Austin McCormick

                                                  Consultant Ophthalmic and Oculoplastic Surgeon MBChB, FRCOphth

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Tel: 01517098442                             Fax: 01517097509                                Email:                               Address:  86 Rodney Street  L1 9AR UK

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Cosmetic Eyelid Surgery

Blepharoplasty and Eyebrow Ptosis Surgery

What is dermatochalasis?

•Dermatochalsis is drooping or folding of excess eyelid skin.

•It is caused by the skin loosing its elasticity, usually due to age.

•It may be associated with prolapse of orbital fat causing the eyelid to bulge (eye bags).

What is eyebrow ptosis?

•Eyebrow ptosis is drooping of the eyebrow. This may contribute to hooding of the upper eyelid skin

•It is often necessary to elevate or fix the eyebrow at the time of blepharoplasty surgery

  1.   It is most commonly caused by ageing, facial paralysis and trauma

What is Blepharoplasty Surgery?

•Depending on an individual, blepharoplasty surgery is the removal or repositioning of eyelid skin, muscle or fat.

•The procedure can be carried out in the upper or lower eyelid.

Upper eyelid blepharoplasty:

•At the beginning of the operation the amount of skin to be removed will be carefully assessed. Marks will be drawn on the eyelid with a sterile marking pen to assist the surgeon during the procedure.

•After this, local anaesthetic will be injected under the skin.

•The skin is removed with surgical instruments. Depending on your particular problem, the muscle beneath the skin may be preserved or partially removed.

  1.   If there is fat prolapse in the upper lid this may be treated with partial fat removal.

  2. Sutures are placed to reform the natural skin crease in the eyelid.

•The skin edges are sutured together with a continuous suture that is removed one week later.

•This operation may be carried out under general anaesthesia, local anaesthesia plus intravenous sedation or simply local anaesthesia on its own.

Lower eyelid blepharoplasty:

•There are 4 elements to lower lid blepharoplasty: skin, muscle, fat and eyelid laxity. The procedure you have will be tailored to suit your problem.

•Fat prolapse in the lower eyelid gives the appearance of ‘eye bags’.

•This fat can be excised or repositioned over the orbital rim to create a smoother transition from the eyelid above into the cheek below as is seen in youth.

•Surgery on the prolapsed fat may be carried out without a skin incision from the inside of the eyelid – transconjunctival  or via a skin incision just beneath the eyelashes – transcutaneous.

•The lower eyelid usually needs to be tightened at the time of surgery. Even a small amount of lid laxity can lead to postoperative lower lid retraction if not addressed at the time of surgery.

•This tightening is called ‘lateral canthal suspension’ and involves a permanent suture from the lid to the bony rim of the orbit.

•The orbicularis muscle, which lies directly beneath the skin is often tightened by placing sutures from it to the bony rim of the orbit – ‘orbicularis suspension’.

  1.   Lower eyelid skin is excised in much smaller amounts than in the upper lid. This is to avoid the unwanted side effect following surgery of eyelid retraction.

  2. This operation may be carried out under general anaesthesia, local anaesthesia plus intravenous sedation or simply local anaesthesia on its own.

What is Eyebrow Ptosis Surgery?

•Eyebrow ptosis surgery is the fixation or elevation of the eyebrow to overcome the downward descent of the eyebrow that occurs with age or facial paralysis

Internal brow fixation surgery:

  1.    Permanent sutures (x2 or x3) are placed underneath the eyebrow, fixing it above the bony orbital rim.

  2.    Alternatively a fixation device called endotine may be used to fix the the brow to the bone itself.

•This is performed through the same incision and at the same time as upper lid blepharoplasty.

External direct brow lift:

•Skin and the underlying fat are removed directly above the eyebrow in a crescent shape to lift a descended eyebrow.

•This can only be done in the outer part of the eyebrow so as to avoid damaging nerves that are found under the inner eyebrow.

•Before surgery the area to be excised will be carefully assessed with you sat up. Marks will be made on the skin with a sterile marker pen.

•This is a more powerful operation than internal brow fixation but has the disadvantage of a skin incision that may be noticeable.

•After the excision the skin is sutured together in a deep layer and separate skin layer.

What are the benefits of  Blepharoplasty and Eyebrow Ptosis Surgery?   

  1.   Surgery can produce a refreshed appearance of the eyelids and help to overcome the tired look that eyebags, excess eyelid skin and eyebrow ptosis can cause

  2.   Dermatochalasis and eyebrow ptosis may reduce the visual field due to the hooding of skin over the eyelid. Surgery can improve this.

  3.   In an attempt to raise the eyebrow and excess skin, people often subconsciously over use the forehead muscle. Fatigue of the frontalis forehead muscle may cause discomfort, particularly at the end of the day and exacerbate forehead wrinkles. Surgery can improve this.

What are the alternatives to surgery?

•Non surgical treatments are available to rejuvenate the eyelids. Restylane filler can be used to help lower eyelid bags and Botox can be used to raise the eyebrow non-surgically. Click to see Non Surgical Botox and Non surgical restylane filler sections.

•Some patients weigh up the risks and benefits of surgery and decide to put up with the problem, feeling that the risks of surgery are too great for them – it is an individual decision.

What will happen if I decide not to have surgery?

•You will continue to have a dermatochalasis and eyebrow ptosis however this will not damage your eye in any way.

What will happen before surgery?

  1.   Before the operation you will attend a consultation with Mr. McCormick. He will listen to your problems, examine your eyes and face and explain treatment options including risks and benefits.

  2. Mr. McCormick will ask you about your problem. He will also ask about other medical problems you have, medications you take (bring a list or the tablets themselves with you) and any allergies .

•He will examine your eyes and will determine if you are suitable for surgery. He will explain exactly what type of surgery he will be carrying out

•If you are to proceed with surgery the operation will be discussed in detail. This will include any risks or possible complications of the operation and the method of anaesthesia.

•You will be asked to read and sign a consent form after having the opportunity to ask any questions.

•You may also see a preoperative assessment nurse. He/She will carry out blood tests and an ECG (heart tracing) if required. They will also advise you if you need to starve before the operation.

What should I do about my medication?

•In some cases you may be asked to stop or reduce the dose of blood thinning tablets like: warfarin, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and you have been instructed by your GP, surgeon or anaesthetist. This will be discussed with you before surgery.

  1.   Other medication should be taken as usual. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery.

  2. You should avoid non steroidal anti inflammatory medications for 2 weeks prior to surgery. Other medication should be taken as usual.

What are the risks and possible complications of surgery?

  1. All surgery caries a risk of bleeding and infection, both are fortunately uncommon in these operations.

•Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the wound. It is treated with antibiotics.

•Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the wound after the operation. Simple pressure on a skin wound is usually enough to control minor bleeding. Rarely bleeding after blepharoplsty may track back behind the eye. This is a serious but fortunately rare complication. It presents as pain, bruised or discoloured eyelids, reduction in vision, eyelid swelling, forward protrusion of the eyeball, all of which progressively get worse. If this occurs it is an emergency and you should attend an accident and emergency department immediately where an oculoplastic surgeon will be contacted immediately. If not managed quickly and correctly it can lead to permanent loss of vision.

•Whenever the skin is incised a scar may form. Every attempt is made by the surgeon to minimise and hide scars but sometimes they can be visible. 

•Your surgeon will take great care to excise the correct amount of skin for your eyelid. It is possible for too much or too little to be excised. Too little may be addressed by further surgery to excise more. Too much may require a skin graft into the eyelid.

•If you have a pre-existing dry eye problem or weakness of the eyelids, these symptoms may be made worse by blepharoplasty surgery. Mr McCormick will assess this prior to surgery.

•The site of surgery is in close proximity to the eyeball. Although extremely unlikely, whenever surgery is carried out close to the eye there is a potential risk of damage to the eye and therefore to eyesight.

•If deep sutures are placed, as in internal brow fixation, there is a risk of puckering of the skin above them or discomfort. This is usually temporary but may necessitate further surgery to remove the suture if persistent.

•After surgery there may be numbness of some of the skin around the incision. This is usually temporary returning gradually over months. Rarely it is permanent and may involve larger areas like the forehead.

•You should have the opportunity to discuss the risks of anaesthesia with your surgeon or anaesthetist prior to surgery. Three types of anaesthesia are used for these procedures: local anaesthetic, local anaesthetic with intravenous sedation and general anaesthesia. Sedation means that you are breathing for yourself and don’t have a breathing tube inserted but you are very relaxed and sleepy and often don’t remember the operation. General means you are completely asleep with a breathing tube inserted.

What should I expect after surgery?

•After surgery you may experience some pain. Simple paracetamol is usually enough to control this.

•The eyelids will be swollen and bruised. The swelling usually gets worse gradually over the first 48 hours and then improves. Eyelid swelling may take up to 2 months to completely subside but usually improves significantly in the first 2 weeks. Bruising may take up to 2 weeks to resolve.

•Cool compresses may help this swelling to settle. Purpose made eyelid coolpacks may be purchased or a bag of frozen peas wrapped in a freshly cleaned cloth will suffice. It is important not to put ice indirect contact with the skin as this may cause an ice burn.

•Immediately after surgery the eyelids are weakened by anaesthesia, swelling and temporary denervation. This may lead to weakened eyelid closure. To counter this Mr. McCormick may prescribe artificial tear drops and ointment to the eye, for the first week.

•Antibiotic ointment should be applied to the wounds 3 times a day for 2 weeks to help prevent infection.

Post-operative instructions

  1.    If an eye pad is placed it should remain until the next morning when you may remove it

  2.    For the first 10 days clean the wound using either sterile water sachets or boiled water that has cooled down and sterile cotton wool balls

•Cool compresses should commence as soon as the pad is removed or immediately if there is no pad. 10 minutes, six times a day for the first 4 days.

•Chloramphenicol ointment to wounds, four times a day for 2 weeks

•Viscotears (artificial tears) four times a day to the eye for 1 week

•Lacrilube ointment to the eye at night for 1 week

•No hot drinks or straining for 48 hours

•Sleep at 45 degrees for 48 hours

•Follow up appointment 1 week later for suture removal (if required).

Click here to see before and after photographs                                                                 Blepharoplasty-photos.html

Blepharoplasty, Eye Bags