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What Is Blepharoplasty (Eyelid Surgery)

Blepharoplasty (also known as tarsoplasty or eyelid surgery) is a surgical procedure used to remove excess fat, skin and/or muscle from the eyelids to create a more youthful appearance around the eye area. Besides correcting baggy, puffy and droopy eyelids that commonly develop with age, this cosmetic procedure is also performed to restore the correct functioning of the affected eyelid. The ageing process around the eye begins in the late 30s or early 40s, as facial muscles start to weaken, eyelids stretch and excess fat accumulates around the eyelids. Sometimes, droopy eyelids may obstruct vision, which can be corrected with blepharoplasty. This procedure cannot be used to remove black circles or wrinkles around the eye.

Blepharoplasty may be performed on the lower eyelids, upper eyelids or both and, depending on the technique used and the extent of surgery, it takes between one and three hours to complete. This procedure is performed under local anaesthesia in an outpatient surgery center. It may be used alone or it can be accompanied by other facial cosmetic surgeries, which can help improve results. Since sagging eyebrows or face can contribute to the appearance of droopy eyelids, additional procedures such as a browlift or facelift may also be performed along with blepharoplasty. Often, patients who have a large overhang in the upper eyelids would get better results if a browlift was performed instead of blepharoplasty.

Types of Blepharoplasty

The two main types of blepharoplasty include transconjunctival and transcutaneous techniques:

Transconjunctival blepharoplasty, in which incision is made through the inside of the eyelid, is used to remove bulging fat from beneath the eyes and does not usually involve the removal of skin. In some cases, in order to achieve a fuller appearance, the bulging fat beneath the eyes can be transferred to more bony areas of the face. This type of blepharoplasty consists in pulling the lower eyelid away from the eyeball while repositioning or removing the fat. The incision can be closed with one or two dissolving sutures, though they are usually not necessary. Transconjunctival blepharoplasty is more suitable for younger patients with thicker and more elastic skin.

Transcutaneous blepharoplasty is different from transconjunctival technique in that incision is made through the outer skin. In fact, incisions are made in areas of the lids where scarring should be the least noticeable such as in the creases of the upper lids or just below the lashes of the lower lids. The surgeon then separates skin from the connected muscle and fatty tissue and removes the excess fat while the loose muscle and skin are trimmed. A few small sutures or stitches are used to close the incision. Transcutaneous blepharoplasty of the upper eyelids happens to be very popular among Asian women born without an upper eyelid crease. This procedure is also known as Asian blepharoplasty.

Before Blepharoplasty

The preparation for surgery should begin with the physician taking a patient’s complete medical history, including medications and lifestyle habits. The patient will be instructed to stop taking certain medications, herbs and supplements that can cause bleeding two weeks before surgery. To avoid skin discoloration, the skin should be protected from sunlight the week before the procedure. You should know that some conditions such as dry eye, thyroid disorder, cardiovascular diseases, diabetes, glaucoma or a detached retina can increase the risk of complications of surgery.

The patient’s eyes will be closely inspected as part of the physical examination performed by the physician. The eyelids are examined, too, to check for the quantity and quality of skin, location of folds, looseness, drooping and other aspects influencing the procedure. In addition, any additional procedures that may be necessary along with blepharoplasty to correct sagging eyelids will be discussed. The appearance of the patient should be documented with photographs before the procedure begins.

During Blepharoplasty

Blepharoplasty is usually performed under local anaesthesia on an outpatient basis in a doctor’s office, hospital or a surgery center while the patient is awake. General anesthesia is given only if several additional procedures are going to be performed. Blepharoplasty is painless, though some patients may experience a pulling sensation or feeling of uneasiness. The procedure typically takes between one and three hours, depending on its extent.

A transconjunctival blepharoplasty is performed only on the lower eyelid. The incision is made inside the interior of the lower eyelid and excess fat is removed. It can be performed either with a scalpel, electrocautery or with laser technology. From the three options, electrocautery is generally preferred due to its high precision and because it is less disruptive to the internal tissues of the eye. However, if a laser is used to make the incision, no bleeding occurs. After the surgery, the incision may be closed with one or two dissolvable sutures, which, however, is often unnecessary and the cut is left slightly open. In fact, the surgical scar from the incision remains hidden beneath the skin, which makes it unnoticeable to the patient and others.

Transcutaneous blepharoplasty is largely used for surgeries of the upper eyelid, though it can be used for correcting the lower eyelid too. The surgery of the upper eyelid begins with marking the area of the skin where the incision should be made. A greater area of skin may need to be removed than during a lower eyelid procedure as the skin folds back naturally when the upper eyelid opens. Once anaesthetic takes effect, the incision is made either using a scalpel, electrocautery or laser and a section of the skin and the underlying fat are removed. Any remaining excess skin is then trimmed and stitched or sutured closed.

After Blepharoplasty

Following the surgery, the eye is wetted thoroughly for protective purposes and the eye area is covered with a small bandage. Ice packs may be applied to minimize swelling. Most patients can leave for home on the day of surgery, though some may be required to stay overnight in the hospital. Patients may be examined weekly in the initial weeks after blepharoplasty. Over time, examinations are needed only once or twice yearly. Patients may begin to feel tightness and tenderness in the eyelids following the procedure which is normal as the anesthesia wears off. The eyes may feel sticky or gummy but also dry, burning and itching for the first couple of weeks. Eyedrops may be used to relieve most of these symptoms. Scars may take as long as three to six months to recede. Once this occurs they are practically unnoticeable.

Other temporary difficulties associated with blepharoplasty include:

  • Swelling, puffiness, numbness or discoloration of the eyelids or eye area. Ice packs or cold compresses may be applied to help minimize swelling and bruising. These difficulties usually subside within two to three weeks following blepharoplasty.
  • Blurred or double-vision usually caused by drops or ointment applied to the eyes during and after surgery.
  • Excessive tearing due to exposure of the tears producing glands is relatively common and usually temporarily.
  • Light sensitivity to sun or bright light for a few days after the procedure.
  • Pain is mostly moderate and easily manageable with over-the-counter pain relievers.

Patients are advised to seek medical attention if any of these symptoms persist for longer than what the surgeon considers as normal. The common measures that can help to speed up recovery and minimize the risk of complications include:

  • Not using facial cosmetics for at least ten days following blepharoplasty to avoid an allergic reaction
  • Not wearing contact lenses for at least two weeks
  • Sleeping with the head elevated higher than the chest
  • Not lifting heavy weights
  • Avoiding strenuous activities

Patients can usually return to work and other daily activities in about seven to ten days following blepharoplasty. Since the eyes are often sensitive to sunlight and wind in the first couple of weeks after surgery, patients are advised to wear sunglasses during this time.

Benefits and Potential Risks of Blepharoplasty

The main benefit of blepharoplasty is the improvement of the patient’s appearance. Some patients may also experience improved vision if a drooping eyelid interfered with their sight. The results of blepharoplasty typically last for several years and for many patients they are permanent. However, there is always a risk that the patient will not like the results. Fortunately, most aesthetic complications can be fixed by repeating the procedure.

The most common aesthetic complications of blepharoplasty include:

  • Uneven folds, multiple folds and folds that are too high or too low
  • Worsening of wrinkles and lines of the eyelid skin
  • A skeletal appearance under the eye due to excess fat removal
  • An uneven appearance when compared to the mid and lower face

Some of the most serious complications associated with blepharoplasty include:

  • Bleeding behind the eye is the most serious complication associated with lower lid blepharoplasty because it can lead to permanent blindness. This condition is also known as orbital haemorrhage.
  • Blood clot behind the eyeball is a rare but serious complication of blepharoplasty. The most frequent symptom of this complication is a steady, stabbing pain resembling that of glaucoma. Less common symptoms include abnormal bulging of the eyeball out of the socket, dilated pupils, eye redness and swelling around the eye.
  • Dry eye syndrome is a complication that may occur in patients with impaired tear glands. Patients with this syndrome have to use artificial tears to keep the eyes moist.
  • Slowing of the heart rhythm can occur in patients who receive local anesthesia for blepharoplasty.
  • Exposed lining of the eyelid, when temporary, is relatively common following lower eyelid blepharoplasty. However, permanent exposure may rarely occur. Corrective surgery or skin grafting may be needed to correct this problem.
  • Watering of the eye is a common, temporary complication caused by irritation of the cornea which triggers excess tearing.
  • Double-vision is a rare complication caused by injury to the muscles that control eye movement.
  • Facial nerve injury is a rare but serious complication, especially for patients undergoing transcutaneous lower eyelid blepharoplasty.
  • Collection of fat under the eye is the most common complication associated with transconjunctival blepharoplasty. These fatty lumps can be usually dissolved with the use of compresses or massage. Sometimes, steroid injections may be needed.

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