be performed under local anaesthesia, local anaesthesia with sedation by a specialist consultant anaesthetist (“twilight anaesthesia"), or under general anaesthesia. Most patients, who are fit and well, choose to undergo the surgery under “twilight anaesthesia” on a day case basis in the operating theatre at Face & Eye. For those patients who live at a distance from the clinic, an overnight stay close by in a local hotel is advised. For those patients who wish to undergo surgery under general anaesthesia, the surgery is undertaken at a local private hospital e.g. Spire Manchester Hospital, Manchester or Spire Regency Hospital, Macclesfield.

About "twilight anaesthesia"

Conscious sedation, also known as "twilight" anaesthesia, is a type of anaesthesia which is preferred by many patients for most of our surgical procedures. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also of advantage for very nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their procedure and have no or very little recollection of it at all. You are looked after throughout the procedure by a specialist consultant anaesthetist who has many years of experience of this type of anaesthesia, so that your surgeon can concentrate fully on your operation.

Shortly before moving to the operating room, a small tube (cannula) is placed into a vein in the back of your hand by the consultant anaesthetist and the anaesthetic drugs are given through that. These are Midazolam (a short acting type of Valium) and Propofol, a drug which is also used for general anaesthesia but, for conscious sedation, much lower doses are used. With conscious sedation there is no breathing tube or breathing machine, just a gentle flow of oxygen given through a plastic tube within a soft sponge protector inserted into one of your nostrils. Once the sedation has been commenced a local anaesthetic solution (a mixture of Marcaine and Lignocaine) is injected into the operative area to ensure a painless procedure. Typical side effects of general anaesthesia including a sore throat and nausea are avoided. Waking up takes only a few minutes at the completion of the surgery and is usually free of any "grogginess." This type of anaesthesia has been used safely and successfully for our surgical procedures for over 15 years.

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. The area of skin to be removed is first marked out, ensuring that the patient can easily close the eye when the skin is gently pinched with forceps (see photo below). In patients with bulges of fat, particularly in the inner corner of the upper eyelid, some of the fat is also removed. Tiny blue dissolvable sutures (stitches) are inserted to close the skin wound. These are removed in clinic after 2 weeks if they are still present.

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. In some patients the appearance of "hooded" upper eyelids with overhanging skin is caused by a droop of the eyebrows rather than just by an excess of upper eyelid skin. A blepharoplasty alone may then be inappropriate and may in fact 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.

	The appearance of a patient complaining of upper lid hooding. This patient's hooding is also caused by a brow ptosis as well as loose upper lid skin (dermatochalasis).		The appearance of the same patient 2 months after a bilateral temporal direct brow lift and upper lid blepharoplasty

 

Alternatively, for some patients, Botox injections are used to achieve a “chemical brow lift” 2-3 weeks before the upper lid blepharoplasty. These are then repeated at 3-4 monthly intervals.

Preoperative marking of an upper lid blepharoplasty incision

Lower lid blepharoplasty

It is generally accepted that the face develops the characteristics of aging as a result not only of sagging of the facial soft tissues but also soft tissue atrophy (loss or deflation of the soft tissues of the face). This is well illustrated in the field of lower eyelid blepharoplasty, in which the traditional approach to the cosmetic surgical improvement of lower eyelid "bags" or “eye bags” is to remove the bulging or prolapsing eyelid fat. While this method can indeed remove eye bags, particularly when these are severe, in many patients it can result in a hollowed or “skeletonized” appearance. This is in contrast to the appearance of the youthful face, in which soft tissue fullness creates a smooth transition from the lower eyelid to the cheek. The bony orbital margin is concealed. The traditional approach of resecting orbital fat is therefore unlikely to produce a full, youthful lower lid contour in many patients. 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 eyelid fat is advanced over the inferior orbital margin rather than removed. This technique is designed to conceal the underlying bony structure of the lower orbital margin (bony socket) in an attempt to impart a more youthful contour to the periorbital area.

A drawing showing 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" defect

 

A drawing showing the septum and fat advanced over the inferiororbital margin and sutured (stitched) to the periosteum (the lining of the bone).

 

Transcutaneous lower lid blepharoplasty

In a transcutaneous (through the skin) blepharoplasty a horizontal incision is made in the skin just below the eyelashes of the lower eyelid and continued along a laughter line at the outer corner of the eyelid. This approach is used for patients who require the removal of loose folds of skin or who also need the addition of a mid-face lift. An orbicularis muscle suspension is usually performed to help to prevent any retraction of the eyelid and to prevent excess skin being removed. This requires a separate incision in the outer aspect of the upper eyelid to gain access to the outer orbital margin where the suspensory sutures are placed and is often performed in conjunction with an upper eyelid blepharoplasty. A very small amount of excess skin is then removed from the outer aspect of the eyelid.

A drawing showing the orbicularis muscle sutured (stitched) to the orbital
rim after passing it under a bridge of intact skin.

 

Transconjunctival lower lid blepharoplasty

Sometimes the surgeon will perform the procedure from the inside of the eyelid which leaves no visible scar on the skin (a transconjunctival blepharoplasty). This is usually performed on younger patients who do not need any skin to be removed. Any associated skin laxity or wrinkling can be addressed by other methods at a later stage e.g. by laser resurfacing using a Fractional laser or with a mild chemical peel using 30% TCA (trichloroacetic acid). This approach is associated with a lower risk of postoperative lower eyelid retraction. The eyeball is protected during the surgery by pulling a flap of conjunctiva upper and over the surface of the eye with stitches.

In patients with very marked fat bulges, the fat will be debulked. In others the fat will be repositioned. If the fat is to be repositioned over the lower bony margin of the orbit, nylon stitches are used for this purpose. The needles are passed away from the eye and are brought out through the skin below the eyelids and tied over small silicone bolsters to protect the skin when the nylon stitches are tied. These are left in place for 4-5 days and are then removed in clinic. The stitches and bolsters look peculiar for a few days. It is best to wear dark glasses to hide the appearance. If you swell excessively, the bolsters will small indentations in the skin temporarily. These will respond to massage postoperatively and typically disappear after 2-3 weeks.

The surgery, both transcutaneous and transconjunctival, is performed using a "Colorado needle" rather than a surgical blade and scissors. This greatly reduces bleeding. This in turn results in a faster recovery time. A laser is not used as this involves more risk to the eye and its use is not necessary.

	Preoperative appearance of a patient with lower eyelid “bags” and tear troughs		Postoperative appearance 2 months following a bilateral lower eyelid transconjunctival blepharoplasty

 

Midface lift

For some patients a midface lift is combined with a lower eyelid blepharoplasty. Patients who have a drooping midface with a loss of the youthful cheek prominence and nasolabial folds may benefit from a midface lift. This can be performed using the same lower eyelid incision as for a transcutaneous lower eyelid blepharoplasty but in some patients an additional incision in the temple is required. The midface is released from its attachments to the underlying bone and can be lifted with the use of sutures (stitches) or with the use of a dissolvable implant, a midface Endotine implant (see drawing below). This implant dissolves over a period of 3-6 months in most patients, after the repositioned tissues of the mid-face have reattached to the underlying bone. The implants are very effective but add expense to the procedure. This surgery is more often undertaken under general anaesthesia with an overnight stay in hospital because of the extra time that this takes.

A drawing showing the position of a midface Endotine implant.

Some patients have “malar mounds” over the cheek bones. These are more commonly seen in smokers. These represent a loss of subcutaneous ligament support of the cheek and can be associated with fluid retention in this area. They can be very difficult to treat surgically and may require an alternative non-surgical approach e.g. laser resurfacing, radiofrequency treatment or they should be left alone.

Preoperative appearance of a patient showing “malar mounds”

A photograph of the same patient taken 4 months following a bilateral mid-face lift performed via lower lid transcutaneous blepharoplasty incisions and using Endotine midface implants

Coleman fat injections (structural fat grafting)

For some patients a lower lid blepharoplasty can be combined with fat injections to enhance the cheeks or midface where there is hollowing. In this procedure, fat is removed from the outer aspect of the flank, buttock or thigh using very light finger suction with a syringe and blunt cannula to avoid damaging the fat. This can be done under “twilight anaesthesia” or under general anaesthesia. A single small “stab” incision is required in the skin and this is closed with a single stitch. The fat is then spun in a centrifuge for a few seconds, separating the fat cells from blood and local anaesthetic solution. The fat cells are then transferred to 1 ml syringes. The fat is then injected into the midface via the blepharoplasty incision or via an additional small “stab” incision in a laughter line, in tiny quantities. Several passes of an small blunt tipped cannula are made to ensure an even distribution and the best chance of the fat gaining a blood supply in the facial tissues and thereby surviving. There is nevertheless a risk of up to 20% that the fat will not survive this process. The risk of failure is higher in smokers. The procedure can be repeated but the fat has to be harvested again as it cannot be stored. (Stored fat does not survive). This is a surgical technique that is commonly used for reconstructive surgery as well as for cosmetic surgery.

	Typical age related changes in the lower lid and mid-face		The appearance of the same patient 3 months after a transcutaneous lower lid blepharoplasty and Coleman fat injections to the midface. (This patient has also undergone a temporal direct brow lift and an upper lid blepharoplasty).

Fat Pearl Grafting and Hollow Eye

Fat pearl grafting is a technique that can help patients who have hollow upper or lower eyelids. This is most commonly used for the management of patients who have undergone an over-resection of fat during the course of cosmetic eyelid surgery, but can also be used for patients who have hollowing as an hereditary problem, as a consequence of previous trauma, or due to disorders such as Rhomberg's hemifacial atrophy. For such patients, it can be combined with Coleman fat grafting to the temple and mid-face. Fat for fat pearl grafting is taken via an incision which is typically made around the lower half of the umbilicus (the tummy button). The fat is then divided into very small "pearls" and transplanted into the eyelid, usually via a skin crease incision in the upper eyelid and via a transconjunctival incision (on the inside of the eyelid) in the lower eyelid. The overall results of this surgery are good and long lasting. This surgery is usually undertaken under "twilight anaesthesia" on a day case basis.

A preoperative photograph showing patient who had undergone a 4 lid blepharoplasty elsewhere and was unhappy with the appearance of the outer aspect of the upper eyelids, a left upper lid ptosis (droop) and high skin crease, and hollowing of the left lower eyelid.

A photograph of the same patient taken a week following a bilateral revision upper lid blepharoplasty with fat pearl grafting on the left side, a left posterior approach Müller’s muscle resection, and transconjunctival fat pearl grafting to the left lower eyelid.

A photograph of the same patient taken 3 months after surgery.

What happens after a blepharoplasty?

After surgery, the eyes are initially covered with pressure dressings for approximately half an hour to reduce postoperative swelling and the wounds are treated with antibiotic ointment. The dressings are then removed and replaced with cool packs. Activity is restricted for 2 weeks to prevent bleeding.

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 the clinic Face & Eye can demonstrate this to you).

A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely.  Swelling takes longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation. You should arrange this surgery after holiday periods or important professional or social events and not before so that you are available for postoperative review and just in case any surgical adjustments are required.

The scars gradually fade to fine white marks within a few months. Those in the upper eyelid are hidden within the skin crease unless an additional skin incision is required to remove a “dog-ear” of excess skin just below the tail of the eyebrow. 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 camouflaged with make up.

You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Hyabak drops, Systane eye drops preservative free, Viscotears preservative free, Liquifilm tears preservative free, or Celluvisc 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 from my clinic Face & Eye or online from the clinic’s online shop (www.faceandeyeshop.co.uk). You should not pull the lower eyelid down to put these drops or ointments in the eyes.

You are advised to sleep with the head raised approximately 30 degrees. It is preferable to raise the head of the bed if possible.

Chemosis, a swelling of the conjunctiva, the membrane covering the white of the eyes, often occurs following this surgery, particularly with the transconjunctival approach. This usually takes 1-2 weeks to resolve but can take longer in some patients. Artificial tears must be used every 1-2 hours during the day until this has gone.

Contact lenses should not be worn for a few weeks following this type of surgery.

A period of postoperative massage is often advised. You will be shown how to do this. It is usually undertaken after applying some Lacrilube ointment to the eyelid skin. The massage helps to reduce swelling and to prevent eyelid retraction. It is usually undertaken for 3 minutes 3 times a day in an upward and side to side direction.

	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.

 

	A patient before and 3 months after a bilateral upper lid blepharoplasty and a bilateral transcutaneous lower lid blepharoplasty with an orbicularis muscle suspension and fat debulking. This patient’s fat bulges were too large to reposition and were instead debulked.

(Please note that, while many of my patients have very kindly consented to the use of their photographs for this website, others prefer that their photographs are only shown in my portfolio in my clinic Face & Eye. These can be viewed at the clinic. Many other patients do not wish their photographs to be used for any purpose other than their own records and their confidentiality is respected).

What happens before eyelid surgery?

You will visit the clinic to have a preoperative consultation with me. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire before seeing me, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery, and any previous non-surgical aesthetic treatments e.g. Botox injections, dermal fillers injections, the use of IPL or laser treatments.  I need to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. I need to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not 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 a general 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.

The nurses are also happy to answer any further questions and to show you the facilities at Face & Eye, including the operating theatre if it is not in use. They can also advise you about additional non-surgical treatments and long term skin care which may enhance and help to maintain the results of surgery. If you have any specific skin problems, I may refer you to our clinic dermatologist for help and advice (Dr Corinna Mendonca).

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. The information is treated confidentially. 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 as long as these are not medically essential. You might need to check this with your GP. Any anti-inflammatory medicines e.g. Ibuprofen, Nurofen must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.

If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined. The general state of your skin is assessed and photographs of your face and eyelids are taken 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.

Q: What are the possible 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.

Most complications of eyelid surgery are amenable to successful treatment.

Complications from cosmetic eyelid surgery include:

• Blurred or double vision, lasting mainly for a few hours, and sometimes up to a day or two after surgery. This may occur for several reasons - ointment put in the eyes immediately after the operation, local anaesthetic used in the operation, swelling of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva (this may mimic a severe hay fever reaction) is referred to as "chemosis" and in some patients can take a few weeks to resolve. If blurring persists for longer than 48 hours, it is important to inform your surgeon.


• Watery eyes - this is quite common for the first few days after the operation due to some irritation of the eyes and a temporary weakness of reflex blinking of the eyelids.


• Dry eyes may persist for two to three weeks or sometimes longer. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (e.g. Hyabak drops, Hylotears, Viscotears, Systane drops) and an ointment at night (Lacrilube). These should be prescribed for you. You will gradually reduce the frequency until you can dispense with them altogether. It is very rare for patients to have to continue with them long-term but this is possible. This is why it is important to exclude a dry eye problem before proceeding with this type of surgery.


• Injury to the surface of the eyeball (a corneal abrasion) that causes persistent pain. If the pain lasts longer than a few hours after the operation, the surgeon must be informed. Such a problem is extremely rare in the hands of an oculoplastic surgeon. Such a problem is treated with antibiotic ointment. Sometimes a bandage contact lens needs to be used.


• Bleeding. A collection of blood around the eyelids or behind the eyeball, is called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately and without delay. This is the most serious potential complication of this surgery but is extremely rare. An oculoplastic surgeon is trained to prevent and to manage such a problem.
A haematoma usually needs to be drained in the operating theatre


• Damage to the muscles that move the eyeball (e.g. the inferior oblique muscle from the use of cautery to seal a bleeding blood vessel adjacent to the muscle) causing double vision is an extremely rare problem and this usually resolves by itself with time. In the very unlikely event that double vision were to persist, a referral to another ophthalmic surgeon with expertise in the management of eye movement disorders and possible further surgical intervention would be required.


• A ptosis (the upper eyelid does not open because of stretching of the muscle or tendon that controls it). Another operation may be necessary to repair this. An oculoplastic surgeon undertakes ptosis surgery routinely.


• Exposure of the cornea, the clear sensitive surface of the eye. When blinking the eyelids do not cover the eyeball completely. This often occurs for a short time after the operation and is treated routinely with artificial tear drops. If too much skin is removed from the upper eyelids, the eyelid closure can be compromised long term. This may require further surgery to correct it. For this reason, great care is taken to mark the skin to be removed before surgery is commenced. Such a problem is very unusual in the hands of an oculoplastic surgeon.


• A sunken-looking eye can occur if too much fatty tissue is removed. Modern approaches to a lower eyelid blepharoplasty aim to preserve and reposition fat in the lower eyelids over the lower eyelid rims to avoid this problem. Should this occur, further surgery can be undertaken to replace fat. This is usually taken as tiny fat pearls from just below the umbilicus (the tummy button). For the same reason, the debulking of fat in the upper lid is also undertaken conservatively.


• Acute glaucoma - this is raised pressure within the eye, which results in pain in the eye, haloes around lights or severe blurring of vision, a headache above the eye, and vomiting. A patient at risk of such a postoperative problem would be identified by an oculoplastic surgeon. An oculoplastic surgeon is trained to diagnose and treat such a problem.


• Infection. An infection following this surgery is extremely rare but it is important to follow postoperative wound care instructions to help to prevent such a problem. These should be given to you in writing for you to take home following surgery.


• Lower eyelid retraction leaving the white of the eye visible just above the edge or margin of the lower eyelid. The incidence of this following a lower lid blepharoplasty varies from surgeon to surgeon and the risk is greater in patients with more prominent eyes and where such surgery has been performed previously. This problem is more commonly seen with a transcutaneous lower eyelid blepharoplasty. Precautions are taken to minimise the risk of this developing. It may require further surgery to address it if it occurs e.g. with the use of a small dermal or dermal fat graft.


• Lower eyelid ectropion. This is a malposition of the lower eyelid where the eyelid hangs away from the eyeball. This is a risk in patients who have a very loose lower eyelid preoperatively. Precautions are taken to prevent this in at risk patients with the use of an eyelid tightening procedure. An ectropion is a common age related problem which is routinely corrected by oculoplastic surgeons.


• A higher lower lid position. Rarely, the lower eyelids may remain slightly high following a lower lid transconjunctival blepharoplasty if the eyelid retractors are not sutured (stitched) or if excessive swelling causes cheese-wiring of the sutures. The eyelid may not move downwards properly when looking down, requiring a chin down posture to compensate for this.


• Rounding of the outer aspect of the eyelids with shortening of the horizontal dimension of the eyelids can occur following a transcutaneous lower lid blepharoplasty. The incidence varies from surgeon to surgeon. This can lead to an unsatisfactory cosmetic result and it can be a very difficult problem to address with further surgery.


• Asymmetry. It is impossible for any surgeon to achieve perfect symmetry although an oculoplastic surgeon strives to achieve this. A cosmetically unacceptable asymmetry e.g. of the upper lid skin crease, fullness of the eyelids, lower lid position is always possible and further surgery may be required to address this.


• Scarring. Most eyelid wounds heal with scars that are barely perceptible although full maturation of the wounds can take some months. Poor scarring can follow infection or wound disruption but this is very rare. Poor scars can be treated with steroid injections or with the application of silicone gels e.g. Kelocote. Rarely, scars need to be revised surgically.


• Eyelid lumps. Lumps can very occasionally occur as a reaction to sutures used to close the wounds. These usually resolve with time but occasionally steroid injections are required. Rarely, lumpiness can occur in fat that is repositioned over the inferior orbital margin. This usually responds to postoperative massage.


• Granuloma. A pink fleshy lump can occur as a stitch reaction on the inside of the lower eyelid following a transconjunctival blepharoplasty. This often resolves with the use of a course of postoperative steroid eye drops but occasionally the granuloma needs to be removed surgically in the clinic or operating theatre.


• Reoperation. Further surgery within the first few weeks to address any asymmetries may be required. This should be borne in mind. There are a number of factors beyond a surgeon’s control, which can have an impact on postoperative progress e.g. postoperative swelling affecting one side more than the other, which in turn can necessitate re-intervention.
  

» Read about Brow lifts

« Return to Treatments Index

back to top