Also known as eye-bag surgery or an eyelift, blepharoplasty is the removal or repositioning of eyelid skin, muscle, or fat.
The procedure can be carried out in the upper or lower eyelid. People have this operation because of eyelid hooding or eye-bags. In the upper lid people are often trying to lift skin away so that they can see their eyelid again. In the lower lid people are often trying to reduce the tear trough and achieve a fresher less tired look.
What is an eye-bag?
An eye-bag is a bulge in the eyelid. It is most commonly seen in the lower eyelids but sometimes also in the upper. It is caused by eyelid fat falling forwards, which is a normal ageing change. In addition the muscle of the eyelid may become loose and sag.
What is the tear trough?
The tear trough is the groove in the lower eyelid that forms beneath an eye-bag. The eye-bag casts a shadow over the tear trough causing a dark ring or tired look. Surgery can flatten this area and reduce the darkness.
What is Upper Eyelid Hooding?
The skin loosing its elasticity, usually due to age, causes upper eyelid hooding. The excess skin falls down, covering the lower part of the eyelid. It may be associated with prolapse of orbital fat causing the eyelid to bulge (eye bags).
Upper eyelid blepharoplasty
At the beginning of the operation the amount of skin to be removed is carefully assessed. Marks are drawn on the eyelid with a sterile marking pen to show the area to be removed. Local anaesthetic is 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. If there is fat prolapse in the upper lid this may be treated with partial fat removal. 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 after one week. 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 canthopexy’ 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’. Lower eyelid skin is excised in much smaller amounts than in the upper lid. This is to avoid the unwanted side effect of eyelid retraction. This operation may be carried out under general anaesthesia, local anaesthesia plus intravenous sedation or simply local anaesthesia on its own.
What are the benefits of Blepharoplasty?
Surgery can produce a refreshed appearance of the eyelids and help to overcome the tired look that eye-bags and excess eyelid skin can cause. Excess upper eyelid skin may reduce the visual field due to the skin hanging over the edge of the eyelid. 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 eye-bags and tear trough. 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 the excess skin and eye-bags however this will not damage your eye in any way. These problems tend to very gradually worsen with time.
What will happen before surgery?
Before the operation you will attend a consultation with Mr McCormick. He will take a full medical history, examine your eyes and face and explain treatment options including risks and benefits. He will 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 operation you have decided to undergo and then discuss it in detail. This will include any risks or possible complications of the procedure 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 or she will carry out blood tests and an ECG (heart tracing) if required. You will be told if you need to starve before surgery.
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, dabigatran, apixaban, aspirin, clopidogrel (plavix), dipyridamole (persantin). This decision is made on an individual basis and you should only do so if it is safe and your GP, surgeon, or physician has instructed you. This will be discussed with you before surgery. You should avoid herbal remedies for 2 weeks prior to surgery as some of these may cause increased bleeding at the time of surgery. 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?
All surgery caries a risk of bleeding and infection, both are fortunately uncommon in blepharoplasty. Infection might present as increased swelling and redness of the skin. There might also be yellow discharge from the incision. It is treated with antibiotics. Bleeding may present as fresh blood oozing from the site of surgery or a lump appearing near the incision after the operation. Simple pressure on a skin is usually enough to control minor bleeding. Rarely bleeding after blepharoplasty 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.
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 3 months to completely subside but usually improves significantly in the first 2 weeks. Bruising will take up to 2 weeks to resolve. Cool compresses may help this swelling to settle. Purpose made eyelid cool-packs will be given to you before you go home and they also can be purchased in pharmacies. It is important not to put ice in direct 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 you should use chloramphenicol ointment to the eye, for the first 2 days. Antibiotic ointment should be applied to the incisions 4 times a day for 2 weeks to help prevent infection.
Post-operative instructions
If an eye pad is placed it should remain until the next morning when you may remove it. For the first 10 days clean the incisions 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. 5 minutes, 5 times a day for the first 5 days. Chloramphenicol ointment to incisions, four times a day for 2 weeks and to the eyes for the first 2 days. 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).
