Bilateral upper & lower lid blepharoplasty



    An upper lid blepharoplasty, also known as an upper eyelid lift or eye lift procedure, is an operation to remove loose overhanging skin from the upper eyelids (also referred to as ‘dermatochalasis’). 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. A herniation of the medial upper lid fat pad (responsible for an oblique bulge seen in the inner aspect of the upper eyelid) is often treated at the same time. The aim of the surgery is an improved appearance without adversely affecting the important function of the upper eyelid i.e. blinking to distribute an even film of tears over the very sensitive surface of the eye – the cornea. An assessment of a patient’s tear status using a slit lamp microscope, looking for any signs of an impending dry eye problem, is essential when examining a patient seeking an upper lid blepharoplasty. It is for this reason that so many patients now seek the skills of an oculoplastic surgeon for their cosmetic eyelid surgery.

    A patient with upper lid hooding

    The patient after a bilateral upper lid blepharoplasty

    Patients often experience headaches due to overuse of the forehead muscle (the frontalis muscle) that raises the eyebrows to compensate for the problem. An upper eyelid blepharoplasty can be combined with ptosis surgery if there is an associated true droop of the upper eyelid(s).

    A patient with marked upper lid hooding, and lower lid ‘bags’

    The same patient following a bilateral upper lid blepharoplasty and a ‘chemical brow lift’ using botulinum toxin injections (Azzalure injections). 

    She has also undergone a bilateral lower lid transconjunctival blepharoplasty with fat repositioning (‘scarless’ cosmetic lower eyelid surgery)

    Often an eyebrow ptosis (drooping of the eyebrows) contributes to the problem and may need to be addressed separately or at the same time.

    Lower lid blepharoplasty: for further information go to https://www.faceandeye.co.uk/cosmetic-procedures/eyelid-surgery-2/lower-lid-bags-3/

    Procedure Overview

    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 (see photo below), ensuring that you 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, usually dissolvable, sutures (stitches) are inserted to close the skin wound. Click here to see a short video demonstrating the placement of the upper lid sutures.

    The preoperative skin marking for an upper lid blepharoplasty

    A patient with severe upper lid hooding

    The patient following a bilateral upper lid blepharoplasty

    For some patients, a subtle change is all that is desired:

    A patient with loose upper lid skin and an intradermal naevus below the left brow

    The appearance following a bilateral upper lid blepharoplasty and a shave excision of the intradermal naevus

    An eyebrow lift or eyebrow 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 people 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 your 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, including non-surgical procedures, which can be undertaken to raise eyebrows. The one most suited to your individual needs, age and general health is selected.

    The procedure can be performed under local anaesthesia on a day case basis. Most patients, however, prefer “twilight anaesthesia”.

    Pre-operative Considerations

    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.

    Some insurance companies request copies of preoperative photographs and some also require a visual field examination, to confirm that the eyelid problem is restricting your peripheral vision.

    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 from upper eyelid 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).
    • 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.

    Post-operative Considerations

    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 1 or 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 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.

    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.

    Twilight Anaesthesia

    Please note that although blepharoplasty surgery (an eyelid lift) can be performed under local anaesthesia alone, local anaesthesia with safe, conscious intravenous sedation given by an 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.

    Click here to listen to Dr Paul Lancaster talking to a patient about twilight anaesthesia at the Face & Eye Clinic. Dr Lancaster is an expert consultant anaesthetist at Manchester Royal Infirmary.

    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.

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    Contact us now to find out how we can help you with your eye, eyelid, or facial problems. You will find our website contains a great deal of helpful information about what we do. We welcome email enquiries.

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