A blepharoplasty is an operation that removes excess loose folds of skin from the upper eyelids and 'bags' from the lower eyelids.

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. 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 that may look unsightly. An ophthalmic consultation can provide a comprehensive assessment of your eyelid problem, and a discussion of the available treatment options.

Preoperative appearance of a patient with "hooded" upper eyelids due to excess upper eyelid skin and a mild brow ptosis (droop)	Postoperative appearance of the same patient 6 weeks following a bilateral upper eyelid blepharoplasty and an internal brow lift

Preoperative appearance of patient with upper and lower eyelid skin excess
Postoperative appearance 3 months after bilateral upper and lower eyelid blepharoplasties with lower eyelid orbicularis muscle suspension

What happens at surgery?

Blepharoplasty surgery can be performed under local anaesthesia, local anaesthesia with sedation by an anaesthetist, or under general anaesthesia.

Upper lid blepharoplasty

When upper eyelid 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.

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 surgical improvement of lower eyelid “bags” is to resect the herniating orbital fat. While this method can indeed remove “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 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. It is more common for the surgeon to perform the procedure from inside the eyelid, which causes less swelling and no scar on the outside (a transconjunctival blepharoplasty). This 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). It is preferable not to remove much lower eyelid skin if possible as this risks eyelid retraction and predisposes to watering eyes at an older age. The surgery is performed using a "Colorado needle" which greatly reduces bleeding.

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 “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 ice packs and the eyes watched closely for any excessive bruising.

What happens before eyelid surgery?

You will visit the hospital a few days or weeks before the date of your surgery, to have a preoperative consultation with your surgeon. He will ask you questions about your current and past health, and will need to know about any allergies you may have, medications you are taking (including over the counter products e.g. aspirin, indomethacin or vitamin supplements), previous surgery, the previous use of fillers or anti-wrinkle injections and whether you smoke. 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), chest x-rays, or complete blood cell counts. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing may be necessary 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 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, the pressure within each eye is measured, and the back of the eye (called the retina) is examined as well as the eyelids themselves. The positioning of the eyelashes is noted. The surgeon examines the general state of your skin, for example the presence of acne or scars, and takes a photograph of your face before surgery so that the results of surgery can be compared with the original appearance.

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.

The procedure 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 after eyelid surgery include:

• Blurred or double vision, mainly for a few hours, up to a day or two after surgery. This may occur for several reasons - ointment put in the eye immediately after the operation, local anaesthetic used in the operation, weakening of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctival 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 the surgeon.
  
  
  
• Watery eyes - this is common for the first few days after the operation due to irritation of the eye
  
  
• Dry eyes may persist for two to three weeks. You will need to lubricate your eyes every 1-2 hours using artificial tears during the day (Viscotears) and an ointment at night (Lacrilube). These will 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.
  
  
• Collection of blood around the eyelids or behind the eyeball, called a haematoma. A sudden haematoma behind the eyeball can cause loss of eyesight if not managed appropriately. An oculoplastic surgeon is trained to prevent and to manage such a problem.
  
  
• Damage to the muscles that move the eyeball causing double vision is a very rare problem and usually this resolves by itself with time.
  
  
• 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.
  
  
• 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.
  
  
• 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.
  
  
• 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.
  
  
• 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 rare but it is important to follow postoperative wound care instructions to help to prevent such a problem These are given in writing to take home following surgery.

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. 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.

You will be asked to clean the eyelids and repeat the application of ointment to the wounds 3 times a day for 2 weeks. The sutures used are usually dissolvable but can be removed after 2 weeks. The skin around the eyes should be protected from direct sunlight, by avoidance if possible or by using sunglasses. Wearing make-up should be avoided for at least 2 weeks. Postoperative bruising and swelling usually takes at least 2-3 weeks to subside. This should be taken into consideration when scheduling the operation. The scars gradually fade to fine marks within a few months. Those in the upper eyelid are hidden within the skin crease. You will need to use frequent artificial tears for the first 2-3 weeks following surgery. These will be prescribed for you e.g. Systane eyedrops preservative free, Viscotears preservative free, Liquifilm tears preservative free, Cellusvisc and Lacrilube ointment at night. These medications can be purchased across the counter at the chemist.