Blepharoplasty
Blepharoplasty in detail
What is a blepharoplasty?
Blepharoplasty is a very popular cosmetic plastic surgery operation to remove excess overhanging folds of skin from the upper eyelids and to reduce or reposition fat from the upper and lower eyelids. This surgery improves “tired” eyes, “baggy” eyes, and “hooded” eyes that create an aged look. In the upper eyelids, the excess skin can prevent the application of make-up and can also impair vision.
Sometimes an upper lid blepharoplasty is combined with surgery to correct drooping of the upper eyelids (ptosis or blepharoptosis). In some people the appearance of "hooded" upper eyelids is caused by a droop of the eyebrows. In such people an upper eyelid blepharoplasty is combined with a brow lift operation. The results of blepharoplasty surgery and brow lifts are enhanced by the use of anti-wrinkle injections (botulinum toxin injections) given 1–2 weeks prior to surgery.
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). An emerging concept in cosmetic surgery is that 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. Coleman fat injections, laser skin rejuvenation.
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 dark circle skin is free to move with the lower eyelid skin and the cheek skin and the dark circle is improved.
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 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. Any associated skin laxity or wrinkling is dealt with by the use of fractional laser skin resurfacing or with a chemical peel. It is preferable not to remove large amounts of lower eyelid skin as this can lead to the risk of eyelid retraction (the eyelid pulling down) or watering eyes as a patient ages.
What happens before eyelid surgery?
You will visit the clinic a few days or weeks before the date of your surgery, to have a preoperative consultation with your surgeon. He or she 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 a general anaesthetic if you are not suitable for surgery under local anaesthesia. (If this is necessary your procedure will be carried out at Manchester Centre for Vision (the private wing of Manchester Royal Eye Hospital, Manchester), The Alexandra Hospital in Cheadle, Cheshire or Spire Hospital Manchester, formerly the BUPA Hospital Manchester, in Whalley Range.)
You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, an ECG, or complete blood cell counts. These should reveal potential problems that might complicate the surgery if not detected and treated early. We may not need to carry out any tests if you are in good health and younger than 55. All questions should be answered completely and honestly 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 and you will be told whether it will be necessary 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 will be carefully examined and your vision in each eye measured. The pressure within each eye may also be measured, and the back of the eye (the retina) examined, as well as the eyelids themselves. The positioning of the eyelashes will be noted. Your surgeon will also examine the general state of your skin, e.g. for the presence of acne or scars, and will take photographs of your face and eyelids before surgery so that the results of surgery can be compared with the original appearance.
What should I expect at the clinic?
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 that you can keep things in perspective. If you have any questions or worries, make sure they are answered, before you sign the consent form. You are, however, quite free to go away and consider the options before committing yourself to any surgery and indeed we encourage this. You can then write to us or email us requesting further information if required. We will respect your wishes if you prefer us not to communicate with your G.P. but it is always preferable to give us permission to do so.
What Happens at Surgery
Most blepharoplasty operations are performed under local anaesthesia with intravenous sedation provided by a consultant anaesthetist (“twilight anaesthesia”). This keeps patients very calm and comfortable. Patients are usually able to go home within an hour of the completion of surgery. Patients often have very little recollection of the surgery, and are not aware of the local anaesthetic injections given prior to the commencement of surgery.
Upper lid blepharoplasty
During surgery a curved incision is made through the upper eyelid crease 5-7 mm above the eyelashes and a crescent-shaped piece of skin is removed. Sometimes underlying fatty tissue is also removed and tiny, dissolvable sutures are inserted to close the incision. Sometimes an upper lid blepharoplasty is combined with surgery to correct drooping of the upper eyelids (ptosis or blepharoptosis) or is combined with a brow lift operation to raise droopy eyebrows or to prevent any further droop of the eyebrows. See the information on brow lift surgery at http://www.faceandeye.co.uk/eye/eyebrowlifts.html
Lower lid blepharoplasty
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 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 dark circle skin is free to move with the lower eyelid skin and the cheek skin and the dark circle is improved.
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. This requires a small additional incision in the outer aspect of the upper eyelid (if an upper lid blepharoplasty is not being performed at the same time) in order to gain access to the outer aspect of the outer bony margin of the eye socket to which the sling of muscle is attached). This operation is referred to as a “lower lid transcutaneous blepharoplasty with an arcus marginalis release, fat repositioning and an orbicularis muscle sling”.
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. Any associated skin laxity or wrinkling is dealt with by the use of Palomar 1540 fractional laser skin resurfacing or with a chemical peel. This might be combined with anti-wrinkle injections (botulinum toxin injections). It is preferable not to remove large amounts of lower eyelid skin as this can lead to the risk of eyelid retraction (the eyelid pulling down), or watering eyes as a patient ages.
Figure 1
Bulging of fat through a weakened orbital septum with a secondary concavity over the lower bony rim of the eye socket responsible for the complaint of “eyebags” and for a “tear trough” deformity
Figure 2
The orbital septum and eyelid fat are advanced over the lower bony rim of the eye socket stitched to the superficial lining of the bone (the periosteum)
How long will I stay in the clinic?
Most cosmetic eyelid surgery procedures are performed as day cases where you arrive at the clinic in the morning or early afternoon and leave approximately an hour after the 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 in a local private hospital may be required if you live some distance from the hospital or a room in the adjacent hotel can be booked.
What happens after a blepharoplasty?
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. Although most of the postoperative swelling disappears within 3-4 weeks of the surgery, it can take up to 3-4 months before you see the final result.
You will need to use frequent artificial tears for the first 2-3 weeks following surgery to prevent any dryness of the eyes due to a temporary incomplete blink of the eyelids. These will be prescribed for you e.g. Systane eyedrops preservative free or Viscotears preservative free, or Liquifilm tears preservative free, or Cellusvisc drops and Lacrilube ointment at night. These medications can be purchased across the counter at the chemist. (There is a chemist next door to the clinic which supplies these).
Side Effects
Complications in the hands of a trained and experienced oculoplastic surgeon are very rare and all precautions are taken to minimise any risks. An oculoplastic surgeon undertakes blepharoplasty surgery routinely and is trained to prevent and to manage any problems.
Some blurred or double vision may be experienced for a few hours for up to a day or two following surgery together with watery eyes due to irritation of the eyes.
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 could 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 which can temporarily weaken the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Conjunctival swelling 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 eyes.
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 (e.g. Systane drops preservative free) 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. Please note that the preservative free artificial tear dispenser contains more than one or two drops. It is perfectly reasonable therefore to reapply the top and to use the rest of the drops on the same day but the dispenser should be discarded at the end of the day.
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. Also, the modern surgical approach described above further reduces any such risk.
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. This refers to drooping of the upper eyelid. With a ptosis the eye does not open fully because of stretching of the muscle or tendon that controls movement of the upper eyelid. Another operation may be necessary to repair this. An oculoplastic surgeon undertakes ptosis surgery routinely.
A dry 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.
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 a very high 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 instructions are given to you in writing to take home following surgery.
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