Eyelid surgery (blepharoplasty)

Blepharoplasty, also called eyelid surgery, can remove excess skin, muscle and sometimes fat from the upper or lower eyelids. In some cases, you might only need skin removed but not muscle — or you might need the procedure done on both upper and lower eyelids.

Sometimes blepharoplasty can improve your vision by providing a less obstructed field of view once droopy eyelids are improved.

An upper eyelid blepharoplasty (sometimes called an eye lift) should not be confused with upper eyelid ptosis surgery, which is a procedure to raise the position of the upper eyelid margin by tightening the muscle and tendon that normally elevate it.

Blepharoplasty surgery can also sometimes elevate an upper eyelid margin slightly if the heaviness of the excessive skin is actually "weighing down" the upper eyelid and causing it to droop.

Droopy eyelids are a major reason why some people consider eyelid surgery (blepharoplasty) to remove and tighten excess eyelid skin for a more alert, youthful appearance.

What Is Cosmetic Blepharoplasty?

Cosmetic eyelid surgery is a surgical procedure that is not medically necessary and is performed solely to improve your appearance.

Unfortunately, your upper and sometimes lower eyelids may become droopy or baggy as part of the aging process. Your eyebrows also may sag or droop as a part of the same process.

The eyelid skin stretches, muscles weaken and fat pockets become more prominent as they bulge. This may be a hereditary condition that runs in your family.

Cosmetically, such conditions may detract from the overall attractiveness of your eyes and face and cause a tired or older appearance.

A number of different types of surgeons can perform cosmetic blepharoplasty, including eye surgeons; general plastic surgeons; oral and maxillofacial surgeons; and ear, nose and throat surgeons.

When Is Functional Blepharoplasty Needed?

A functional blepharoplasty (in contrast to a cosmetic blepharoplasty) is eyelid surgery performed for medical reasons.

In most cases, a functional eye lift is performed to remove loose skin from the upper eyelid if it droops low enough to impair your vision for driving or other visual tasks.

Another functional problem is difficulty wearing glasses or contact lenses, whether from baggy upper or lower eyelids.

Other medical conditions that may require functional eyelid surgery include:

• Irritation from excess folds of eyelid skin rubbing together.

• Forehead discomfort from overused muscles that strain to lift sagging skin in the eyelid area.

As with cosmetic blepharoplasty, functional blepharoplasty is most often performed by eye surgeons. However, general plastic surgeons; ear, nose and throat surgeons; and oral and maxillofacial surgeons also perform medically necessary eyelid surgery.

Ptosis and Eyelid Surgery

Ptosis is the medical term for drooping of the upper eyelid — a condition that may affect one or both eyes. Ptosis that is present since birth is called congenital ptosis. Droopy eyelids in general occur when the edge of the upper eyelid (eyelid margin) falls from its normal position.

When the edge of the eyelid falls too low and covers part of the pupil, it can block the upper part of your vision. In most cases, a drooping upper eyelid results from the aging of previously normal structures.

Typically, the eyelid falls when the tendon of the muscle responsible for lifting the eyelid stretches. Surgical correction of a drooping upper eyelid involves repairing the stretched tendon and is most often performed by eye surgeons.

It is not uncommon for a person to develop a droopy upper eyelid following cataract surgery or other eye surgeries because manipulation of the eyelid during a procedure can cause weakening of the muscle that holds the eye open. Stroke and trauma can also cause ptosis.

Who Are the Best Candidates for Eyelid Surgery?

If you don't know whether you're a good candidate for blepharoplasty, schedule an appointment with your eye care professional, who can evaluate you for any medical problems related to your eyelids.

If you don't have a medical reason for a blepharoplasty procedure, you can discuss with your eye care professional any concerns or interest you might have regarding cosmetic eyelid surgery.

You might consider blepharoplasty if you have excessive drooping and sagging of skin around your eyes, which is often due to normal aging. Sagging skin can also be exaggerated when you have other conditions such as puffy eyes caused by eye allergies or edema.

If you are interested in blepharoplasty strictly for cosmetic reasons, then your eye care professional will likely advise you to keep expectations realistic.

While cosmetic procedures can sometimes dramatically improve appearance, the aging process will continue and — as with any cosmetic procedure — changes made during an eye lift will not last indefinitely. At some point in the future, you might want to consider repeating the procedure. However, depending on your health and other factors, a blepharoplasty can last as long as 10 years.

Your eye care professional will also evaluate you for possible surgical risk factors such as dry eye problems, thyroid eye disease and diabetes. Keep in mind that the severity and number of health problems you have may eliminate you as a candidate for blepharoplasty.

For example, smokers are at increased risk of surgical complications because they heal more slowly. If you are a smoker, your eye surgeon may advise you to quit smoking for at least several weeks prior to a procedure.

Eyelid surgery tends to be more difficult to perform on people of Asian descent because of the unique structure of this ethnic group's eyelids. For this reason, Asians might be more at risk of having less-than-optimal outcomes than other ethnic groups.

Preparation for a Blepharoplasty Procedure

You'll need to clarify with your eye surgeon whether you'll be undergoing local or general anesthesia for your eyelid surgery.

If you have local anesthesia, you will remain awake during the procedure, but the area around your eyes will be numbed with a drug administered through a needle. Local anesthesia can be enhanced with the use of systemic sedatives given either orally or intravenously.

You may require general anesthesia if the blepharoplasty is more complicated or if you plan to undergo other cosmetic procedures at the same time.

If you need general anesthesia, you will be given an intravenous injection that will render you unconscious for the duration of the procedure, which can last from 20 minutes to two hours, depending on the complexity of the surgery and whether both upper and lower eyelids are involved.

Prior to the day of the procedure (and particularly if you'll be undergoing general anesthesia), you may be asked to take steps such as these:

• If your eye surgeon advises this, stop taking any medication that can thin your blood and prevent it from clotting normally. This includes pain relievers such as aspirin and ibuprofen. You'll need to stop these medications one to two weeks beforehand to reduce the possibility of excess bleeding during the procedure.

• Eat only a light meal such as soup the evening before your surgery.

• Do not eat or drink anything after midnight.

• On the morning of your procedure, you should take essential medications — such as for blood pressure — with a small sip of water.

• Do not wear makeup of any kind on the day of surgery.

• Make sure someone is available to transport you home and look after you during the first several hours after you are released following surgery.

Procedures are typically performed in a day clinic or at the eye surgeon's office. Ordinarily you would not need an overnight hospital stay unless you plan to have several complex cosmetic procedures on the same day.

What Happens During Eyelid Surgery?

Blepharoplasty can be performed on upper eyelids, lower eyelids — or both at the same time.

Incisions made in the upper and lower eyelid in blepharoplasty are placed so they leave no visible scars after the procedure.

During surgery, incisions are made in the natural folds of the eyelid, in the crease of the upper eyelid and just beneath the lashes or behind the lower eyelid. This way, incisions are virtually unnoticeable after they have healed.

While you are lying down during blepharoplasty, your surgeon will make precise markings to designate where excess skin and fat pads need to be removed. Some underlying muscle may also be removed.

These tissues are removed with surgical instruments such as scalpels, surgical scissors, radio-frequency cutting devices and sometimes cutting lasers. Sutures or tissue adhesives (glue) are then carefully applied to smooth and reconfigure areas around the eyebrows and eyelids.

During the procedure, your surgeon will make judgments about how much skin, muscle and/or fat to remove based on a preoperative evaluation of factors such as your underlying facial muscle structure, bone structure and the symmetry of your eyebrows.

Dry eye patients frequently require that less tissue be removed to avoid exposing more of the eye to the air, which can cause symptoms to worsen.

Your eye surgeon may also use a carbon dioxide laser to enhance the procedure by resurfacing skin and smoothing out any remaining wrinkles in the eyelid and eyebrow area.

In cases where the eyebrows are also droopy, a procedure to elevate the eyebrows may also be appropriate. This procedure, called a brow lift, involves making incisions into the scalp and tightening the skin to lift the eyebrows.

Recovery From Blepharoplasty

Following an eye lift procedure, topical antibiotic ointment will be applied. Eye patches are rarely necessary.

On the first day, you should apply cold packs each hour you are awake for about 10 to 15 minutes at a time. The ice should reduce the swelling and keep bruising to a minimum. On the second day, apply cold packs every few hours for about 10 to 15 minutes at a time.

After 48 hours, warm compresses should be applied to promote faster healing.

Your eye surgeon will instruct you about what pain medication to take (if needed). Most people only need non-prescription pain relievers — narcotics are rarely necessary.

You can expect mild discomfort during the immediate recovery period, but if pain is severe or vision changes occur, call your eye surgeon's office immediately.

While you recover, your eye area will be bruised and red with swollen eyes, particularly during the first few days. The whites of your eyes (sclera) may also become red and bloodshot. It may take a few weeks for healing to be complete, during which time you should not wear eye makeup.

You can resume wearing contact lenses when the eyelid swelling subsides enough to allow the lenses to be comfortable. If you wear eyeglasses, you can put them on carefully at any time after surgery.

Often the sutures used for your procedure will dissolve on their own in four to seven days, and you will not need to have them removed. If non-dissolving sutures are used, then your eye surgeon will remove them about a week after the procedure.

Most people who undergo eyelid surgery report satisfaction and improved self-image, and those whose vision was impaired by excess folds of skin often have improvements in their visual field after surgery.

Possible Complications of Eyelid Surgery

A possible complication of eyelid surgery is a temporary inability to close your eyelids completely. This means that your eyes may become abnormally dry.

Usually this condition resolves after a few weeks or months, during which time you would need remedies such as eye drops, humidifiers or even taping your eyes closed at night to provide lubrication. Some surgeons will have you massage your eyelids a couple of weeks after the stitches have been removed, to soften the remaining skin and allow better closure of your eyelids.

If the condition persists beyond two or three months, an additional procedure might be required to restore enough skin to the eyelids to enable complete closure over the eyes.

Other potential complications of blepharoplasty include:

• Vision loss from retrobulbar hemorrhage

• Eyelid infection

• Double vision

• Noticeable surgical scarring

• Malpositioned eyelids

• Undercorrection (not removing enough of the excess skin)

• Overcorrection (removing too much skin)

• Numbness of the eyelids

If you experience severe pain, a change in vision or any other complications following a procedure, you should call your eye surgeon immediately.

Page published on Wednesday, 16 March 2022