Facial Rejuvenation

Upper and Lower Blepharoplasty and Ptosis

When an excess of skin and/or fat, known as dermatochalasis, is present in the eyelids, patients may desire surgical correction for visual, comfort or cosmetic reasons. It can involve either the upper and/or lower eyelids. Surgical correction is known as blepharoplasty. Ptosis is present when the margin of the upper eyelid sags closer to the pupil, either separately or in combination with dermatochalasis. Ptosis repair may be combined with blepharoplasty.

Due to a combination of factors the skin and delicate structures of the eyelids begin to stretch. Factors include:

heredity aging chronic allergies thyroid disorders smoking

fluid retention certain medications (steroids) wearing gas-permeable contact lenses injuries

When the upper eyelids are involved, the fold of skin, which generally is well above the eyelashes, tends to rest on or over the eyelashes. The actual margin of the eyelid may drop down closer to or actually cover the pupil (ptosis). There may be puffiness of the tissue due to fluid retention or a forward herniation of the normal fat around the eye.

The patient can experience a tired, heavy feeling from muscular fatigue, especially in the forehead, from the need to raise the eyebrows. Additionally, the overhanging skin may cause interference with peripheral vision, either to the sides or above. This necessitates raising the eyebrows in order to see more clearly.

The same underlying factors are responsible when the lower eyelids are involved. The lower eyelid is suspended to the bone toward the nose and ear by tendons, which support the eyelids much the same way a hammock is suspended. If one or both tendons stretch, the edge of the lower eyelids may sag below the cornea causing a pooling of tears on the eye, or occasionally, dry eye symptoms due to exposure of the delicate surface structures to the air. The fat below the eye will bulge forward causing a puffy tired appearance to the eyes. Finally, there may be pockets of fluid just above the cheekbones known as festoons.

The eyebrows themselves may be drooping due to a combination of forehead laxity and stretching of the supporting ligaments to the orbital bone above the eye. This is sometimes difficult to detect if the forehead is being raised to compensate for the eyelids. When the eyes are closed, the need to compensate is removed and one can see the brow drop to its true resting position. If it is not corrected at the time of ptosis repair or blepharoplasty, the eyebrows will appear to be too low postoperatively because the compensating force has been removed. Therefore, it is best to repair the eyebrows at the same time (browpexy).

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Blepharoplasty Frequently Asked Questions

1. What is Blepharoplasty?
2. How is the procedure performed?
3. Is there much scarring with a Blepharoplasty?
4. At what age is Blepharoplasty performed?
5. Will a Blepharoplasty rid me of my eye wrinkles?
6. What should I expect post-operatively?
7. When will my stitches be taken out?
8. When will I be able to see the results?
9. What are the risks of Blepharoplasty?

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1. What is Blepharoplasty?

Blepharoplasty or eyelid surgery is designed to remove the excess fat, skin and atrophied muscle from the upper and lower eyelids. It is a very popular procedure as hooded eyes seem to lack luster and seem old or tired by many patients. Many individuals who choose this procedure are very aware that their upper eyelids have seemed to disappear within the herniated fat of the upper eye area. Fat herniation is quite normal and will happen to everyone once we age. However some individuals have herniated fat in the upper area of their eyes even in their early teens. It can be genetic as well.

Sometimes a blepharoplasty can improve an individual's vision. This is achieved by removing the excess fat and skin that may block an individual's peripheral field of vision. Whatever the case, the purpose of a blepharoplasty is for the aesthetic appeal that wider, youthful eyes possess.

2. How is the procedure performed?

Blepharoplasty is usually performed using local anesthesia and light sleep sedation or General. The incisions are made within the natural creases of the eyelids. Your surgeon removes the herniated fat and excess skin and sutures the incision with very fine hair-like sutures. It should be mentioned that removal of the entire fat pads underneath the eye should be discouraged. Aggressive removal of this fat has proven to be quite disastrous in most patients, even further down the line in their lives. Aggressive fat removal often results in hollowness or a dark, sunken appearance. Although minimal removal (or re-suspension) has proven quite beneficial in those who may need it. In those who do not need it, only the excess skin should be removed.

3. Is there much scarring with a Blepharoplasty?

As with any surgical procedure some scarring should be expected. Although the scarring associated with blepharoplasty is quite minimal and practically non-existent after several months. The scars are placed within the normal creases and folds of the upper and lower eyelids so that when the eyes are open the scars are invisible. With lower blepharoplasty, where the fat is to be removed only with no skin excision, the incision can be made either on the inside of the eyelid or right under the lash line. Many surgeons prefer the transconjuctival incision with fat removal-only cases. However, not all surgeons will offer this or agree with its efficacy.

4. At what age is Blepharoplasty performed?

Although there is no set age when blepharoplasty is performed, the usual ages that patients start making consultation appointments for blepharoplasty is from 35 years of age and up. However, this is highly individual and excess skin and fat around the eye area may be desired to be removed younger than 35 years of age.

5. Will a Blepharoplasty rid me of my eye wrinkles?

A blepharoplasty is not designed to remove the wrinkles (i.e. sagging brows and Crow's feet) from the eye area. It is designed to remove the excess skin and herniated fat from the lid areas only. There are other procedures available that are area-specific to these complaints Laser Treatments can help soften peri-ocular (around the eye) wrinkles significantly. Please consult with a qualified surgeon to determine your exact needs. It is also best to seek at least three opinions.

6. What should I expect post-operatively?

Swelling will be apparent at first and there may be some bruising. Although, this factor should be considered individual. Some are prone to bruising more than others. Your eyelids may feel tight and sore as the anesthesia wears off, but your pain medication should be able to control any discomfort. Your vision may be a little blurry for the first few days due to the swelling and your eyes may be watery or they may be dry. You should not be in any extensive pain. Patients have described post-operative pain as associated with blepharoplasty as mild discomfort, as if the skin was sunburned, wind burned or the eyeballs having been irritated or scratched.

7. When will my stitches be taken out?

Your stitches are normally removed within 3 to 5 days of the operation. The removal process may sting a little bit as the tight, fine sutures are very small and require very fine tweezers and scissors for removal. The surgeon might accidentally snip a piece of superficial skin and there may be a stinging sensation form tugging on the sutures while removing them.

8. When will I be able to see the results?

After the swelling goes down you will be able to see a definite difference with the amount of over hang in the upper eye area if you had an upper blepharoplasty. You must realize that when you wake up no matter what time of day there will be increased swelling. This is due to fluids pooling, especially if you are not elevated properly. There is even increased swelling in the upper or lower eye area in individuals who have not had blepharoplasty. The tissues swell with fluid retention when you are at rest. If you sleep with your head well elevated (with two pillows) this will be less apparent.

9. What are the risks of Blepharoplasty?

The minor complications that are associated with blepharoplasty include double or blurry vision for a few days, temporary swelling at the corners of the eyelids, and milia (or tiny whiteheads) that can be removed by your surgeon by pricking them with a sterile micro-needle. It is possible to develop asymmetry during healing or excessive scarring if you are prone to such a thing.

It is possible that you may experience difficulty in closing your eyes when sleeping. In rare instances this condition may be permanent. Also there is the rare possibility of ectropion. Ectropion is a condition where your lower lids are pull down or gape. If you should develop ectropion, further surgery will more than likely be needed to correct it. Which could lead to more risks and more cost to you, the patient.

If you have thyroid problems (hypothyroidism or Graves' disease) dry eyes or insufficient tearing, circulatory disorders or high blood pressure, having blepharoplasty may be more risky for you than an otherwise healthy individual who does not have such disorders. Grave’s disease is frequently associated with severe swelling of the periorbital tissues. This swelling may be misdiagnosed as excess under eye fat pads. If you are myxedematous* (in a severe state of hypothyroidism) you may have severe edema, or fluid retention, especially in the eye area; is a common symptom of hypothyroidism. The fluid filled tissue areas are often misdiagnosed as excessive fat in the eye area and when removed can lead to disastrous results. As your edema subsides and your fluid levels level out, after removal, the eye area will look very sunken in. Ascertain that your surgeon establishes whether or not your eye bags are caused by fat or chronic edema prior to your blepharoplasty. Edema will not be corrected by surgery.

Other disorders that may increase your risks are myasthenia gravis, cardiovascular disease, diabetes, a detached retina or glaucoma (and other high pressures of the eye), poor circulation and poor elasticity. Please disclose all disorders or concerns with your plastic surgeon --you're health and well-being might depend on it.

Sometimes the eye area will not heal correctly and you just may have to have an additional surgery to correct it. The surgeon normally does not charge any additional fees if another surgery is necessary. I think the doctor shouldn't charge you but you may not be that lucky.

There is also the risk of a doctor cutting and removing too large of an oval of skin for your eye size, resulting in smaller eyes. Completely changing your appearance rather than rejuvenating it. There may be a need for "eye spacers" to open up the eyes more. I am not even completely sure how these work but I will attempt to gather more information of this.

There is also the risk that your doctor may remove too much of your fat pads(sub orbicularis oculi fat pad, SOOF) under your eyes. More and more, doctors are discontinuing this as they are finding an increasing amount of patients suffering eye abnormalities with this practice. Patients are complaining of sunken eyes, eye hollowness and a tired, aged look.

*myxedematous: severe hypothyroidism characterized by firm inelastic edema, dry skin and hair, and loss of mental and physical vigor. (Merriam-Webster dictionary)