Blepharoplasty surgery is now available at One Ashford Hospital, but what exactly does it involve?
Consultant Plastic Surgeon Miss Anita Hazari explains what is involved in cosmetic eyelid surgery (blepharoplasty) and what you can expect from the procedure.
The skin loses its elasticity and our muscles slacken with age. 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 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 bags 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 the 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.
Bags are caused by an accumulation of fat and with age the skin stretches and the muscles around the eye weaken.
What can be done?
An eyelid reduction (blepharoplasty) 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. If only the fat is being removed from the lower eyelids, then this can be removed from the inside of the lower eyelid avoiding an external excision (transconjunctival blepharoplasty).
What are the consequences?
People who have the familial problem of bags beneath the eyes may well undergo surgery in their 20’s. Ageing effects of the skin are apparent earlier in the eyelids than elsewhere. A reduction of the skin can be carried out from the age of 35. Patients with thyroid disease often develop eye signs which can be helped by surgery. Where there is reduced secretion of thyroxine (hypo-thyroidism) there is an increase in fat and where there is an increase in thyroxine (hyper-thyroidism) there is often so much increase in fat that the eyes protrude. An extended eyelid reduction (Olivari’s procedure) can treat this satisfactorily.
What are the limitations?
It is important for you to understand that only the wrinkles which are in the skin will be removed. We are only treating the eyelids within the bony margin of the orbit (eye sockets). 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 eye the upper eyelid will need to have surplus skin when it is open. Descent of the eyebrow can be helped by endoscopic brow lift. Sometimes residual or recurrent wrinkles are suitable for treatment by chemical peeling, dermaroller micro-needling or laser resurfacing. The operation has no effect at all on the dark colour of the lower eyelid.
Upper eyelid surgery can be carried out under local anaesthesia or general anaesthesia. Lower blepharoplasy is usually performed under general anaesthesia, especially if procedures such as canthopexy or re-draping of lower lid fat is being carried out. In a typical procedure the surgeon makes incisions following the natural lines of your eyelids; in the creases of upper lids and just below the lashes in the lower lids (see illustration). These incisions are extended a little way into the crow’s feet or laughter lines at the corner of the eyes. Through this incision surplus fat is removed and excess skin and sagging muscle removed in upper blepharoplasty. In lower lid blepharoplasty, though fat is sometimes removed, generally fat is draped or reset to restore a more youthful contour. Most patients with some lower lid laxity will require a canthopexy (tightening of the lower lid lateral canthal tendon) to prevent eversion or a downward pull on the lower lid leading to scleral show (more visibility of the white of the eye). The trade-off is that the lower lid may appear tight and this could last for 2-3 weeks after surgery. Occasionally, a lateral tarsorraphy (making the eye aperture smaller by placing a suture lateral to the dark of the eye) may be required to protect the eye and decrease the swelling under the conjunctiva (chemosis) for the first 3-4 days after surgery. If you have a pocket of fat beneath your lower eyelids without surplus skin then the fat may be removed through the inside of the lower eyelid.
Following surgery it is best to keep your head elevated for a few days to reduce swelling. Cold compresses can also help. The surgeon will normally apply some suture strips or steri-strips as support to the eyelids after surgery and if these become crusted they can be replaced. Cleaning the eyes with water is useful and the surgeon may advise the use of eye drops or ointment. If a lateral tarsorraphy suture is placed, it is then removed 3-4 days after surgery. The rest of the sutures are usually removed after 5-6 days and soon after you will be able to use make-up. Sometimes you will be advised to use the suture strips or steri-strips as support to the lower eyelids for a week or so. The closure of the eyes appears tight after surgery because of the swelling and because skin has been removed. If closure is not complete at night the patient should apply some eye ointment before going to sleep to avoid corneal exposure. This sensation will settle as the swelling goes down. The eyes appear watery after surgery, partly because of swelling under the conjunctiva (chemosis) and partly because the tear ducts are swollen and do not drain as readily. This will last a few weeks. Although there is 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 become almost invisible.
What are the risks?
All surgery carries some uncertainty and risk. When eyelid surgery is performed by a qualified Plastic Surgeon complications are infrequent and usually minor. You can check that your surgeon is on the Specialist Register kept by the General Medical Council (telephone 0171 9153638). All members of the British Association of Aesthetic, Plastic and Reconstructive Surgeons (BAPRAS) and British Association of Aesthetic Plastic Surgeons (BAAPS) are on the Register. You can reduce the risks by closely following your surgeon’s instructions both before and after surgery. You should tell him/her of any thyroid disease, high blood pressure, diabetes or eye disorder such as detached retina or glaucoma. It may be that he/she will wish you to be checked by an Ophthalmologist. It is important that you provide your surgeon with a recent eye test which records the intra-ocular pressure to ensure that you do not have a tendency for acute glaucoma which may be precipitated if you are prescribed steroid eye drops after surgery. Commonly, there will be swelling of the eyelids and bruising which may take a few weeks to subside. Occasionally a pool of blood can collect under the skin after the operation has finished (haematoma) this usually disperses spontaneously over 2 or 3 weeks but it may need to be drained if it is large. Infection is uncommon. 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 suture strips or steri-strips. However, if you have significant laxity of the lower lid, a canthopexy will be performed at the same time to prevent lower lid malposition. Very occasionally another operation is necessary.
Dry eyes or watering of the eyes may persist for a few weeks, especially if present before the operation and may require eye-drops. Though scars settle and fade well in most patients, some patients may occasionally develop hypertrophic scarring. Sometimes tiny white cysts can appear along the stitch line. They are nothing to be concerned about but can be pricked out with a needle. Blindness is an exceptionally rare complication and is due to bleeding behind the fat in lower lid surgery.
Miss Anita Hazari
Miss Anita Hazari has been a Consultant Plastic Surgeon at the world- famous Queen Victoria Hospital NHS Foundation Trust, East Grinstead since 2006.
Anita is a fully accredited specialist in plastic surgery, and is on the Specialist Register in Plastic Surgery with the General Medical Council and is a full member of BAPRAS, BAAPS and ABS.
She has written several papers on breast reconstruction. Her research thesis was on nerve regeneration and the Royal College of Surgeons of England recognised her original work in nerve grafting, awarding a Hunterian Professorship in 1999.
For further information on Miss Hazari, please click here