Eyelid Lift (Blepharoplasty)
An upper eyelid lift is a procedure to remove excess skin of the upper eyelid. The goal of the upper eyelid lift is to restore a youthful appearance to the eye region which is then harmonious with other facial features. Some young patients, by heredity, have excess upper eyelid skin. In this case, this is more from genetics than an aging process. These patients can benefit from an eyelid lift even in their twenties or thirties. Extra eyelid skin from aging is more commonly noticed in the late thirties to early forties. Patients often complain of excess upper eyelid skin and “looking tired”. Patients may also complain of excess wrinkling in the forehead due to the fact they are lifting their eyebrows to help eliminate the extra skin of the upper eyelid. They complain of feeling more tired at the end of the day due to this constant contraction of the muscles that lift the eyebrows. It is important when evaluating a patient for an upper eyelid lift that the eyebrows are also examined. The perception of excess upper eyelid skin could in fact be an abnormal position of the eyebrow. A patient may feel that they have excess skin of the upper eyelid, when, in fact, once the brow is lifted into a normal position, the excess eyelid skin disappears. Therefore a patient may only need a brow lift procedure to improve their brow position, which then improves their upper eyelid. Or, they may need a combination of both upper eyelid lift and brow lift to give them the best results.
The incision for this procedure is in the eyelid crease so it is not seen when the eyes are open. The incision is carried into a natural wrinkle of the outer eyelid and once it is healed, is very difficulty to detect. In years past, fat was removed from the upper eyelid quite frequently to decrease the fullness in the upper middle eyelid. This is still performed occasionally but we are much more conservative about removal of the fat as we have found that the amount of facial fat tends to decrease with aging and can actually result in a more aged appearance of the eye in later years.
Occasionally older patients may also have ptosis of one or both of the eyelids, which is sagging of the eyelid margin itself rather than just extra skin of the upper eyelid. This may cause a partial block of the patient’s vision and would need to be corrected at the same time as the upper eyelid lift. Although upper eyelid lift is most commonly considered a cosmetic procedure, quite extensive excess upper eyelid skin that blocks vision or actual eyelid ptosis is often covered by insurance due to the fact that it is medically necessary to improve vision. If either of these are a possibility, the patient will be referred to an ophthalmologist or optometrist for visual field testing to see if the blepharolasty will be covered by their insurance company.
The upper eyelid procedure is a thirty to sixty minute procedure done either in the office under local anesthesia, or in the operating room under local anesthesia with sedation. After surgery, the patient should be driven home and should have a friend or family member with them the first night after the procedure. The patient needs to keep their head elevated, and ice on the area as much as possible the first 24 hours to decrease the swelling and bruising. Slightly blurry vision due to swelling may occur. Sunglasses are recommended to protect sensitive eyes. Discomfort for 1-3 days at incision sites is common. The sutures are removed in 5 to 7 days and makeup can be placed as soon as the incisions are healed. Patients may return to work within 3-7 days for upper eyelid surgery and slightly longer for lower eyelid surgery.
Lower eyelid lift procedures consist of several different options to rejuvenate the lower eyelid. Because excess skin of the lower eyelid does not block vision, the lower eyelid procedure is almost always considered a cosmetic procedure. A patient will benefit from a lower eyelid lift if they have moderate excess skin and wrinkling of the lower lid and/or they have excess lower lid fullness. A youthful lower eyelid has very little distinction between the lower eyelid and cheek margin. With aging, a separation develops between the lower eyelid skin and the cheek skin resulting in a hallowing between these two, which is referred to as a “tear trough” deformity. As with the upper lid lift, the amount of fat excised is kept to a minimum. The fat of the lower eyelid is often used to help fill in the tear trough deformity to improve the contour between the cheek and the lower eyelid. There is a layer of tissue beneath the skin called the septum, which, in youth, is tight and holds the fat around the eye. With age, this septum weakens leading to bulging of the lower eyelid, which causes the tear trough deformity.
Part of the lower eyelid lift includes re-draping of the fat as well as tightening of the septum to give a more youthful appearance. In a patient who has minimal wrinkling but a distinct tear trough deformity, this can be corrected through an incision inside the eye (transconjunctival incision) to re-drape the fat and tighten the septum. (Another option for this would be injection of a filler in the tear trough area. Please see the filler section for more information on this.) If the patient has minimal to moderate wrinkling, the transconjuctival procedure can be performed to re-drape the fat and laser resurfacing used to tighten the skin. More extensive wrinkling or extra skin of the lower eyelid will require an incision on the outside of the eye just beneath the eyelashes. This would involve treatment of the fat as before, but would also involve re-draping, tightening, and removing excess skin of the lower eyelid to give the best results.
An additional technique, called a canthopexy, may also be needed to tighten the lower eyelid edge.
This procedure is performed as an outpatient with local anesthesia and sedation in approximately 1 ½ to 2 hours. The patient would need to have a friend or family member drive them home and should have a responsible adult with them the first night after the procedure. It is important for the patient to keep the head elevated as much as possible the first night after surgery and to use ice as much as possible to decrease swelling and bruising. Sutures would be removed at approximately 5 to 7 days and make-up may be applied as soon as the incisions are healed.
After the surgical wounds have healed, you will be instructed on massage of the lower lids. The lower lids have a tendency, at times, to have significant swelling, which can lead to retraction of the lower lid and therefore massage is performed to decrease this occurrence.
Complications are a possibility and these include bleeding, hematoma, infection, bruising, scarring, asymmetry or retraction of the lower lids. An extremely rare, but most severe complication is blindness caused by the collection of blood behind the eye. If this occurs, it is most common the night of the procedure. If any change in vision, pressure or pain in the eye develops the first night after surgery, the patient should go directly to the emergency room for evaluation and treatment. If the hematoma is treated quickly, the chance of blindness is quite rare.
Realistic expectations are a very important part of the decision to undergo cosmetic surgery. It is important to remember that with any of these cosmetic procedures, results are permanent although you will continue to age. In other words, 15 years after the eyelid lift, a patient can expect to look younger than they would have if they had not had the eyelid lift, but they will have aged since the procedure.