Blepharoplasty has become one of the most requested facial cosmetic procedures, surpassing even facelift and rhinoplasty in popularity.
Blepharoplasty is a Greek word that originates from “Blepharo”, which refers to the eyelids, and “plasty” referring to making changes. So, blepharoplasty literally means plastic surgery of the eyelids. Blepharoplasty can be further classified into upper eyelid and lower eyelid surgery. The surgery can be used for both reconstructive and cosmetic surgery procedures and is intended to reshape the upper or lower eyelid by removing or repositioning excess tissue and reinforcing the surroundings of the soft tissues.
In the upper eyelid, common changes which are a combination of facial ageing and genetics include hooding of the upper eyelid, skin laxity and fullness associated with orbital fat prolapsing forwards. Upper blepharoplasty involves trimming excess skin and shaping the underlying soft tissues, including the orbicularis oculi muscle and orbital fat. In all patients there is individual variation in facial ageing as a consequence of genetic, environmental and ethnic factors, Dr De Silva advises surgery should be tailored to the individual as the shape of the eyelids, contour and relative ageing are all unique. Non-surgical methods are not effective in re-shaping the upper eyelids.
Common changes in a person’s lower eyelids include bags under the eyes, swelling, skin laxity and wrinkles. Often, patients describe being questioned by friends, family and colleagues regarding tiredness and lack of sleep. The swelling and eye bags are caused by orbital fat coming forwards through the eyelid as a bulge. Although common in patients over thirty, Dr De Silva sees many patients who have changes in their late teens and twenties as a consequence of their genetics.
Lower blepharoplasty is usually a cosmetic procedure. It involves removing fat from around the lower portion of the eye, which generally causes bulges around the eyes as we age. The procedure can be performed from inside the eyelid, or possibly through a small incision in the skin just below the eyelash line. Dr De Silva uses the more advanced hidden incision technique to avoid visible scars in the eyelid. There is individual variation in facial ageing in all patients as mentioned above, and surgery should be tailored to each individual.
Trans-Conjunctival blepharoplasty is the more modern surgical technique for lower eyelid surgery/blepharoplasty. The technique avoids a visible incision, as the surgery is performed from the inside of the eyelid. The transconjunctival technique accesses the lower eyelid from the inside of the eyelid, leaving important anatomy (including the skin, orbicularis oculi muscle and orbital septum) intact. The technique is more challenging to perform, but overall is safer and avoids leaving a noticeable scar.
The older surgical technique is termed transcutaneous lower eyelid surgery/ blepharoplasty and involves making a surgical incision in the lower eyelid. The older technique results in a scar in the lower eyelid skin and has a risk of lowering the lower eyelid resulting in lower lid retraction or rounding of the lower eyelid.
There is a degree of artistry in lower blepharoplasty. Key to the success of the surgical technique is removing an optimal amount of fat. If too much is removed, it results in a hollowed-out appearance to the lower eyelid. Whereas, too little fat removed results in a remaining fat bulge. Dr De Silva’s approach is conservative and preserves as much of the orbital fat as feasible with the fat translocation technique.
Increased droopiness of the upper eyelids is a common change with increasing age. It is frequently a result of ageing of the eyelids and increased laxity in the soft tissues.
Non-surgical treatment options for droopiness of the upper eyelids include lifestyle changes (healthy sleep, reduced stress), the use of wrinkle injections in the forehead area, limited skin tightening with radiofrequency or laser resurfacing. However non-surgical options are usually of only modest effect with a short and limited improvement. Only a surgical correction will improve the appearance after the changes are more readily apparent.
Assessment of the eyelids is crucial to exclude other factors that may be influencing the position of the upper eyelids including ptosis, dry eyes or thyroid eye disease. Ptosis is a condition where the fine muscle that elevates the eyelid has become weak or detached, requiring ptosis correction surgery to improve it. Patients who have undergone previous laser refractive surgery should have an evaluation to exclude dry eyes before considering upper eyelid surgery.
Upper blepharoplasty helps improve the shape of the eyelids by rejuvenating their appearance. Most changes in the upper eyelids and lower eyelids are a consequence of facial ageing. However some changes are related to both genetics and the environment (e.g. sun damage and smoking). Blepharoplasty in the upper eyelid involves trimming excess skin and shaping the underlying soft tissues, including the orbicularis oculi muscle and orbital fat.
Although fat bulging of the upper and lower eyelids is usually seen as one of the characteristics of an ageing face there are a smaller proportion of patients who have a genetic predisposition to eyelid ageing. In these patients, fat bulges may be present in their late teenage years and early twenties.
The treatment of lower eyelid bags in young adults with a negative vector requires specific techniques to support the lower eyelid after blepharoplasty, which is essential to avoid lower eyelid retraction. Support of the lower eyelid ensures a good shape to the lower eyelid after surgery.
Some patients may require additional techniques combined with lower blepharoplasty for the best result, including lower eyelid volume augmentation, fillers and cheek implants.
Dr De Silva has had patients travel long distances for opinions on lower eyelid bags, who have been refused surgery by local surgeons. However, please note lower blepharoplasty is not always indicated if you have very early signs of lower eyelid bags.
There is no specific age limit for blepharoplasty. Key to a successful blepharoplasty is your general health and fitness. If you have any underlying medical conditions such as high blood pressure, it is important to check and control with appropriate medication.
An assessment of your general medical health and your specific eyelids is important to ensure safety and to guide surgical planning to obtain the best result. Often there may be additional factors to consider with increasing age, these can include dry eyes, eyelid laxity and droopy eyelids (termed ptosis), which may require additional treatments at the same time of surgery to ensure a successful result.
In addition, the choice of anaesthesia is important. Local anaesthesia or twilight anaesthesia has additional safety benefits over general anaesthesia and a quicker recovery time.
– To look refreshed
One of the early changes in facial ageing can be attributed to softening of the contours of the eyelid skin and bulging of fat pockets above and below the eyes. With droopy eyelids or bulging pockets, the face may project an inappropriate look of fatigue and lack of vigour despite adequate rest and good health. Friends and relatives may frequently comment on how patients look tired.
– Easier to apply eye makeup
One of the reasons for blepharoplasty is “I can’t put my makeup on like I used to without it getting all over the place”. Early symptoms of blepharoplasty may include various changes, including the diminishing appearance of the upper eyelid with hooding and puffiness. This is most noticeable to patients when they have difficulty applying makeup to the upper lid, and is one of the commonest features patients describe.
In the upper eyelid, as a result of the ageing of the soft tissues, there can be an unnecessary amount of upper eyelid skin present which would benefit from upper blepharoplasty. The skin may hang over the eyelashes and can cause a loss of peripheral vision. A cosmetic effect of the excess skin is that it can reduce the eye’s youthful appearance by decreasing the amount of visible upper eyelid, which is referred to as a reduction in tarsal show or dermatochalasis. With time, the fold of skin may cover the upper aspect of the eye, commonly affecting the field of vision and causing difficulty with activities including reading or driving.
In the lower eyelid, fat pockets may bulge forwards and lower blepharoplasty is required to improve the puffy appearance of the lower eyelids and to reduce eye bags and wrinkling of the skin.
Many plastic surgeons perform blepharoplasty in the same or similar manner for all patients. An analogy for this would be like visiting a hairstylist who can only cut everyone’s hair in the same way. Achieving a natural-looking rejuvenation that does not look like a patient has had surgery requires an artistic interpretation by the surgeon and a customized approach for each patient.
Depending upon the scope of the procedure, the operation takes approximately 1 to 3 hours to complete. The procedure may be completed only on the upper eyelids, the lower eyelids or both concurrently. Commonly, surgery may be combined with tightening the lower eyelid tendon (canthopexy or canthoplasty) or rejuvenating the lower eyelid skin (laser treatment or skin peels).
Blepharoplasty will not correct changes in the skin quality including pigmentation, discolouration or wrinkles. The procedure may be coupled with skin resurfacing techniques, including peels or laser treatments to improve skin quality. The dynamic lines that are seen at the corner of the eyes, often termed crows fee, are a consequence of the activities of the orbicularis oculi muscle underlying the skin. These wrinkles are not affected by blepharoplasty and are best treated with anti-wrinkle injections treatments.
Other medical conditions do not necessarily preclude you from blepharoplasty, but Dr De Silva will want to ensure you are in the best possible health before he considers you for surgery. Medical conditions that are a concern include:
Depending upon your medical history and age, certain medical and laboratory tests may need to be ordered before eyelid surgery. An ECG/EKG or heart tracing is required on men 45 and over and women 55 and over as routine screening. Blood work may need to be performed depending upon individual health history. Women of childbearing age should undergo a pregnancy test the week before the surgery to make sure that they are not pregnant at the same time as undergoing blepharoplasty.
Smoking has a negative impact on surgery by delaying healing and may lead to unsatisfactory results. If you are a smoker you are advised to stop smoking, or at least to cut down on cigarettes for at least one week before eyelid surgery. Smoking slows down the recovery process and it can also increase the risk of complications.
It is important to avoid any medications that thin the blood and encourage bleeding before eyelid surgery. This includes aspirin, ibuprofen, vitamin E, and any type of herbal supplement. You should stop all vitamins and herbal supplements two weeks prior to surgery.
It is important that blepharoplasty patients arrange a caretaker for the first 24 hours after their surgery. Patients need a responsible person to be with them for the first night. Patients are not allowed to drive themselves, take public transport or stay home alone because of the effects of anaesthesia. The London Facial Plastic Surgery staff will ask for your caretaker’s name and contact information, as well as who will be taking you home from the recovery room after your surgery.
Blepharoplasty is routinely performed under local anaesthesia and may include the use of sedation (oral or intravenous), also called MAC (Monitored Anaesthesia Care) or “twilight anaesthesia”. Compared to general anaesthesia, local anaesthesia with sedation is associated with less bleeding, increased safety and faster recovery.
Upper eyelid blepharoplasty is completed through a fine incision in the upper eyelid skin crease. This makes the scar barely visible even as early as 1 week after the surgery.
In lower eyelid blepharoplasty the incisions can be made through the skin or through the conjunctiva (a hidden incision through the inner aspect of the lower eyelid), or both approaches concurrently. The advantage of the transconjunctival incision (through the conjunctiva) is the incision cannot be seen after surgery and it may reduce postoperative swelling, bruising or lower lid retraction. The incision through the lower eyelid skin may be preferable if there is excess skin to prevent excessive wrinkling or rolling of the skin.
The technique used is often based on a mixture of clinical signs and the surgeon’s preference for technique.
The concept of laser blepharoplasty to cut-through tissues in place of the scalpel is being suggested as an alternative to traditional surgery. However, there is a degree of marketing hype that surrounds the use of laser technology in a number of medical fields, as there is a lack of validated medical studies showing the advantages of laser blepharoplasty.
The eye sits in a bony socket of the skull, termed the orbit. Orbital fat cushions the eye from the bony walls of the orbit. The bulges in the upper and lower eyelid are caused by prolapse of the orbital fat.
The volume of fat is very small and is less than 5cc in volume. The only method of removing this fat at present is through blepharoplasty surgery. There is no current evidence that medical treatments with creams or injections are able to reduce the volume of bulging eyelid fat.
There is initial swelling and bruising that occurs after blepharoplasty surgery, which takes about 1 to 2 weeks to resolve. With the use of ice packs (a bag of peas or frozen rice in a ziplock bag will suffice) applied every hour while awake for the first three days, there is a reduction in the amount of postoperative swelling. Typically, the patient may return to normal non-strenuous activities 1 week after the procedure and after 2 weeks the eyelids are, on average, 90% improved. The best result is usually seen several weeks to several months later.
Blepharoplasty is an operation that can reinvigorate an ageing face by the removal of excess skin and fat bulges. However, if too much skin or fat is removed from the eyelids it can result in a hollowed or tight appearance and the whole face will appear aged and unnatural. This can be difficult to correct.
Although a hollowed-out appearance of the upper eyelid was fashionable in the 1980s, the long term appearance is unsatisfactory, and modern-day surgery places emphasis on avoiding such an appearance. The modern-day philosophy in eyelid rejuvenation focuses on restoring natural and youthful characteristics by relying less on subtraction and more on the restoration of volume, with the goal of looking like yourself, but younger.
The anatomy of the eyelid is unique, complex and includes multiple layers of soft tissues to bone, including unique skin, fat pockets, numerous muscles, tendons, a tarsal rigid plate and conjunctival lining that lubricates the surface of the eye. The skin of the eyelid is very thin and represents the thinnest skin on the body, enabling the rapid movement required for blinking. Underlying the skin is the orbicularis oculi muscle, which acts as a circular ring around the eye, closing the eye shut. Beneath the muscle is a fibrous layer, termed the septum, that separates the eyelid from the contents of the orbit (bony socket that the eyeball sits in).
The orbital fat is the cause of fat bulges in the upper and lower eyelid as it prolapses through the fibrous septum. There are multiple variables in eyelid anatomy that differs from person to person as a consequence of both genetic and environmental factors. Each blepharoplasty is tailored toward the needs of each patient, requiring surgical interpretation and modification of the technique for the best results.
Eyelid surgery is not regarded as painful, but generally causes a mild ache or discomfort which usually settles within 48 hours. Typically, over-the-counter analgesia is sufficient to reduce the discomfort (e.g. Paracetamol or Tylenol).
Most patients experience some bruising, particularly of the lower eyelids, but it is usually gone within about 2 weeks.
Postoperative swelling tends to peak the day after surgery, and mostly resolves over the next two weeks. Sometimes, a small amount of swelling may persist for several months or more after eyelid surgery.
When you arrive home after eyelid surgery we encourage you to relax and keep your head elevated on several pillows, at a 30-40 degree angle. For the next two weeks, you should sleep on your back with your head elevated.
For the first 48-hours, you should use ice compresses over your eyes for approximately 15 minutes of every hour. This reduces swelling and aids your comfort.
You may shower the day after your surgery and care should be taken to avoid the direct spray of water on your face. Baby shampoo is preferred for washing your hair because it is gentle on your eyes.
Avoid straining, or doing activities that cause a feeling of pressure in the face and eyes. Strenuous physical should be avoided from 2-6 weeks. You should not be driving if you are still taking pain medicine or have any blurring of vision.
Eyeglasses can be worn after your surgery if you need them. Contact lenses can be used after a 2-week period. Sun exposure should be avoided as much as possible.
Most people are advised to take a week off work. However, in most cases, normal tasks can be resumed within two days. Exercise or any strenuous activity that may lead to an elevation in blood pressure are advised against for a minimum of 1 to 2 weeks as they will lead to an increase in swelling and delay in resolution.
Many patients ask about using a computer and watching television. Eyelid surgery causes some blurring of the vision for several days as a consequence of eye drops, ointment and swelling. Watching television or using a computer will not affect the healing process and can usually be resumed after several days.
In upper blepharoplasty, the incision is hidden in the crease of the eyelid and is often difficult to see even 1 week after surgery.
In lower blepharoplasty, the incision is placed either in the conjunctiva (termed transconjunctival) of the eyelid, in which case it is completely hidden. Or, the incision is made just below the lower lid eyelashes (termed transcutaneous). Within several weeks this incision is hidden by the eyelashes of the lower eyelid.
The eyelid skin is unique in that it is very thin, and although patients who are predisposed to keloid scarring may worry about developing them, keloids on the eyelids are exceptionally rare.
Upper Blepharoplasty Scar at 6weeks. All scars are initially slightly pink in colour and lumpy bumpy in appearance. Over a period of weeks to months, the colour returns to normal and the scar smoothens out. Dr De Silva takes care to hide scars in natural lines and creases and avoid scars wherever possible. Issues with scars are relatively rare and occur in less than 1%.
Lower Blepharoplasty at 6weeks. No scar is visible. Dr De Silva prefers to avoid scars in lower eyelid surgery by hiding the scars and completing the surgery on the inside of the eyelid. There are a small proportion of patients who may not be suitable for this technique however each patient’s surgery must be tailored to the individual to give the best possible natural-looking result.
Puffy eyelids have a similar ageing and negative appearance on a man as they do on a woman. More men are seeking blepharoplasty on a year-by-year basis.
In the competitive and youth-oriented world of business, both men and women have come to appreciate that in addition to being well-qualified for a particular job, their appearance remains a key component of success.
The dark circles that may occur around the eyes may be a combination of ageing changes in eyelid contours and actual pigmentation changes in the skin. Blepharoplasty may improve the appearance of dark circles around the eyes as a result of recontouring, however, surgery does not result in a complete cure of dark circles. The treatment of dark circles often involves a multi-disciplined approach using both medical and surgical tools to reduce their appearance.
There is interchangeable terminology here and it is worthwhile clarifying that eyelid hollowness is different to cheek hollowness (tear trough).
If the eyelids themselves have become hollowed due to previous blepharoplasty or ageing changes, the treatment is challenging and highly complex. The restoration of volume around the eyelids is fraught with technical difficulties owing to the very thin characteristics of the skin. Volume restoration following hollowing requires individual evaluation as it will depend on multiple characteristics including severity, location, skin colour, thickness, and previous treatments.
There are often a number of different treatments, both surgical and non-surgical, that may be utilised to improve the hollowed appearance.
This is an important symptom that should be known to the clinician before surgery. Blepharoplasty has a tendency to make the eyes drier and depending on the severity of the dry eyes, the surgical technique should be modified accordingly. Patients with severe dry eyes would require a markedly conservative surgery to avoid a potential increase in symptoms of post-operative dry eyes.
Blepharoplasty is one of the commonest cosmetic procedures in the world and is regarded as safe. As with any surgery, some potential risks and complications may occur.
Complications in blepharoplasty may occur because of several reasons. One of the most important factors responsible for the success of the surgery is the surgeon. The surgeon must have complete knowledge of how the surgery has to be performed. Blepharoplasty, particularly of the lower eyelid, is demanding and requires in-depth knowledge of anatomy and attention to detail. Dr De Silva’s number one procedures are blepharoplasty and revision blepharoplasty.
Complications can be defined as any unforeseen occurrence during or after the surgery. The complications that can occur during or after blepharoplasty may be divided into four categories; intra-operative, immediate post-operative, early and later post-operative.
Intra-operative complications occur during the surgery. For example, these can occur due to a reaction to some medication or due to the local or general anaesthesia given. They are managed by the surgical team at the time of surgery.
Immediate post-operative complications occur immediately after the surgery when the patient is in the initial recovery stage and may include bleeding or a reaction to the medication. These complications need to be handled immediately by the surgeon who operated.
Early post-operative complications in blepharoplasty occur once the patient has been discharged. These appear almost immediately after the person returns to a normal routine. They can include bleeding, a reaction to medication and infection. They can be corrected by contacting the doctor immediately.
Late post-operative complications associated with blepharoplasty may occur when the patient fails to take proper care after the surgery due to the surgical technique used or the patient’s body’s response to the healing process.
Complications in the upper eyelid include asymmetry, scarring, hollowing, inability to close the eyes and dry eyes. In the lower eyelid complications include asymmetry, residual fat bags and lower lid retraction. Most of these complications are minor and can easily be corrected. However some, for example, lower lid retraction, require complex revision surgery with the use of graft material and reconstructive techniques.
The commonest complications are bleeding and bruising, all of which are treatable. There is a risk of asymmetry between the two eyes and this may settle with time or in approximately <5% cases may require a small revision procedure that can be completed under local anaesthesia. The most serious and feared complication of blepharoplasty is loss of vision following surgery due to bleeding that collects behind the eye. This is an extremely rare complication and if recognized early it can be treated. Blepharoplasty is generally a popular surgery with high patient satisfaction and a low risk of complications.
Blepharoplasty, like all cosmetic surgery, is dependent on the technique and skills of the surgery. There are techniques that have been developed over the past 10 years with an emphasis on obtaining a natural result that avoids changing the appearance of the patient. The focus is on the rejuvenation of the eyelids to make them appear 10 or more years younger.
How do you know if your surgeon’s technique will suit what you have in mind? The best way to evaluate a surgeon’s technique is by looking at photographs of their past patients.
There is no surgery that can result in perfection. The nature of surgery is dependent on 3 principle factors: the patient (a combination of genetic and environmental factors), the surgeon and technique, and the healing process—which differs from patient to patient.
Generally speaking, patients have a high degree of satisfaction after surgery. However, those expecting perfections are likely to be disappointed.
Blepharoplasty is a long-lasting surgery that generally has a lifelong result. All of us develop further ageing signs over time. So, if you have blepharoplasty in your 30s to 40s that turns the clock back 10 years, you will have further ageing after your surgery, but it will be 10 years behind!
Blepharoplasty may be conducted by surgeons with a number of different subspecialties, including oculoplastic surgeons, oculofacial plastic surgeons, facial plastic surgeons (ear, nose and throat surgeons), general plastic surgeons, oral and maxillofacial surgeons (dental surgeons) and dermatologists. The spectrum of surgeons will have different interests, techniques and experiences that will vary considerably.
In the United States, it has been estimated that an average cosmetic or plastic surgeon performs less than one blepharoplasty per month, compared to oculoplastic surgeons who complete blepharoplasty for cosmetic and reconstructive indications between 10 to 20 cases per month. An oculoplastic or oculofacial surgeon is a plastic surgeon who is a specialist in eyelid surgery and blepharoplasty with a vast knowledge of the structures immediately around the eyes.
Cost is tailored to individual patient needs, based on the type of blepharoplasty and whether it is combined with additional procedures. For example, is upper eyelid surgery, lower eyelid surgery or both required simultaneously? Do additional techniques need to be used to enhance the results, i.e. volume augmentation, skin resurfacing or specialised eyelid contouring techniques?
Also, prices differ depending on whether it is a revision or primary blepharoplasty, as revision blepharoplasty can be challenging technically. For an accurate assessment of price, a consultation is recommended. If you decide to have surgery, the consultation fee will be deducted from your surgical fee. Shopping for price may be counter-productive, as a good long-lasting result that is free of problems is the preferred outcome. Although cost is an important issue, the quality of your care and outcome is the most crucial factor. Low-cost surgery is ill-advised as there will be compromises in safety and the quality of the result.
Blepharoplasty is most commonly a cosmetic procedure that is not covered by insurance or the NHS. In cases where the eyelid droops severely and reduces a patient’s upper field of vision, or is secondary to an underlying medical condition then health insurance may cover the cost of upper eyelid surgery.
Any medications that have a potential to thin the blood and increase bleeding should be avoided before surgery. These include avoiding aspirin, ibuprofen (and other anti-inflammatory medications) and vitamin E products for 2 weeks prior to and after surgery. You may take paracetamol or panadol if experiencing pain such as a headache. This is very important as if you take such medications your surgery may have to be postponed to another date as there is an increased risk of bleeding.
Relatively strenuous activity such as swimming, gym or other athletic activity should be avoided for a minimum of two weeks. A sport that results in high pressure and potential traumatic injury to the eyelids needs to be avoided for two months, this includes diving and water skiing. After surgery, sports should be avoided for a minimum of two months.
After blepharoplasty you may wear eye shadow or false eyelashes a minimum of ten days after surgery.
Asian blepharoplasty is defined as eyelid surgery that creates or re-defines an upper eyelid crease. It may appear that there are many different ways in which the surgery can be performed, but effectively there are only two types of surgery. One uses stitches to form the eyelid crease and there is no removal of the excess tissue. It tends to be temporary and often requires repeating. The other is with a skin incision to remove excess tissue. There is also a third type that is a hybrid version of the suture and skin incision method, which also tends to be short-lasting). There are many different types of suture techniques that have been described, which are all variations on the same theme. Dr De Silva prefers to use the skin incision method as this leads to a natural appearance and long-lasting results.
Most patients are able to have upper blepharoplasty under local anaesthesia alone. Modern-day medications can avoid the need for sedation or general anaesthesia, the advantage being a more comfortable experience and faster recovery.
Lower blepharoplasty may also be completed under local anaesthesia, but the lower eyelid is more sensitive than the upper eyelid and the use of sedation may be a useful adjunct for surgery. With lower eyelid surgery, it is often combined with other procedures such as fat grafting and skin resurfacing. With these additional procedures, light sedation is generally preferred. General anaesthesia is not a requirement of blepharoplasty unless a patient has marked anxiety or relative resistance to local anaesthetics.
One week after surgery the majority of the swelling and bruising will have resolved. In fact, approximately 80-90% of the swelling resolves over this period. There are steps that you can take to speed up the recovery process, such as applying cold compresses in the first three days after surgery, sleeping with your head elevated and remaining relatively sedentary by avoiding exercise for at least the first week.
You can wash the day after surgery. The eyelids will be stitched, but you must avoid rubbing or scrubbing the eyelids as this will encourage swelling and may lead to mild bleeding. Any crusting on the eyelids can be cleaned with water and cotton buds or an eye pad. Avoid using a hand towel or flannel to clean the eyelids as this may not be adequately clean for the healing eyelids.
Healing after surgery includes a process of inflammation. This process attracts cells and other healing agents to the area of surgery that leads to the repair of the soft tissues and the healing process. As a consequence of inflammation, the eyelid swells, which is variable and unique to each person.
In general, the inflammation and swelling gets worse for three days before improving on the fourth day. For some people, the time is shorter. There are steps that you can take to reduce swelling and speed up the recovery period, including the use of cold compresses on the eyelids after surgery and sleeping with your head elevated.
Sedation is also known as “twilight anaesthesia” or MAC (Monitored Anaesthesia Care). Twilight anaesthesia means that your body is sleepy and relaxed but you are still conscious and able to respond to questions and instructions—unlike general anaesthesia where you are unconscious and the recovery after surgery is longer. Typically you won’t remember the procedure or the short period of time following it, though you will feel a little euphoric. Most of our patients have eyelid surgery under local anaesthesia with or without sedation. The benefits of sedation are that it relieves your anxiety around surgery and the recovery is faster.
With upper eyelid surgery, the stitches are generally removed one week after surgery. Dr De Silva uses very fine non-absorbable stitches that are removed one week after surgery, these stitches cause minimal irritation and scarring. Dissolvable stitches can also be used which fall out themselves, but they can cause more irritation. Fibrin tissue glue can be used in place of the stitches, so there are no stitches that need to be removed.
Stitch removal causes minimal irritation and discomfort. No numbing creams or anaesthesia are required for the removal of stitches.
Eyelid fat that bulges forward in the lower eyelids with facial ageing is orbital fat that functions to cushion the eyeball, both supporting and protecting the eyeball from the bone skull. This fat differs from body fat and does not change with weight loss. Unlike other facial cosmetic surgeries including neck lift and facelift surgery, losing weight will not have an effect on bags around the eyelids. However, exercising and weight loss do have a positive effect on health and well-being, as well as a positive effect on healing and improving recovery after surgery.
Immediately after eyelid surgery it is very common that the eyes do not close completely due to swelling. The eyelids are impaired by local anaesthesia which prevents closure of the eyes. Over the first 6-weeks, it is common that the eyes may be slightly open as they will not be blinking 100% as a consequence of swelling after the surgery. After this, the blinking and closure of the eyes will return resulting in normal eyelid closure. If the eyes are not closing your surgeon may advise the use of tear lubricants to avoid symptoms of dryness and exposure. The front surface of the eye is very sensitive, and dryness can be uncomfortable.
The surgical technique used for upper blepharoplasty is important to avoid too much soft tissue being removed, which can result in difficulty closing the eyelids long-term. Additionally, it is a challenging problem to correct. Dr De Silva takes great care with measurements of the eyelids prior to surgery to prevent this occurrence.
Generally speaking, difficult closing the eye is common soon after the surgery and with normal healing this returns over a period of weeks, tear lubricant drops may be required during this period.
The eyes are a key feature of communication and they may indicate a lack of sleep or tiredness as a result of changes from facial ageing.
Common changes around the eyelids are loose skin, heaviness of the soft tissues and the appearance of eye bags. These changes are effectively reduced or removed with blepharoplasty, or eye lift surgery as it is sometimes referred to.
The position of the eyebrows does change in position in some people. However, lifting the eyebrows can have dramatic effects and in some people change the person’s appearance. Although some people appear to have low brows as they age, often after looking at old photographs, these individuals also had low brows in their youth. The brow can drop with time as a result of a group of depressor muscles pulling the brow down with facial expressions, including frowning and squinting.
In contrast, only a single muscle called the frontalis elevates the brow with a facial expression. These muscles are often treated with wrinkle injections to reduce forehead and glabellar lines and wrinkles. Wrinkle injections can result in drooping of the brow by impairing the frontalis muscle that elevates the brow.
A youthful feminine brow is positioned above the level of the orbital rim, which is the upper margin of the bony socket in which the eye resides. An elegant female brow is gently arched laterally, with the “tail” of the brow going higher than the inner aspect near the nose. However, this is a generalization as each woman can have highly variable positions of the brow, including low-set brows, depending on their genetics and ethnicity. Care is required when performing brow lifts in these patients as lifting a naturally occurring low brow can change a person’s appearance. In the past, brow lift surgery was common, but we now know that many people who had low brows in their youth do not necessarily need their brow lifting when they are older. Dr De Silva always adopts a conservative approach as this gives a more natural-looking result.
In a man, the position of the masculine brow is often lower at the boney margin of the orbital rim. Dr De Silva advises caution against lifting the brows in men as it can create a surprised and more feminine appearance. There is individual variation in the position of the brows that guides treatment.
Blepharoplasty is more commonly required to give a natural rejuvenation around the eyes and is required more commonly than brow lifting. Every person is unique and the degree of changes in their appearance must be evaluated individually. In addition, other factors may be relevant to both blepharoplasty and brow lifting including dry eye and previous laser refractive surgery.
With Upper Blepharoplasty the incision can be hidden in the natural skin crease, which means although there is a scar after surgery the scar is virtually invisible as it is hidden in the natural skin crease. Care is required with the surgical technique and position of the skin crease as a person’s eyes and facial appearance can be changed if the detail of the upper eyelid is not adhered to. Dr De Silva has corrected the position of this scar when the scar has been placed too high by other surgeons, or it becomes visible and looks unnatural.
Closure of the skin with stitches also can affect the healing of the scar. Non-absorbable stitches that require removal are generally preferred as these cause minimal irritation of the skin surfaces and minimise scarring. After the surgery, like all scars anywhere in the body, the scar can initially be thicker in texture and occasionally have small bumps. With time the fibres remodel and the scar thins over a period of months. Gently massaging the scar may aid this process. In most people, after 12-months the scar in the upper eyelid is barely visible.
Some individuals may have a medical condition that causes increased scarring, termed Keloid scarring. If you have keloid scarring you should inform Dr De Silva. The skin around the eyes is relatively unique as the thinnest skin in the entire body, but this appears to offer protection against keloid scarring in the eyelid area.
In lower eyelid surgery, the Lower Blepharoplasty can be completed through the skin (transcutaneous) or the inside lining of the eyelid (trans-conjunctival). Dr De Silva’s preference is the trans-conjunctival blepharoplasty which avoids any scars in the lower eyelid as the surgery is all on the inside of the lower eyelid. The trans-conjunctival technique is a newer technique and some surgeons may not offer it. Some surgeons prefer the older skin incision technique (transcutaneous blepharoplasty), and although it is technically more straightforward, it always leaves a scar on the skin. The scar can be seen immediately below the eyelashes in the lower eyelid. After months the scar does fade, particularly in Caucasians, however it cannot be made entirely invisible, unlike the trans-conjunctival approach.
Overall, modern surgical techniques can make scarring after blepharoplasty very difficult to be seen.
After surgery, there is a period of recovery when it is best to leave contact lenses out to enable healing of the eyelids and avoid unnecessary stretching of the skin when the tissues are healing. For upper eyelid surgery, it is best to wait for 1-week before using your contact lenses. For lower eyelid surgery it is best to wait for 2-weeks before using your contact lenses. A further consideration is that with blepharoplasty the tear production may be affected, and the eyes may feel more tired for a few weeks after surgery. Thus, it may be more comfortable to reduce contact lens wear to 6-8 hours for the first few weeks.
The surgical technique conventionally uses a scalpel to remove skin and soft tissues, and additional instruments to reduce bleeding and swelling. The laser blepharoplasty technique is a new technique that uses a laser to remove skin and shape soft tissues. The laser beam cauterises incisions as it cuts, which results in little bleeding. The benefit to patients is less bleeding and a shorter recovery time with reduced bruising and swelling. Many surgeons do not have access to such a laser and are not able to offer laser blepharoplasty to their patients. Dr De Silva utilises both laser blepharoplasty and conventional scalpel surgery, offering a tailor-made approach to individuals dependent on their specific eyelid changes and signs of facial ageing.
Blepharoplasty helps improve the shape of the eyelids by rejuvenating their appearance. Immediately after blepharoplasty surgery, the eyes may feel dry as a consequence of swelling and reduced blinking.
Laser refractive surgery improves the refractive properties of the eyes to improve vision and involves making a flap in the front window (termed cornea) of the eye, followed by laser treatment. The procedure often results in some dryness immediately after the surgery, and contact lenses are often placed over the eyes to aid recovery in the short-term period.
Although blepharoplasty is surgery on the eyelid only with no surgery on the eye itself, both different techniques can lead to dryness immediately after the procedure. It is recommended that they are not completed on the same day and that a minimum interval of 6 weeks to 3 months is left between the different procedures.
There are some advantages to completing the surgery at the same time. The recovery is generally 1-2 weeks for both surgeries, hence the recovery time is doubled if the procedures are completed separately. In addition, there is a cost-saving as returning to surgery for a second time does result in increased use of resources.
Dr De Silva finds that some of his patients prefer to have both surgeries completed at the same time. Yet others prefer to have a shorter procedure first, and after gaining confidence in the results, have the other eyelids as a second procedure. The decision to have the procedures at the same time or separately is a personal preference and will not affect the final result of the blepharoplasty.
Having a small lump on the eyelid incision after blepharoplasty is relatively common. Often a small lump soon after surgery may be healing scar tissue which will improve with time. If, however, it continues to enlarge in size and has a shape like a small ball it is likely to be a cyst. In the skin, there are small glands that can produce a small cyst if they become trapped. They are not serious and have no long-term implications. It is not known why some people are more prone to cysts, but it is likely to be partly due to genetics and skin type. A small cyst may spontaneously resolve but if it is increasing in size it may be necessary to complete a small procedure to remove the lesion. The procedure to remove a cyst usually takes less than 5-minutes with local anaesthesia.
When considering having further eyelid surgery it is key to wait a sufficient time until healing is complete from the previous surgery, which may taken 6 to 12 months. However, the timing of revision surgery does depend on the indication for revision blepharoplasty and the underlying symptoms. Dr De Silva performs revision upper blepharoplasty and lower blepharoplasty on patients who have been to other surgeons and who have undergone surgery abroad. Swelling is often present for months after surgery and early intervention may be less predictable. In specific situations, such as eyelid retraction with dryness and symptoms of ocular irritation, Dr De Silva advises urgent surgery to avoid damage to the person’s vision.
With upper blepharoplasty, artistry is required with the surgical technique to hide the scars in the natural creases of the upper eyelid. If there is marked laxity in the skin towards the outside of the eye, the natural lines (termed crows feet) can be used to hide the incision. Often there are eyelid asymmetries and changes in the position of a person’s skin crease that occur with facial ageing that need to be taken into consideration to give a final natural-looking result. The final result of a scar is 12-18months after surgery, and with careful planning and consideration should result in a fine line that is hidden in a person’s natural skin crease. Dr De Silva has revised the scars of patients who have undergone surgery elsewhere to improve symmetry and hide the skin incisions in a natural eyelid crease.
Multiple factors cause dark circles around the eyes. These commonly include a combination of loss of volume (fat loss resulting in depression and shadow under the eyes), very thin skin (thinnest in the body) with fine blood vessels visible under the skin, ethnic pigmentation, skin laxity and wrinkles.
As a consequence, each of these factors needs to be addressed with treatment. The combination of treatments may include non-surgical treatments, such as volume augmentation of the tear trough depression. This does not require general anaesthesia or surgical intervention and has a rapid recovery of less than one week. During recovery, there may be mild bruising and some swelling in the lower eyelid.
For some patients, there may be additional changes in the lower eyelid including fat bags and/or malar oedema and skin laxity. These additional changes may require eyelid surgery (blepharoplasty) to correct.
Unfortunately, there is no cream used in isolation that is effectively going to improve dark circles on their own. However, some patients find a combination of specific eye depigmentation creams may be used with non-surgical or surgical treatments to enhance the results.
As a general principle, dark circles can be substantially improved with a customised approach to their treatment. There is not a single treatment that offers a silver bullet, and most treatments will be effective in offering an improvement, as opposed to a cure.
The length of a blepharoplasty or eyelid procedure will depend on the complexity of the surgery. On average, an upper blepharoplasty will take from one to two hours. There is a great deal of individual variation in eyelids and good surgery requires meticulous attention to detail. It is important that your surgeon takes adequate time to complete the surgery cautiously and without rushing. Combined upper and lower blepharoplasty takes on average two and a half hours. The other consideration is a type of anaesthesia as local anaesthesia generally requires a slightly longer surgery, as further anaesthesia is added during the surgery which can take additional time.
Dr De Silva allows a minimum of two hours for most eyelid procedures and allows additional time to ensure the best possible result. For more complex blepharoplasty, including laser resurfacing and combination treatments such as fat transfer and canthopexy, up to three hours may be required. Dr De Silva generally limits blepharoplasty to four hours as after this time there can be increased swelling affecting the appearance of eyelids.
In most people, discomfort and pain after blepharoplasty settles 24-48 hours after the surgery. In a minority of patients, some sensitivity and discomfort may be apparent for several weeks. In some patients, the eyes can be dry for a period of weeks, and they may feel uncomfortable or painful. Tear lubricants are useful to help reduce these feelings during the recovery period. There can be a wide variation in individual patients’ pain thresholds, but most patients report only mild or minimal discomfort.
With the techniques Dr De Silva uses most patients describe surprisingly little pain, and usually for less than 24-48 hours. Oral analgesia is adequate for a couple of days after surgery, and many of Dr De Silva’s patients never take any analgesia.