Upper Blepharoplasty Surgery
Step-by-step upper blepharoplasty
The overhanging skin of the upper eyelid is first marked with the patient either 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 woman between 8-10mm, there is considerable individual variation in skin crease position between people. Dr De Silva uses your natural crease in the majority of patients unless there is marked natural asymmetry or the skin creases are inconsistent with a natural looking result as a high skin crease can look artificial in some facial shapes. When the eyelid has been marked, this shape leaves an ellipse in the upper eyelid. The surgeon’s technique and appreciation of fine eyelid anatomy is key to remove the correct amount of excess skin. Inadequate removal will result in a residual overhang of skin, 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.
The bottom edge of the upper eyelid ellipse follows the line of the natural eyelid crease and 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 your recovery.
Underlying the eyelid skin is a ring of orbicularis muscle that surrounds the eye, this muscle provides 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. This 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 the opposite side.
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 with a combination of factors including ageing, environmental factors that promote tissue aging such as smoking or some 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 resulted 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 much more challenging to correct once too much fat has been removed. Thirty percent of the patient’s Dr De Silva treats have had previous eyelid surgery, the eyelids are an intricate part of the face where millimetres make a considerable difference.
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, 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 these 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 has pioneered the use of regenerative medicine with blepharoplasty. This surgical innovation is preferred by his patients, as it enables your natural growth factors to aid healing improve speed of recovery and reduce bruising.
All of Dr De Silva’s patients are able to see after the surgery and are able to go home thirty minutes after the procedure is completed, patients do not require hospital admission overnight with the Dr De Silva’s techniques.
Drooping of the upper eyelid, Ptosis
Drooping of the upper eyelid is a relatively common eyelid condition that usually occurs with aging of the facial tissues. In medical jargon this is called ptosis. Humans have an exquisite ability to recognize less than one millimetre asymmetry between the eyelid heights, and half a millimetre or more drooping of one eyelid can be noticeable. There is a small muscle behind the upper eyelid that opens the eyelid (the levator aponeurosis) and with facial aging or as consequence of genetics (inherited from your parents), the muscle can slip or is weak resulting a droopy eyelid. 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 in the UK and USA 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 over 90% of NHS Hospitals as the treatment of choice. It is notoriously unpredictable with a need for further surgery in 10-30% of patients.
- Hidden incision (Internal Approach) is performed from the under surface 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. Less surgeons in the UK and USA are able to perform this surgical technique. This technique has a far higher success rate, with a need for further surgery in 3-10%.
- Ptosis could also be caused by a nerve problem or from birth and can require further investigations. Rarely if the muscle is too weak, a sling procedure is required that connects the forehead muscle to the eyelid muscle to help elevate the upper eyelid.
The hidden incision technique that involves internal access to levator muscle elevation is relatively less known technique. Dr De Silva uses a modified hidden incision technique as it avoids scarring and more accurate result. In patients with a small amount of ptosis (approximately 1 millimetre) the hidden incision technique gives more predictable and natural looking results.