Cosmetic eyelid surgery

Cosmetic eyelid surgery (cosmetic blepharoplasty) is a very popular cosmetic plastic surgery operation to remove loose or excess skin and to reduce or reposition fat from the upper and lower eyelids. Blepharoplasty surgery improves “tired” eyes, “baggy” eyes or “eye bags”, and “hooded” eyes that create an aged look. These are very common complaints. In the upper eyelids, the excess skin can prevent the application of make-up and can also impair vision or cause irritation.

Cosmetic blepharoplasty alone (cosmetic eyelid surgery) does not treat drooping eyebrows or wrinkled sun-damaged eyelid skin.

Blepharoplasty is therefore often combined with other cosmetic surgical operations e.g. a brow lift, Coleman fat injections (structural fat grafting) and non-surgical treatments such as anti-wrinkle injections (botulinum toxin injections) to improve crow’s feet lines, and facial or eyelid dermal filler injections.

To see examples of cosmetic eyelid surgery results please click on the following links:

http://www.cosmeticeyesurgeon.co.uk/blepharoplasty Mr Ataullah's personal website

http://www.eyelidsurgery.co.uk/cosmetic-eyelid-surgery-blepharoplasty/ Mr Leatherbarrow's personal website

Upper lid blepharoplasty

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.                                               

In patients with bulges of fat, particularly in the inner corner of the upper eyelids, some of the fat may also be removed. Tiny blue dissolvable sutures (stitches) are inserted to close the skin 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. 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 eyebrow lift 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 your individual needs, age and general health is selected. The results of blepharoplasty surgery and brow lifts are often enhanced by the use of anti-wrinkle injections (botulinum toxin injections) to weaken the muscles which pull the eyebrows down, given 2-3 weeks prior to the surgery.

Lower lid blepharoplasty

A lower eyelid blepharoplasty is designed to improve the appearance of eye or eyelid “bags”, loose folds of excess skin or dark circles (a 'tear trough defect'). The face develops the characteristics of ageing not only because of sagging but also because of soft tissue wasting. The traditional approach to the surgical improvement of lower eyelid “bags” has been to remove the protruding fat around the eye. This method can indeed remove “bags” but it may also eliminate the soft tissue that conceals the bony rims beneath the eye, creating a hollowed, sunken or bony appearance and thereby worsening the tear trough deformity. More modern advanced surgical techniques which reposition rather than remove fat help to conceal the underlying bony structure of the eye, resulting in a more youthful appearance to the surrounding tissues. This can also be combined with other techniques e.g. microfat injections.

During surgery an incision is made either through the skin just below the eyelashes of the lower eyelid (a “transcutaneous” blepharoplasty) or on the inside of the lower eyelid (a “transconjunctival” blepharoplasty). During the procedure the arcus marginalis, a fine ligament attached to the bone of the lower eye socket, is released which frees up the dark circle or Tear Trough. Once the arcus marginalis has been released the eyelid fat is repositioned over the bony rim disguising the underlying bony structure and preventing reattachment of the arcus marginalis.

The transcutaneous approach is used in people who have loose folds of skin in the lower eyelid requiring a removal of a strip of skin. In order to prevent the eyelid retracting this surgery is combined with an orbicularis muscle suspension in the outer aspect of the eyelid. This creates a sling effect using the muscle of the eyelid which contracts on smiling. In some patients who have a mid-face ptosis, a mid-face lift or cheek lift may be required in combination with the blepharoplasty. This is often achieved with the use of a modern implant referred to as a mid-face Endotine implant. This helps to create an even lift. Once the tissues have settled into their new position, the implant dissolves naturally and completely over the course of a few months.

The transconjunctival approach is used in people who have no excess eyelid skin. This has the important advantage of leaving no visible scar on the eyelid and, more importantly, does not change the shape of the eyelid, a potential complication of the transcutaneous approach. The eyeball is protected during the surgery by pulling a flap of conjunctiva upper and over the surface of the eye with stitches. Any associated skin laxity or wrinkling can be dealt with later by the use of a chemical peel. Although a 'skin pinch' can be undertaken to remove a small amount of excess skin, it is preferable not to remove lower eyelid skin wherever possible as this can lead to the risk of eyelid retraction (the eyelid pulling down) or watering eyes as a patient ages. This approach is associated with a faster recovery time and is ideal for patients who want to avoid any tell-tale signs of the surgery.

In patients with very marked fat bulges, the fat can just be debulked. In others the fat can be repositioned over the lower rim of the eye socket. 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 sponge bolsters to protect the skin when the nylon stitches are tied. These are left in place for 2 days and are then removed in clinic. It is best to wear dark glasses to hide the appearance of these until they have been removed. If you swell excessively, the bolsters will leave small indentations in the skin temporarily. These will respond to massage postoperatively after applying Auriderm cream and typically disappear after 1-2 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.

Both upper and lower lid blepharoplasy surgery can be performed under local anaesthesia on a day case basis. Most patients, however, prefer to undergo the surgery under “twilight anaesthesia”. For some patients who are very anxious, particularly those undergoing more extensive surgery, a general anaesthetic at a local private hospital can be arranged.

Cosmetic blepharoplasty

You will visit the clinic to have a preoperative consultation. This usually lasts 45 minutes. You will be asked to complete a healthcare questionnaire, providing information about:

  • your aims
  • your current and past health
  • any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery
  • any previous non-surgical aesthetic treatments e.g. anti-wrinkle injections, dermal fillers injections, the use of IPL or laser treatments
  • any eye problems e.g. dry eyes, or if you use contact lenses
  • any previous major surgery or significant illnesses
  • any allergies
  • medications (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements),
  • any skin problems
  • whether or not you smoke

You will have your blood pressure checked by the nurses at the clinic.

It is very helpful if you have old photographs which you can bring along to the consultation. If you are happy to email digital photographs of your current appearance in advance of the consultation with details of your concerns, this is also enormously helpful and saves time. Your photographs will be kept confidential and will form part of your clinical record.

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.

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 should be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. You will be given a leaflet advising you on what medications, foods, and vitamin supplements to avoid prior to surgery. It is important that your blood pressure should also be under good control if you take medications for hypertension.

If you can, try to stop smoking at least six to eight weeks prior to surgery. Smoking has an adverse effect on healing and damages your eyelid skin and supporting tissues and your eyes (it can result in premature cataract formation and age related macular degeneration with a loss of central vision).

         

  • Your vision in each eye will be measured.
  • Your eyes will be examined carefully using a slit lamp (a special ophthalmic microscope as seen in the photographs above)
  • Your tear film status is determined to ensure that you do not have a predisposition to a dry eye problem
  • The back of the eyes (called the fundus or retina) is examined as well as the eyelids themselves
  • The rest of your face is then examined

Photographs of your face and eyelids will be taken before surgery so that the results of surgery can be compared with your original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.

The risks and potential complications of surgery should be considered but these need to be kept in perspective. Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimize any risks.

What are the possible complications of cosmetic eyelid surgery?

Most complications of eyelid surgery are amenable to successful treatment. (Complications are rare in the hands of a skilled and experienced oculoplastic surgeon).

Complications from blepharoplasty 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. 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
  • 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. This risk is very small.
  • 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 an upper eyelid blepharoplasty aim to remove fat in the upper eyelids very conservatively 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).
  • Lower eyelid retraction - this is a risk associated with the skin incision approach to this surgery and is increased in patients with a prominent eye (a 'negative vector' eye). It is not a risk if the transcutaneous approach is used.
  • 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.
  • 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, 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 or due to some thickening of fat that may have been placed as a graft. These usually resolve with time but occasionally steroid injections are required.
  • Numbness. Any skin incision can cause minor areas of numbness as the very fine delicate sensory nerves can be cut. This is occasionally noticeable after upper eyelid blepharoplasty. It is usually mild and improves over a period of a few weeks or months after surgery.
  • 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.

Cosmetic 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. (Lower lid bolsters and sutures following a tranconjunctival blepharoplasty with fat repositioning are removed after 3-4 days). 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 nurses at the clinic can demonstrate this to you). It is important to devote a lot of time to your aftercare for the first 2 weeks and some patients find this somewhat labour intensive.

A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to subside completely. Swelling takes much longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient as does the extent of the swelling. 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 upper lid scars gradually fade to fine white marks within a few months. The scars 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.

The lower lid scars following at transcutaneous blepharoplasty also fade to fine white marks just underneath the eyelashes within a few months. The scars at the outer aspect of the eyelids are more visible but can be camouflaged with make-up in female patients after 2-3 weeks.

You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops if you have any allergies. 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 following any upper lid 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 Face & Eye or online from the clinic’s online shop (www.faceandeyeshop.co.uk).

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

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

A period of postoperative massage is often advised following lower eyelid surgery. 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.

Click here to download a PDF which provides details of when you can resume a variety of activities following your surgery.

Twilight anaesthesia

Please note that although cosmetic blepharoplasty can be performed under local anaesthesia alone, local anaesthesia with safe, conscious intravenous sedation given by a very experienced and skilled consultant anaesthetist (commonly referred to as “twilight anaesthesia”) is also available where requested. This form of anaesthesia is extremely popular with our patients and the effects are reversed very quickly. It enables local anaesthetic injections to be given painlessly with little recollection of the surgery, and helps to keep patients calm, relaxed and comfortable. It also helps to prevent rises in blood pressure thereby minimizing bleeding and postoperative bruising.

Any patients requiring general anaesthesia or who are unsuitable for surgery at our day case facility, the Face & Eye Clinic, will be treated by our surgeons in a local private hospital e.g. Spire Manchester Hospital.


Click here to listen to a patient talk about her experiences of twilight anaesthesia.

What our patients say

My only regret is that I did not have this done years ago. Read RJ's comments