Upper lid blepharoplasty can be carried out using either a local or general anaesthetic and can be combined with ptosis (droopy eyelid) or eyebrow surgery if required. Although prolapsing fat can be removed, removal of too much fat from the upper eyelid can give a skeletalised appearance and can be undesirable. Blepharoplasty surgery is therefore customised to the individual patient, giving each patient a bespoke procedure.
Why have Blepharoplasty Surgery?
Upper eyelid blepharoplasty is the most common surgical cosmetic procedure and is typically performed for people with droopy, overhanging eyelids that impair vision, cause frequent blinking, eyelid fatigue or which simply look unsightly. In addition, some find that the application of make-up is hindered as a result of excess skin.
Surgery can be combined with ptosis surgery if the upper eyelid position itself is low; this will be pointed out to you at the consultation if you are not already aware of this. An eyebrow ptosis (low-lying eyebrow) may contribute to your problem and may need to be addressed during surgery.
Lower eyelid blepharoplasty is typically performed on patients with puffy lower eyelids, which may look unsightly.
There are many different kinds of eyelid surgery, depending on your specific type of problem. One person’s operation is naturally different to another’s, so please do not assume that you will undergo the same procedure as a friend.
Eyelid surgery cannot stop the ageing process. However, it can diminish the look of loose skin and bagginess in the eyelid region.
Blepharoplasty surgery is obviously not compulsory for patients with excess eyelid tissue and no harm will come to you if you do not go ahead with surgery. Among the alternatives to surgery are no treatment at all, clever use of make-up, as well as various proprietary skin treatments. In addition, Botox and fillers (e.g. Restylane) can also be used to enhance your facial appearance in general (whole face, not just the eyelid region) and may be suggested and administered by Mr Madge, if appropriate.
What happens at surgery?
Eyelid surgery can be performed under local anaesthesia, local anaesthesia with sedation by an anaesthetist, or under general anaesthesia (asleep).
With a local anaesthetic you will be awake during the operation and you may feel sensations (e.g. pressure) in the area being operated upon, but you should feel nothing sharp or painful. You may be able to see some of what is happening, but you will be aware of the very bright operating theatre lights. In some cases, I will ask specifically ask you to open your eyes or look up / down, but otherwise feel free to keep your eyes closed unless otherwise directed, which will probably leave you most comfortable.
Upper eyelid blepharoplasty
A curved incision is made through a natural crease of your eyelid above the eyelashes and a crescent-shaped, appropriately sized piece of skin is removed. If necessary, underlying fatty tissue is also removed. Sutures are then placed to close the incision, leaving a scar in a natural eyelid crease position.
Ptosis surgery or eyebrow surgery can be performed at the same sitting, typically through the same incision.
Lower eyelid blepharoplasty
There has been a recent shift in our understanding of the ageing process, in that until recently it was felt that removal of, for example, prolapsed fat from the eyelid region led to a rejuvenated appearance. While this approach certainly removes ‘bags’, in many patients it simultaneously removed the soft tissue that conceals the bony orbital rims, creating a hollowed – skeletonised – appearance. In addition, excess removal of lower eyelid fat can lead to a deepening of the normal depression in the upper eyelid below the eyebrow, enhancing the aged look. In the youthful face, there is a smooth transition from the cheek to the lower eyelid as a result of soft tissue fullness, with the bony margin being concealed.
There have recently been devised many surgical approaches to address this problem, for example, techniques that preserve and reposition the orbital fat, so allowing a smooth transition between lower eyelid and cheek but simultaneously eliminating the troublesome eyelid bags.
An incision is typically made 1-2mm below the eyelashes, but the procedure may also be performed from inside the eyelid (transconjunctival blepharoplasty). Excess tissues are either removed or repositioned and the lower eyelid is typically tightened to prevent lower eyelid sagging after the procedure. Skin incisions are closed with sutures, which are typically removed at one week.
The procedure may be carried out as a daycase or with an overnight stay, depending on the individual patient’s requirements.
Aspirin / warfarin / clopidogrel drugs
If you are taking any of these drugs, you will be given instructions about how to proceed at your consultation. If you start taking any of these medications between your consultation and surgery, or if this was not discussed at your consultation, it is vital that you contact my secretary prior to your operation going ahead. I will then advise you how to proceed. If you take non-steroidal anti-inflammatory drugs (e.g. ibuprofen, voltarol, etc.), it is preferable to avoid these prior to surgery, however, these are often necessary for other ailments and should not be stopped if you would otherwise be in pain.
Please dress casually and comfortably. Avoid wearing jewellery and thoroughly clean your face prior to coming to hospital. No emollients, make-up or contact lenses please on the day of surgery. Please take your standard oral medication (except see above re. aspirin / warfarin / clopidogrel / ibuprofen etc.) on the morning of surgery.
If possible, stop smoking for at least 4 weeks prior to surgery and until wounds are fully healed and at least 2 weeks thereafter.
In order to help you relax during surgery, I can arrange for some music to be played while in theatre. If you would prefer to bring your own choice of CD with you, please do so.
After surgery, you can experience some swelling / bruising for 1-2 weeks and occasionally longer. Please bear this in mind when scheduling your surgery. Typically the swelling is at its worst after about 48 hours, so please do not be alarmed if bruising worsens the day after surgery; this is normal and in some cases the discolouration spreads down your face from your cheeks to your chin. If so, it will soon fade.
You may still have a little oozing or bleeding from the site of surgery over the first few hours, which should resolve by itself. Following surgery, I prefer to apply a firm dressing to the surgical site until at least the following morning, typically secured with elastoplast tape. While some surgeons do not do this, I believe that the great reduction in swelling / bruising achieved with this technique is worth the temporary inconvenience that padding causes. Should you wish not to have your eye padded shut following surgery, please discuss this with me prior to surgery. In patients undergoing surgery on both left and right eyelids, I typically pad both eyes closed, one for around an hour after surgery and the other until the following morning.
If the patch becomes loose, apply more tape. Do not remove the patch. While the patch is on, do not get it wet. Shower from the neck down or take a bath.
Cool packs applied to the wound are very helpful at reducing the swelling and bruising. If you wish to, apply a cool pack (cold flannel / frozen peas wrapped in clean flannel / ice cubes in plastic bag wrapped in flannel) to the area for 10-15 minutes, 6 times per day for the first 2 days.
As the local anaesthetic wears off, you will experience tightness of the eyelids. Pain after surgery is typically minimal, however, if you experience significant discomfort please take mild pain relief as required (e.g. paracetamol). Paracetamol taken regularly works better than when taken occasionally.
Avoid strenuous exercise, bending or heavy lifting for a few days after surgery as this can precipitate bleeding. Sleep with 2-3 pillows in order to keep the head elevated – this will help to reduce swelling / bruising.
Antibiotic ointment should be applied to the wound three times a day, which prevents scab formation and may reduce the risk of infection. Wash hands thoroughly prior to applying ointment. If crusting occurs, you may clean the wound with warm boiled water using cotton wool or cotton buds to remove crusts and pat dry. Do not use soap. Then apply a layer of antibiotic ointment. You may shower and wash your hair, but try and avoid getting soap on the wounds. Dab them dry afterwards and apply ointment.
Stitches / sutures
Skin stitches typically need to be removed, although in certain cases I will use dissolvable stitches. If stitches are to be removed, I typically remove these 5-10 days following surgery at your follow-up appointment.
What are the possible common complications of cosmetic eyelid surgery?
Complications in the hands of trained, experienced oculoplastic surgeons are rare and precautions are taken to minimise risks. The list below is designed to be comprehensive; significant complications following blepharoplasty are uncommon.
Complications after eyelid surgery include:
· Blurred or double vision, usually for a few hours but occasionally a few days, following surgery. This may occur as a result of antibiotic ointment smearing the vision, local anaesthetic used during surgery or swelling of the normally clear covering of the eye (conjunctiva). Conjunctival swelling is known as ‘chemosis’, and may take a few weeks to resolve. If blurring persists or worsens, please inform Mr Madge.
· Watery eyes. This is common for several days following surgery and is due to temporary irritation of the eye.
· Dry feeling eyes. Such a sensation may persist for 2-3 weeks. Intensive lubrication with artificial tears may be necessary and the need for lubricants in the longer term is a possibility.
· Corneal abrasion. This is a mild injury to the surface of the eye (akin to a child’s fingernail injury on the eye) sustained during surgery and is uncommon in surgery performed by an oculoplastic surgeon. This can cause intense pain and dislike of bright lights, but rapidly heals.
· Collection of blood around the eyelids or behind the eyeball, called a haematoma. A sudden haematoma behind the eyeball can cause permanent loss of sight if not managed appropriately. An oculoplastic surgeon is trained to prevent and to manage such a problem. Loss of sight following upper eyelid blepharoplasty is exceptionally rare; following lower eyelid blepharoplasty, the incidence of this rare complication is thought to be less than 1:10,000.
· Damage to the muscles that move the eyeball causing double vision is a very rare problem and usually resolves with time.
· Ptosis, where the upper eyelid does not open properly due to stretching of the muscle / tendon that normally opens the eye; further surgery may be required. Oculoplastic surgeons routinely undertake ptosis surgery.
· A sunken-looking eye can occur if too much fatty tissue is removed. Modern techniques aim to avoid this complication – see above.
· Scarring. Although good wound healing is expected in this anatomical region, abnormal scars can occur both within the eyelid and deeper tissues. There is the low possibility of visible marks on the eyelid or small skin cysts from sutures, which may be temporary or permanent.
· Asymmetry. The human face and eyelid region is normally asymmetrical. Eyelid surgery can only rarely correct this and this is not usually the goal of surgery.
· Infection. An infection following this type of surgery is rare but it is important to follow postoperative wound care instructions and to use antibiotics to help prevent such a problem. Limited infections – typically due to organisms from the patient’s own body – are rare, but are usually easily treated with oral (or extremely rarely intravenous) antibiotics. More devastating infections, such as ‘necrotising fasciitis’, are exceptionally rare (incidence less than 1:10,000) and could potentially result in permanent disfigurement or even death. I stress that such outcomes are exceptionally uncommon and their inclusion in this leaflet are purely for completeness from a medicolegal perspective.
· Chronic pain. This may occur extremely infrequently following blepharoplasty surgery. Tenderness over the eyebrows that persists for months may commonly be experienced if eyebrow lifting surgery is undertaken.
· Ectropion and lower eyelid retraction. Displacement of the lower eyelid away from the eye may occur uncommonly following lower eyelid blepharoplasty and surgical steps are taken to prevent this complication. If it occurs, further surgery may be necessary.
· Eyelash loss. This may occur in the lower eyelid and its occurrence is unpredictable. While typically temporary, it may potentially be permanent.
· Lack of satisfaction with the final result. As with any operation, there is a possibility that you may be disappointed with the final results of surgery and infrequently subsequent ‘touch-up’ surgery may be necessary.
- Allergy. In rare cases, local allergies to tape, suture materials or topical preparations have been reported. Unexpected systemic reactions occurring to drugs (e.g. anaesthetics) used during surgery are rare, but can be serious or even potentially fatal and are a risk in any form of surgery anywhere on the body.