Upper Eyelid (Blepharoplasty) Surgery Step-By-Step
Written by Dr. Julian De Silva
Upper Eyelid (Blepharoplasty) Technique
The goal of upper blepharoplasty surgery is to enhance the natural curvature of the eyelid, uncover the skin immediately about the eyelid (termed the tarsal platform), sharpen the upper eyelid skin crease and remove any bulging of the fat pockets that tends to come forward with age. The key for natural looking surgery is to avoid hollowing the eyelid or altering brow position, these are the sequela that give an unnatural “done” appearance. This appearance is completely avoidable with good surgical technique and experience.
The images below are taken from Dr. Julian De Silva’s forthcoming book on Facial Cosmetic & Plastic Surgery, the sequence of figures show the principles of blepharoplasty only, blepharoplasty surgery is tailored to the individual.
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 15-20 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 the 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. Julian 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 speed-up recovery.
Underlying the 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 2-3mm 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 boney 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 they 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. Fifteen 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 fibrin glue with blepharoplasty. This surgical innovation is preferred by his patients, as it enables the surgery to be completed with no skin stiches. In addition the tissue adhesive works on the triggering the patient’s natural clotting, as a result the technique reduces both bruising and swelling, speeding up the recovery. The glue is not suitable for all patients, where there is greater potential for tension on the soft tissues, such as revision eyelid surgery. Dr. De Silva prefers to use a combination of interrupted and continuous non-dissolving fine stitches in these cases to allow for scarring and changes in the natural anatomy.
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.
Recovery after Blepharoplasty
The majority of patients undergoing cosmetic eyelid surgery report mild aching that is well controlled with paracetamol and cold compresses. Most patients have minimal discomfort after surgery and usually analgesia is not required. Ice packs should be used immediately after surgery and for 3-days.
Swelling peaks on the morning after surgery and then mostly resolves over the next week, using intermittent ice packs speeds up this process.
Most people experience moderate bruising that begins to fade several days after surgery and is gone by two weeks. There are generally two philosophies after surgery. Some people prefer to “lay low” for about 1-week until the majority of the eyelid swelling and bruising has resolved. Other people who are not concerned about resolving bruising and swelling, are largely back to normal after 2-3 days.
Normal day-to-day activities may be resumed within two days of surgery. Strenuous activity should be avoided for 3-weeks.
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