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Upper Eyelid (Blepharoplasty) Surgery Step-By-Step

How is upper blepharoplasty completed?

Written by Dr Julian De Silva

  • Firstly, the overhanging skin of the upper eyelid is marked with the patient sitting up. The marking is key to the procedure, and in some cases this can take 10-15 minutes to complete.
  • Millimetres make a difference in the eyelid and meticulous care is required to ensure the markings are accurate on the right and left sides.
  • In men, the normal skin crease is usually between 6-8mm and in women between 8-10mm. There is considerable individual variation in skin crease position between people.
  • For the majority of patients, Dr De Silva uses the natural crease in the eyelid to make the incision—unless there is marked natural asymmetry or the skin creases are inconsistent with a natural-looking result.
  • The marked eyelid should resemble an ellipse shape.  The surgeon’s technique and appreciation of fine eyelid anatomy is key to removing the correct amount of excess skin.
  • Inadequate removal will result in a residual overhang of skin, whereas the removal of too much skin and soft tissue will result in troublesome dry eye.
  • In addition, bulging of the fat pockets in the upper eyelid should be marked as this indicates orbital fat that is prolapsing forwards, which is addressed during upper blepharoplasty.
Upper Eyelid (Blepharoplasty) Surgery Step-By-Step
  • The bottom edge of the upper eyelid ellipse follows the line of the natural eyelid crease. It extends from the area just above the tear duct medially to the outer edge of the eyelid opening temporally, where it then arches up upwards and outwards into an existing natural crease.
  • The skin above the incision is gently pinched while the eyes are closed to determine the maximum amount of skin that can safely be removed without pulling up on the upper eyelid margin or down on the brow. The upper eyelid skin is removed using a fine scalpel blade, scissors and forceps.
  • Dr De Silva uses specialised equipment, including CO2 laser precision or electrocautery to aid removal of skin and to minimise bleeding. Reduced bleeding during the surgery results in less bruising and speeds up recovery.
  • Underlying the eyelid skin is a ring of orbicularis muscle surrounding the eye. This muscle plays an important part in blinking. With facial ageing, the orbicularis muscle often acquires increased laxity.
  • Dr De Silva removes 1-2mm strip of muscle in approximately two-thirds of cases, depending on the relative fullness of the upper eyelid and a person’s individual facial ageing.
  • The decision to remove a strip of orbicularis muscle is depending on the amount of fullness of the upper eyelid, the laxity of the soft tissues and symmetry with the opposite side.
Upper Eyelid (Blepharoplasty) Surgery - Step-3 and Step-4
  • In the majority of people, there is a degree of bulging and fullness of the upper eyelids, this is a consequence of orbital fat pushing forwards through the eyelid.
  • The eye sits in a cushion of orbital fat that line the bony orbital socket, this is important in insulating the eyelid for example with exercise to prevent the delicate eyeball coming into contact with the surrounding orbital bone.
  • With time, thinning of the soft tissues often results in a bulging of the orbital fat forwards creating a bulge on the surface of the upper and lower eyelids.
  • Although this may happen in a young adult as a consequence of genetics, it is usually attributed to a combination of factors including ageing, environmental factors, such as smoking or some medical conditions such, as thyroid eye disease.
  • If orbital fat is seen bulging, a structurally fibrous layer known as the orbital septum is opened. The fat is generally removed or shaped, although in some cases the fat is repositioned without excision.
  • Dr De Silva favours conservative removal and repositioning of fat as over-removal of fat can result in a “hollowed-out” appearance to the eyelid that is unappealing.
  • Although it is always possible to remove more soft tissue, including fat, it is far more challenging to correct if too much fat has been removed.
  • Thirty percent of the patients Dr De Silva treats have had previous eyelid surgery elsewhere and are unsatisfied with the results.
  • As the eyelids are an intricate part of the face where millimetres make a considerable difference, the expertise of a surgeon who is specialised in this surgery is always advised.
  • Rarely, there can be asymmetry in this area that can be improved with specialised techniques, including fat transposition and fat transfer.
  • Dr De Silva uses specialised state-of-the-art technology, including a US-manufactured CO2 laser or monopolar electrocautery, to establish meticulous control of bleeding which is key to preventing both bruising and preserving good vision after surgery.
  • The skin incision is closed using a combination of interrupted and continuous non-dissolving fine stitches. Non-dissolving stitches are preferred as they avoid scarring and stitch lines. On occasion, non-dissolving stitches are used which naturally fall out and do not need removal.
  • Dr De Silva also pioneered the use of regenerative medicine with blepharoplasty. This surgical innovation is preferred by his patients, as it enables natural growth factors to aid healing, improve the speed of recovery and reduce bruising.
  • All of Dr De Silva’s patients are able to see after surgery and are able to go home thirty minutes after it is completed. No overnight hospital admission is required with Dr De Silva’s techniques.
Upper Eyelid (Blepharoplasty) Surgery - Step-4 and Step-5

Drooping of the upper eyelid, “Ptosis”

Of key importance when considering eyelid surgery is a thorough evaluation of the eyelids to exclude subtle signs of a droopy upper eyelid, termed ptosis in medical jargon. The signs of drooping may be subtle.

However, recognition is of key importance to ensure a good natural result after eyelid surgery. Oculo-facial plastic surgeons are specialists in this area of facial surgery. Drooping of the upper eyelid is a relatively common eyelid condition that usually occurs with aging of the facial tissues.

“People have an exquisite ability to recognise less than one-millimetre asymmetry between the eyelid heights, and half a millimetre or more drooping of one eyelid can be noticeable,” says De Silva. “Meticulous detail is important”.

There is a small muscle behind the upper eyelid that opens the eyelid (the levator aponeurosis) and with facial ageing, or as a consequence of genetics (inherited from your parents), the muscle can slip or it may be weak, resulting in a droopy eyelid.

Ptosis can be quite obvious and increase over a period of years. In addition, ptosis can also be subtle and vary throughout different times of the day.

Ptosis repair can be repaired in two main ways:

  • Traditional skin incision technique (termed Trans-Cutaneous Approach). The most common method for repairing a droopy eyelid is by making an incision in the crease of the upper eyelid skin, reattaching the muscle and closing the skin with stitches.
  • This method is used in the majority of NHS Hospitals as the treatment of choice. It is notoriously unpredictable, with a need for further revision surgery in 10-30% of patients.
  • Hidden incision (internal approach) is performed from the undersurface of the eyelid, leaving no visible scars. The levator muscle is reattached further down the eyelid in order to allow a wider opening of the upper eyelid. Fewer surgeons are able to perform this surgical technique, but it has a far higher success rate, with a need for further surgery in only 3-10% of patients.
  • Ptosis could also be caused by a nerve problem or from birth and can require further investigations. In rare circumstances, if the muscle is too weak a sling procedure is required to connects the forehead muscle to the eyelid muscle which helps elevate the upper eyelid.

Revision Surgery

Over 30% of Dr De Silva’s patients have undergone previous surgery, termed revision eyelid surgery or revision blepharoplasty.

Click here to read more about Revision Upper Blepharoplasty.

Before & After Photos

Woman's face, before and after Upper Eyelid (Blepharoplasty) treatment, front view

* Results may vary

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