Blepharoplasty

What is a blepharoplasty?
A blepharoplasty is an operation that removes loose folds of skin from the upper eyelids and eye bags from the lower eyelids. It is often referred to as cosmetic eyelid surgery, an eyelid lift, an eye lift, cosmetic eye surgery, or an eye bag removal operation.

What are the reasons for having a blepharoplasty?
An upper lid blepharoplasty is performed for patients who have droopy, overhanging eyelids that cause a visual field problem, cause eye irritation and eye fatigue or create a cosmetic problem. The operation can be combined with ptosis surgery (droopy eyelid surgery) if there is an associated droop of the upper eyelid (ptosis or blepharoptosis). An eyebrow ptosis (a drooping of the eyebrows) often accentuates the problem and this problem may need to be addressed at the same time or separately.

A lower eyelid blepharoplasty is undertaken on people who have "puffy" lower eyelids or eye bags that create an aged or tired look and affect self esteem. A consultation with an oculoplastic specialist can provide an expert assessment of your cosmetic eyelid problem, and a discussion of the treatment options. It is important that an undiagnosed medical problem is excluded as an underlying cause of the complaint e.g. an underactive thyroid gland can cause puffy eyelids.

What happens at surgery?
Blepharoplasty surgery can be done under local anaesthesia, local anaesthesia with sedation by an anaesthetist (“twilight anaesthesia”), or under general anaesthesia. Most patients choose to undergo the surgery under “twilight anaesthesia” on a day case basis. For those patients who live at a distance from the hospital, an overnight stay is advised.

About “twilight anaesthesia
Conscious sedation, also known as "twilight" anaesthesia, is a type of anaesthesia which is preferred by many patients for most of our eyelid operations. It is a very comfortable and gentle type of anaesthesia which is far less invasive than the typical general anaesthesia but at the same time highly effective. It is also very good for nervous or anxious patients undergoing quite minor procedures. Typically patients sleep most of the way through their operation and have no or very little recollection of it. You are looked after throughout the procedure by an anaesthetist.

Upper lid blepharoplasty
When an upper lid blepharoplasty is undertaken, a crescent-shaped piece of skin is removed just above the skin crease. In patients with bulges of fat, particularly in the inner corner of the upper eyelid, some of the fat is also removed. Tiny blue dissolvable sutures (stitches) are inserted to close the skin wound.

An eyebrow raising or stabilizing procedure is often performed at the same time to achieve the desired result and to prevent the brow from becoming more droopy 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 worsen the appearance. An operation to lift the eyebrows may be required instead of or in addition to an upper lid blepharoplasty.

Lower lid blepharoplasty
Transcutaneous lower lid blepharoplasty
In a transcutaneous (through the skin) blepharoplasty a horizontal incision is made in the skin just below the eyelashes of the lower eyelid and continued along a laughter line at the outer aspect of the eyelid. This approach is used for patients who require the removal of loose folds of skin. An orbicularis muscle suspension is often performed to help to prevent any retraction of the eyelid and to prevent excess skin being removed. This requires a separate incision in the outer aspect of the upper eyelid to gain access to the outer orbital margin where the suspensory sutures are placed and is often performed in conjunction with an upper eyelid blepharoplasty. A very small amount of excess skin is then removed from the outer aspect of the eyelid.

Transconjunctival lower lid blepharoplasty
Sometimes the procedure is performed from the inside of the eyelid leaving no visible scar on the skin (a transconjunctival blepharoplasty). This is usually performed on younger patients who do not need any skin to be removed. Any associated skin laxity or wrinkling can be addressed by other methods at a later stage e.g. by laser resurfacing using a Fractional laser or with a mild chemical peel using 30% TCA (trichloroacetic acid). This approach is associated with a lower risk of postoperative lower eyelid retraction. In patients with very marked fat bulges, the fat will be debulked. In others the fat will be repositioned.

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.

Mid-face lift For some patients a mid-face lift is combined with a lower eyelid blepharoplasty. Patients who have a drooping midface with a loss of the youthful cheek prominence and nasolabial folds may benefit from a midface lift. This can be performed using the same lower eyelid incision as for a transcutaneous lower eyelid blepharoplasty but in some patients an additional incision in the temple is required. This surgery is more often undertaken under general anaesthesia with an overnight stay in hospital because of the extra time that this takes.

Coleman fat injections (structural fat grafting) For some patients a lower lid blepharoplasty can be combined with fat injections to enhance the cheeks or midface where there is hollowing. In this procedure, fat is removed from the outer aspect of the flank, buttock or thigh using very light finger suction with a syringe and blunt cannula to avoid damaging the fat. This can be done under “twilight anaesthesia” or under general anaesthesia.

What happens after a blepharoplasty? After surgery, the eyes are initially covered with dressings for approximately half an hour to help to minimize 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 postoperative 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) to the wounds 3 times a day for 2 weeks. The sutures (stitches) used are dissolvable but are usually removed in clinic after 2 weeks. Wearing make-up should be avoided for at least 2 weeks. After 2 weeks the use of mineral make-up is recommended.

A realistic period of recovery must be expected. Postoperative bruising usually takes at least 2-3 weeks to resolve completely. Swelling takes longer. Most of the swelling disappears after 3-4 weeks but this can vary considerably from patient to patient. The final result is not seen for at least 3-4 months. This should be taken into consideration when scheduling the operation.

The scars gradually fade to fine white marks within a few months. Those in the upper eyelid 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. Those in the lower lids are barely visible beneath the eyelashes. The marks in the laughter lines at the outer corner of the eyelids can usually be camouflaged with make up.

You will need to use frequent artificial tears for the first 2-3 weeks following surgery. It is preferable to use preservative free drops. These will be prescribed for you e.g. Viscotears preservative free 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 but note that this will cause blurring of vision. (You should not drive for the first few days after surgery). You should not pull the lower eyelid down to put these drops or ointments in the eyes.

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

Chemosis, a swelling of the conjunctiva, the membrane covering the white of the eyes, often occurs following this surgery, particularly when the transconjunctival approach has been used. This usually takes 1-2 weeks to resolve but can take longer in some patients. Artificial tears must be used every 1-2 hours during the day until this has resolved.

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

A period of postoperative massage is often advised. 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.

What happens before eyelid surgery?
You will visit the hospital to have a preoperative consultation with your surgeon. This usually lasts 30-45 minutes. You will be asked to complete a healthcare questionnaire before seeing your surgeon, providing information about your current and past health, about any previous eye, eyelid or facial surgery or treatments including refractive surgery or laser eye surgery, and any previous non-surgical aesthetic treatments e.g. Botox injections, dermal fillers injections, the use of IPL or laser treatments. Your surgeon needs to know if you have a past history of any eye problems e.g. dry eyes, or if you use contact lenses. Your surgeon needs to know about any allergies you may have, medications you are taking (including over the counter products e.g. Aspirin, Indomethacin, Nurofen, Diclofenac or vitamin supplements), previous major surgery or illnesses, any past dermatology history and whether or not you smoke.

You will have your blood pressure checked by the nurses. 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. You may need to have some routine laboratory tests, such as urinalysis (tests of your urine), a chest x-ray, or a blood cell count. These should reveal potential problems that might complicate the surgery if not detected and treated early. No testing is usually necessary, however, if you are in good health and younger than age 55.

Please answer all questions completely and honestly as they are asked only for your own wellbeing, so that your blepharoplasty surgery can be planned as carefully as possible. The information is treated confidentially. 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 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 must be discontinued at least 2 weeks before surgery. These medicines predispose you to excessive bleeding. Your blood pressure should also be under good control if you take medications for hypertension. This is very important.

If you can, try to stop smoking at least six to eight weeks prior to surgery.

Your vision in each eye is measured. Your eyes are examined carefully using a slit lamp (a special ophthalmic microscope). Your tear film status is determined and the back of the eyes (called the retina) is examined as well as the eyelids themselves. The rest of your face is then examined. The general state of your skin is assessed and photographs of your face and eyelids are taken before surgery so that the results of surgery can be compared with the original appearance. The photographs are confidential and can only be used for any purpose other than your own records with your specific written permission.

What should I expect at the hospital?
Following a consultation you are advised to consider the options discussed carefully in your own time. You will be sent you a written report detailing what has been discussed. The letter will only be sent to you unless you have specified that you are happy for the letter to be sent to your GP. You can then research the options further.

Wherever possible, it is preferred that you come back to see your surgeon for a follow-up consultation before proceeding with surgery. At this consultation you will then be asked to sign a consent form saying that you understand the procedure and that you have been told about any risks or potential complications. Very rare complications will be described, as well as any more common ones, so try to keep things in perspective.

If you have any questions or concerns these will be addressed.

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 from cosmetic eyelid surgery 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 eyes immediately after the operation, local anaesthetic used in the operation, weakening of the muscles that control eye movement or swelling of the normally clear covering around the eye (the conjunctiva). Swelling of the conjunctiva 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 me at the clinic.
• Watery eyes - this is quite common for the first few days after the operation due to some irritation of the eyes and an incomplete blink.
• 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. Viscotears) 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.
• 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. This is the most serious potential complication of this surgery. An oculoplastic surgeon is trained to prevent and to manage such a problem.
• Damage to the muscles that move the eyeball causing double vision is an extremely rare problem and this usually resolves by itself with time.
• 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 almost every week routinely.
• 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 extremely unlikely in the hands of an oculoplastic surgeon.
• 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. 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 are given in writing for you to take home following surgery.
• Lower eyelid retraction leaving the white of the eye visible just above the edge or margin of the lower eyelid. The incidence of this in my practice is less than 2%. This is more commonly seen with a transcutaneous lower eyelid blepharoplasty. Precautions are taken to minimise the risk of this developing. It may require further surgery to address it e.g. with the use of a small dermal or dermal fat graft.
• Lower eyelid ectropion. This is a malposition of the lower eyelid where the eyelid hangs away from the eyeball. This is a risk in patients who have a very loose lower eyelid preoperatively. Precautions are taken to prevent this. An ectropion is a common age related problem which is routinely corrected by oculoplastic surgeons.

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.

How long will I stay at the hospital?
Most cosmetic eyelid surgery procedures are performed as day case procedures where you arrive at the hospital in the morning and leave the same afternoon or evening after the operation. Someone must be available to take you home and stay with you for up to 24 hours after the operation. Alternatively an overnight stay may be required if you live some distance from the hospital. Some patients like to stay in a local hotel close to the hospital rather than in hospital over night. You can then return to see the nurses in the clinic/on the ward the following day for a check before going home.

Consultants who undertake this procedure:

Saj Ataullah
Anne Cook
Brian Leatherbarrow
Ahmed Sadiq