Blepharoplasty

What Is Blepharoplasty?


Blepharoplasty is one of the most commonly performed functional and cosmetic facial plastic surgical procedures. It is generally a safe and effective aesthetic treatment, which, in the right hands, will offer a significant improvement in appearance, with a low-risk profile. Blepharoplasty deals with the contours of the upper and lower eyelid space.

An upper eyelid blepharoplasty concentrates on the region between the eyebrow and the eyelashes. Lower eyelid blepharoplasty focuses on the area between the eyelashes and the cheek. In essence, a blepharoplasty procedure concerns the removal of excess skin and muscle from these areas and either reduces or repositions the underlying fat to a more youthful configuration.

Why Undergo Eyelid Surgery?

Blepharoplasty can be performed for a variety of reasons. The ‘tired’ look is the most common reason as to why patients opt for blepharoplasty surgery. The heaviness of the eyelids and bags under the eyes give a constantly exhausted and tired appearance.

In some patients, the appearance of the eyelids may be asymmetric and blepharoplasty may be performed to improve symmetry.

For some people, saggy upper eyelid skin can obstruct the visual field (you may not be able to see the full extent of your lateral vision) so blepharoplasty is performed to remove this obstruction and improve vision.

Additionally, there are several disfiguring conditions, such as Thyroid Eye Disease, which require blepharoplasty surgery to restore the natural appearance of the eyes. This type of surgery is highly specialised.

How do Ageing Changes Occur Around the Eyes?

As we get older, the eyelid skin often shows the earliest signs of ageing, as the elastic fibres within the skin tissues are lost, leading to a loss of resilience and a sagging appearance of the skin. As the skin ages, the underlying orbicularis oculi muscle also loses tone and becomes loose with redundant bulk of muscle.

A significant exacerbating factor is the forward movement of fat from the eye socket. This fat is normally retained by the orbital septum, which weakens with time and then allows fat to herniate forward, causing the tell-tale bulges in the inner aspect of the upper eyelid and also lower eyelid bags.

Another key ageing change is the descent of the midface. A youthful lower eyelid harmoniously shares a contour with the cheek. The ageing lid often becomes disjointed from the cheek as the midface descends, making us appear older.

Moreover, a youthful face is full of volume, which is also lost with age, causing lines and hollows and sometimes a gaunt appearance. Although these are all natural ageing changes, they are accelerated by smoking, sun exposure and hereditary factors.

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At What Age Should You Get a Blepharoplasty?

Eyelid surgery is usually undertaken after the late 30s or older when the signs of ageing have manifested. However, it really is a matter of preference, as there is no age requirement for blepharoplasty.

If there is a real underlying problem, the surgery can be performed in the early 20s. Many patients with constitutional lower lid bags will have surgery at this age.

How Is Blepharoplasty Surgery Performed?

There are two different types of blepharoplasty: upper eyelid blepharoplasty and lower eyelid blepharoplasty. The way the surgery is performed is different depending on the type, but many years of expertise is required to execute all forms of blepharoplasty surgery.

Upper eyelid blepharoplasty is a procedure offering rapid recovery. The blepharoplasty incision is measured and marked. Variable amounts of skin, underlying muscle and fat are removed, or if there is pre-existing upper eyelid hollowness, these tissues can be repositioned to fill the hollows, in order to achieve a pleasing and youthful appearance of the eyelid and to improve the visual field. After the desired amount of excision is accomplished, hidden dissolvable stitches are used to close up the skin surface.

A lower eyelid blepharoplasty is a more complicated procedure, requiring an incision under the eyelash line, running beyond the corner of the eye. Excess skin, muscle and fat can then be removed or repositioned through this incision. Sometimes, particularly for younger patients, the main aesthetic issue is the underlying fat bulge. In these cases, a transconjunctival ‘scarless’ approach through the inside of the eyelid is preferred.

The skin closure is made using either removable sutures or with glue, meaning that sometimes no suture removal is required. Mr Ezra will advise on which method would be most appropriate for you.

Animations representative of the procedure can be viewed on the procedure animations page. Please note that these animations provide a general guide to how the procedure is performed and do not in any way accurately reflect the surgical technique applied to each patient.

What Type of Anaesthetic is used?

Upper eyelid blepharoplasty surgery is most often performed under local anaesthesia, either with or without sedation. Lower eyelid blepharoplasty is usually performed under Local anaesthesia with sedation, or general anaesthesia if the patient prefers.

When having both upper and lower eyelid surgery together, Mr Ezra’s preference is for general anaesthesia, owing to the length of the procedure, although this could be performed under local anaesthesia with sedation if the patient prefers.

Plastic Surgeon or Oculoplastic surgeon?

This is the first question you need to approach. Eyelid surgery is a highly specialised area. It is anomalous that general plastic surgeons still carry out aesthetic eyelid surgery, given that all functional surgery of the eyelids is undertaken by oculoplastic surgeons in every hospital throughout the UK as there is a recognition that eyelid surgery is best undertaken by surgeons trained in eye surgery.

Although many plastic surgeons are competent at executing aesthetic eyelid surgery, they have no training in ophthalmology and are unable to examine the eye, understand eye disease, anticipate eye problems that may affect the surgical plan, or identify complications.

Plastic surgeons have no training is the use of the basic equipment required to examine the eye. In contrast, Oculoplastic surgeons have training throughout several years in microsurgical ophthalmology followed by highly specialised training in the oculoplastics only. This means that the status of the eye itself is paramount in the eyelid surgery planning.

The table opposite summarises some of these differences.

Oculoplastic SurgeonPlastic Surgeon
Well trained in executing eyelid surgery
Also performs facelift, Breast augmentation/reduction, tummy tucksX
Trained to deal with functional eyelid disease such as eyelid cancer, ptosis, entropion and lid malpositionsX
Performs eyelid (and related) surgery onlyX
Trained to examine the eyeX
Can identify pre-existing eye diseaseX
Can examine the eye postoperatively to ensure that there are no eye related complicationsX
Can manage any eye related postoperative complications if they ariseX

What Happens During a Blepharoplasty Consultation?

When you attend a consultation for the first time, you will have a full and detailed history taken which will include your medical history and a discussion of your goals of any prospective surgery. You will also be counselled on what the expected outcomes may be to ensure that your expectations are realistic and achievable.

An essential aspect of the consultation is an evaluation of older photographs to ensure that surgery is planned to suit your facial features and history and to ensure that you still look like ‘you’ after the surgery.

You will also have a detailed examination of the eye and eyelids as well as the facial skin and underlying tissues to ensure that the surgery will not compromise the health and integrity of your eyes. If drooping of the brows or eyelids is present, this will be taken into consideration and an eyebrow lift or ptosis surgery may be discussed.

You may also be questioned about any dryness or watering of the eyes and may be asked to undergo some extra tests to eliminate any problems with your tear function.

Daniel Ezra will generally always require a second consultation (either in person or over the telephone) at no extra cost before any prospective surgery to ensure that you have had time to digest the important issues and have a clear understanding of the nature of the surgery, postoperative care, outcomes and potential risks. This will also be an opportunity to have any further questions addressed. Mr Ezra recommends that you write a list of questions to ensure that you have covered all of your concerns.

In addition to old photographs, Mr Ezra also offers a 3D imaging service using the state-of-the-art VECTRA M3 system to allow a detailed evaluation of the facial contours which can sometimes be very helpful in planning surgery.

How Should I Prepare for Blepharoplasty Treatment?

All patients having local anaesthesia with sedation or general anaesthesia will be required to fast (no food, water, cigarettes or gum) for 7 hours prior to surgery. It is also essential not to wear any make-up or apply creams on the day of surgery. All patients should arrange in advance how they will be getting home and should ask a friend or family member to accompany them home.

Before surgery, patients will be asked about their past medical history, including medications they are taking, allergies, smoking habits, previous surgery and more. Any patients who are taking aspirin or other non-steroidal anti-inflammatory drugs, such as Ibuprofen or Voltarol, are instructed to discontinue this for 2 weeks prior to the surgery.

If these medications are essential to treat heart conditions, Dr Ezra will contact the patient’s cardiologist to discuss this further. Patients will also be instructed to cease smoking for a given period before and after the procedure.

What Happens During the Post-Operative Blepharoplasty Recovery Period?

When you awake from the surgery, the first thing that you will notice is that your vision is blurred. This is due to a very thick antibiotic ointment that is applied in order to prevent the ocular surface from drying. You will be asked to use the ointment 4 times daily and this should be applied inside the eye and rubbed onto the wounds. Artificial tear drops can be prescribed to prevent dryness in the postoperative period.

You can typically get up and walk around the evening of the surgery or the following morning. Patients are likely to experience moderate swelling and bruising of the skin. The degree of swelling and bruising differs markedly from patient to patient. The swelling and the bruising both subside within 1-2 weeks for upper eyelid blepharoplasty or 2-4 weeks after upper and lower eyelid blepharoplasty, after which time it is typically not noticeable that you underwent surgery. Please note that there is significant variability in postoperative swelling and a small number of patients may be swollen for longer than this.

In the week following surgery, it is sensible to use a range of measures to reduce swelling. Ice packs should be applied over the operated area for 1 week after the surgery. If specialised ice packs are not available, a bag of frozen peas wrapped in a towel can be extremely effective and these should be applied for a few minutes 3-4 times daily or more if required. Ice packs are applied over the operated area for 24 to 48 hours.

You will also be encouraged to sleep in a ‘sitting up’ position with several pillows under your head. This has the effect of preventing fluid accumulation and the associated swelling. It is also important to avoid strenuous activity for the first 7 days after the surgery. Walking at a gentle pace is encouraged, and patients should try to ensure that they are mobile.

Depending on the clinical details, the surgeon may use dissolvable stitches (sutures) and the skin then closed with glue, which means that no suture removal is necessary. However, sometimes removable sutures will be required and these will then have to be removed after 7-10 days. This will depend on how things settle after surgery.

Usually, makeup can be worn after two weeks.

Is Eyelid Surgery Painful?

Fortunately, a blepharoplasty procedure is rarely associated with significant pain, although appropriate painkillers will be supplied to you so that they are at hand if needed. You can typically get up and walk around the evening of the surgery or the following morning.

How Long Will I Be Off From Work?

Typically, patients having upper lid blepharoplasty surgery can return to work after 7-10 days. It would be unusual for anyone to notice that you have had surgery at this point. For lower lid blepharoplasty, the recovery is longer at about 10-14 days and 2 weeks should be taken off work.

However, for both of these treatments, you should be fine to work from your home using a computer from 2 days after surgery and this will in no way harm the eyes or compromise the outcome of the surgery.

Will I Have a Bandage or Dressing After Blepharoplasty Surgery?

A bandage is usually not required after the surgery. Sometimes, in anticipation of excessive bruising or swelling, dressings may be placed over the eyes postoperatively. Following the completion of the procedure, ointment may be applied over the incisions for approximately one week.

How Do I Wash After Blepharoplasty?

One of the most common questions asked is regarding washing. The following instructions should be followed:

Days 1-2 postoperatively. Keep the eyes dry, but it is fine to bathe without wetting the eyes or have a shower below the level of the nose. The hair can be back washed. Do not worry too much if the eyes get splashed by water, one needs to avoid the wounds being exposed to longer periods of moisture.

Days 3-7: start to wash the eyes gently with soap and water. Lightly dab the eyes to dry them. Do not pick out any of the crusts, they will fall away when they are ready.

Day 7: This is the typical time that the sutures will be removed. Once the sutures are removed, one can get back to normal washing routines.

Day 14: Makeup can be used again.

Does Blepharoplasty Surgery Leave Scars?

Whilst any skin incision will always leave a scar, the eyelids are the site in the body that heal the best with very little residual scarring. The upper lid scar is carefully hidden in the skin crease and disguised very well in the open position. The lower eyelid scars are hidden under the lashes and are barely perceptible. There is usually small scar extending laterally by a few millimetres into the crow’s feet areas which can sometimes be more noticeable. Generally, it is extremely rare for noticeable scarring to be an issue for patients after blepharoplasty. This is in contrast to other forms of facial aesthetic surgery, such as a facelift, where the scars are much more of an issue for patients.

The photographs here demonstrate the typical degree of scarring of the upper eyelid after 6 and 12 weeks.

Mr Ezra has undertaken laboratory research on skin cells derived from the eyelids to investigate their scarring potential. He has identified that eyelid fibroblasts (scarring cells) differ in comparison with other cells in the body, having a much lower propensity to contract and form scars, even in response to pro-scarring growth factors. This unique aspect of eyelid cell biology explains the light nature of scarring in the periocular area.

6 weeks after surgery 6 weeks after surgery 12 weeks after surgery 12 weeks after surgery

How long do Blepharoplasty Results Last?

The results of blepharoplasty are long-lasting and natural. The surgery is designed to improve the look of the eyelids, and most patients do not feel the need to undergo a second procedure. Of course, the natural ageing process continues and the results do vary between patients, but we find that the majority of people are happy with the results of blepharoplasty which should last between 10-15 years.

Will I Need Revision Surgery?

Although the result of blepharoplasty surgery may be expected to last for years, the natural ageing process will continue. Drooping and bulging of the eyelids may, therefore, recur. This is not down to any post-operative failure or complications.

As with all aesthetic surgery, an "ideal" result may not be achieved after one surgical procedure and subsequent refinements may be necessary. In such instances, additional approaches can be considered.

Can Other Procedures be Done at the Same Time?

Patients will often opt for ‘Blepharopasty Plus’ and have additional procedures which can enhance the result of blepharoplasty. The blepharoplasty plus page covers a range of procedures which can be used to enhance the initial result.

UPPER LID BLEPHAROPLASTY: ADVANCED TECHNIQUES

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