Eyelid reduction (Blepharoplasty)

With increasing age, skin loses its elasticity and our muscles slacken. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper lids and forms deepening creases in the lower lids. At the same time there is a slackening of the muscle beneath the skin, allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bagginess to develop during early adulthood before any skin changes.

The problem often seems worse in the morning, particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day, tends at night to settle in areas where the skin is loose, such as your eyelids. Drooping of the eyelids is also an effect of the ageing process and aggravates the accumulation of the skin in the upper eyelids. Sometimes, so much skin accumulates in the upper lids that it hangs over the eyelashes to obstruct vision.

If you have these changes, blepharoplasty can enhance your appearance and your self-confidence. The best candidates for eyelid surgery are men and women who are physically healthy, psychologically stable, and realistic in their expectations. Most are 35 or older, but if baggy eyelids run in your family, you may decide to have eyelid surgery at a younger age.

A few medical conditions make a blepharoplasty more risky. They include thyroid problems such as hypothyroidism and Graves disease, dry eyes or lack of sufficient tears, high blood pressure or other circulatory disorders, cardiovascular disease and diabetes. A detached retina or glaucoma is also a reason for caution. These conditions may necessitate a referral to an Ophthalmologist before your surgery.

What can be done?

An eyelid reduction removes the surplus skin and protruding fat to produce a more alert appearance and reduces the morning swelling. Sometimes it is only necessary to reduce the skin, sometimes the skin and the fat, and sometimes just the fat.

What are the limitations?

It is important for you to understand that only the wrinkles which are in the skin which is cut away will be removed. Folds of skin extending on to the cheek (festoons) will not normally be improved. Wrinkles in the area of the Crow's feet will remain and although the skin is much tighter it is still necessary to be able to open and close the eyes freely. The skin has less elasticity with age and for proper closure of the eyes the upper eyelid will need to have some surplus skin when it is open. Descent of the eyebrow can be corrected by an endoscopic brow lift.

Planning your surgery

The initial consultation is very important. I will need to ask you your complete medical history. You should inform me if you have any allergies, if you are taking any medications or other drugs, and if you smoke. During this consultation your vision will be tested and your tear production will be assessed. You should also provide any relevant information from your ophthalmologist if you have had a recent eye examination. If you wear glasses or contact lenses, you should bring them along to the consultation.

We will carefully discuss your goals and expectations for surgery. We will discuss whether to operate on all four eyelids or just the upper or lower ones, whether skin as well as fat will be removed and whether any additional procedures are appropriate. I will explain the techniques and anaesthesia and the risks and costs involved.

You should be aware that most insurance policies do not cover eyelid surgery, unless the drooping upper lids interfere with your vision. You should check with your medical insurer about this. Do not hesitate to ask me any questions you may have especially those regarding expectations and concerns about the results.

Preparing for your surgery

I will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking or avoiding certain medications. While you are making preparations, it would be wise to arrange for someone to drive you home after surgery and to help out at home for a few days if needed.

Types of anaesthesia

Eyelid surgery can be performed under local anaesthesia or general anaesthesia. If you choose to undergo local anaesthesia, the area around your eyes will be numbed. You will be awake during surgery, but relaxed and insensitive to pain. However, you may feel some tugging or occasional discomfort.

The surgery

Blepharoplasty usually takes between one to three hours, depending on the extent of the surgery. In a typical procedure, the incisions follow the natural lines of your eyelids. These will be in the creases of the upper lids and just below the lashes in the lower lids. These incisions extend a little way into the Crow's feet, or laughter lines, at the corner of the eyes. Through these incisions surplus fat is removed and excess skin and sagging muscle removed. The incisions are then closed with very fine sutures and will be covered with adhesive paper strips (steri-strips).

After your surgery.

After surgery it is best to keep your head elevated for a few days to reduce swelling. This means sleeping on an extra pillow or two at night. Cold compresses can also help. These will be applied to your eyes immediately after surgery. This helps to reduce swelling and bruising. Bruising varies from person-to-person, reaching its peak during the first week, and generally lasting between two weeks to a month. The adhesive paper strips may become encrusted and these can be replaced in the outpatients department. It is a good idea to clean your eyes with water on a daily basis and I may recommend that you use eyedrops or ointment. For the first few weeks you may also experience excessive tear production. This is due to swelling under the conjunctiva and also because the tear ducts are swollen and do not drain normally. You may also experience sensitivity to light, and temporary changes in your eyesight such as blurring or double vision. The closure of your eyes may feel tight after surgery because of the swelling and because skin has been removed. If closure is not complete at night, you should apply some eye ointment before going to sleep. This sensation will settle as the swelling subsides.

You will be reviewed after a week and your sutures will be removed. Once the sutures have been removed, the swelling and discoloration around your eyes will gradually subside and you will start to look and feel much better. Although you will have bruising, it can quite readily be disguised with make-up and dark glasses. The scars will be pink for a few months, but eventually they should become almost invisible.

Getting back to normal

You should be able to read and watch television after two or three days. You will not be able to wear contact lenses for about two weeks, and even then they may feel uncomfortable. Most people feel ready to go out in public and back to work in a week to 10 days. You may be sensitive to sunlight, wind and other irritants for several weeks, so you should wear sunglasses and sunblock on your eyelids when you go out. I will advise you to keep your activities to a minimum for three to five days and to avoid more strenuous activities for about three weeks. It is especially important to avoid activities that raise blood pressure, including bending, lifting and rigorous sports. It is also advisable to avoid alcohol, since this causes fluid retention.

What are the risks?

All surgery carries some uncertainty and risk. You can reduce the risks by closely following your instructions. Occasionally a small amount of blood can collect under the skin after the operation has finished (haematoma). This usually disperses spontaneously over two or three weeks but if it is large it may need to be drained. Quite commonly the margin of the lower lid is slightly pulled away from the eye during the first day or two after surgery due to swelling. This will settle on its own or with the help of steri-strips. Very occasionally another operation is necessary to correct this. You may have double or blurred vision for a few days, temporary swelling at the corner of the eyelids and a slight asymmetry in healing or scarring. Tiny whiteheads may appear after your stitches are taken out. These can easily be removed when you are seen in outpatients, with a very fine needle. Another fairly rare complication is ectropion, a pulling down of the lower lid. If this is the case, further surgery may be required. Blindness is an exceptionally rare complication.

Your new look

Healing is a gradual process and your scars may remain slightly pink for several months after surgery but should eventually fade to a thin, nearly invisible white line.

The positive results of your eyelid surgery, such as a more alert and youthful look, will last for years. For many people, these results will be permanent.

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