What is a Blepharoplasty?

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Blepharoplasty is the medical name for the surgical removal of excess eyelid tissue. The excess tissue is most commonly skin and muscle, but sometimes there is excess fat which can be additionally removed from the eyelid to give a better result, depending on the needs and appearance of each specific patient. This information sheet will focus mainly on excessive skin and muscle in the eyelid (dermatochalasis) and surgery to correct this.

Excess skin and/or protruding fat can be present in one or both upper or lower eyelids, but is most common in the upper lids. The excess skin may initially be more of a cosmetic problem but over time the skin can droop in front of the eye, blocking the upper vision.  It can also cause an uncomfortable heavy, tired sensation, particularly when reading or concentrating. Sometimes the skin can press down on the eyelashes causing discomfort and even push the eyelashes down into the field of vision which can reduce the overall visual quality. If the eye lids are particularly heavy the lashes and upper eye lid skin may actually be in contact with the eye itself which causes irritation and pain. Finally, excess skin on the outer side of the upper eyelid sometimes tracks tears in the wrong direction (‘wicking’) causing a watery eye.

Excess skin most commonly occurs with aging, but sometimes occurs in younger age groups and can run in families. It is sometimes associated with ptosis (drooping of the upper eyelids) – (see ptosis information for further details).

Sometimes the eyebrow also descends with age and I might suggest lifting the brow a little (usually with hidden sutures – internal brow pexy) in addition to removing the excess upper eye lid tissue.

 

What will happen at my clinic appointment?

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In clinic I will assess your vision, examine your eyes, eye movements and eyelids and asses the degree of excess upper lid tissue. It is important to identify whether you have pre-existing dry eyes as symptoms of dryness can be temporarily worsened following the surgery. It can be helpful to see old photographs if you have any available to show me. If I think surgery can help we will discuss the risks and benefits of the surgical procedure. You may need a pre-assessment appointment depending on the type of anaesthetic that will be used (see below) and any other medical conditions that you may have.

 

How is excess eyelid skin treated?

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The most common blepharoplasty operation involves carefully assessing and marking the excess skin and surgically removing it. I will discuss with you how much skin and additional eyelid tissue (usually fat) to remove. The incision for the surgery is almost always made in the skin in the existing eyelid crease (skin fold) and is invisible a few weeks after surgery. I close the skin incision with sutures that are removed 1-2 weeks after the surgery.

 

I will arrange for studio photos to be taken by a photographer prior to the operation so that I can plan the surgery and compare the position of the eye lids after surgery. The operation takes about 30-45 minutes per eye and is almost always a day case procedure, with no need for an overnight stay in hospital. It is usually done with local anaesthetic (injections to numb the eyelid skin) as this enables me to assess the eyelid position during the operation (by asking you to open and close your eyelids) so I can make adjustments as required. However, in some operations, for example for patients with severe tremor or anxiety, we can offer sedation, which makes you feel relaxed and a little sleepy during the operation. If both eyes require blepharoplasty surgery it is usually best to operate on both sides at the same time to give the highest likelihood of a symmetrical result .

 

There are other blepharoplasty operations, for example, lower eyelid fat only blepharoplasty, that are used in specific situations that are not discussed in detail in this information sheet.

 

What are the possible complications or risks of upper lid blepharoplasty surgery?

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Pain

The local anaesthetic will wear off in the first few hours after surgery. At this time, the eyelid can become quite painful. You can take simple painkillers such as paracetamol if you have no allergies or contraindications to these. If you are in pain immediately after the operation, please let me know and we can give you painkillers. If you experience scratching, pain and a feeling as though your eye might be opening under the eye dressing its best for the dressing to be removed to avoid a pad abrasion. 

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Bruising

It is common to have bruising of the eyelid or the whole area around the eye after eyelid surgery. You may have a ‘black eye’, which can take a week or so to settle down. There also may be a scab along the suture line or some numbness of the upper eyelid.

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Bleeding

You may have a little bit of bleeding or oozing of blood stained fluid in the hours or even first few days after surgery. You can gently dab this with a clean tissue. Occasionally there is more bleeding at about five days after surgery, particularly in people who take blood thinners such as aspirin. If there is a lot of bleeding at any time please put some firm pressure on the bleeding area with a pad of tissues and if it does not stop contact me immediately.

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Infection

Infection is uncommon after eyelid surgery, although any wound can become infected. Infection will cause the eyelid to become increasingly red, swollen and tender a few days after surgery and there may be some discharge. If this occurs you should contact me immediately or attend an eye casualty department or GP surgery.

Poor eyelid closure - The eyelids may feel ‘tight’ after surgery. Inability to close the eyelids after surgery (lagophthalmos) happens very occasionally. Eye lubricating cream can be used to keep the surface moist and comfortable and this almost always settles with time.

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Dryness and grittiness of the eyes

The combination of eyelid surgery and the improved eye opening can cause the eyes to feel dry and gritty after ptosis surgery. This can usually be managed with artificial tear/lubricant drops, gels or creams and almost always settles in time. If the eyes are already slightly dry before surgery, they might be worse after the operation and I will discuss this carefully with you before the surgery.

Unsatisfactory eyelid appearance or asymmetry: at least 95% of patients are corrected satisfactorily after the operation. Approximately 5% or less may require a further surgery to improve the appearance of one or both eyelids.

Recurrence: the excess skin does gradually recur in time, although usually many years or decades after the initial operation. This may require a repeat procedure.

 

 

Additional complications of lower lid blepharoplasty or “eye bag” surgery

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Lower lid blepharoplasty or “eye bag” surgery is much less commonly undertaken than upper lid surgery. It is a more challenging operation with a greater risk of an unsatisfactory outcome and should only be undertaken by a surgeon with training and experience in this procedure. The major additional complication is that excision of excessive skin can cause the outer side of the lower eyelid to curve downwards slightly (lid retraction) . This usually improves in time, but occasionally continues to have a poor cosmetic appearance and very rarely revision surgery, sometimes with skin grafting is required to improve it.

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Visual Loss

There is a tiny risk (probably less than 1 in 10,000) of visual loss with any eyelid surgical procedure. The risk is slightly higher for lower lid blepharoplasty than upper lid blepharoplasty

 

What should I do in preparation for surgery?

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Blood thinning medications such as aspirin, clopidrogel (Plavix, Iscover), Edoxaban, Apixaban and warfarin can make bleeding more likely during and after surgery. If you are taking these drugs please tell me and we can discuss whether to continue them. If possible it is advisable to stop anti-inflammatory drugs like ibuprofen (Nurofen), fish oil, ginger, ginseng, St Johns Wort, Arnica and garlic containing supplements 2 weeks before surgery.

If you smoke I would recommended that if possible you stop smoking for at least 3 days prior and 1 week after surgery, because smoking impairs wound healing and increases the risk of infection.

Avoid heavy alcohol intake in the days before and after surgery. If you are having sedation or general anaesthetic, you are required to have nothing to eat or drink for at least six hours before surgery.

On the day of surgery please dress casually and wear a top which buttons at the front. Please wash your face on the morning of surgery and ideally men should shave. Do not wear any makeup, jewellery or contact lenses.

 

What happens after my operation?

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An eye patch is normally placed over the eye(s) after surgery. You can remove it the next morning unless the nurse or I give you different instructions. If surgery has been done on both eyelids and we need to patch both sides, both of these will normally be removed after one hour and before you go home. You will be given drops and ointment to use and a clinic appointment will be made for a check-up about a week later. I will normally advise you to apply cold compresses to your eye(s) particularly as you will have had upper eye lid surgery. You will be given instructions by the nursing team on how to apply these and given some sterile saline and swabs to get you started with. You can use boiled cooled water kept in a sterile container in the fridge. Often I suggest using these as much as once every hour or so applying them for as long as you can whilst resting at home. This can be very important for getting the best results from the surgery and I may suggest doing this for one week and sometimes longer following the surgery. 

 

You will usually need about one or two weeks off work. Try to avoid driving for a few days after the operation.

 

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