What is a blepharoplasty?
Blepharoplasty describes eyelid surgery to address issues such as hooding of the upper eyelids, excess skin, excess fat, or bags under the eyelids. It is commonly carried out for cosmetic reasons to provide a more youthful, rested look, although in some severe cases, where excess skin is overhanging the eyelid and obstructing vision, it can be done for functional reasons to improve the field of vision.
Upper eyelid blepharoplasty
Upper eyelid blepharoplasty involves removing and repositioning excess tissues, particularly skin and fat, from the upper lids between the eyebrows and the eyelashes. It is carried out through an incision which is hidden in the natural upper eyelid skin crease, and is generally a less invasive procedure than lower eyelid blepharoplasty. It can be carried out under local anaesthetic, with sedation if needed, or can be performed under general anaesthetic if desired.
Lower eyelid blepharoplasty
Lower eyelid blepharoplasty is typically used to treat bags under the eyes, by removing and repositioning fat, skin and muscle. It is usually carried out through an incision just below the eyelashes, extending into a laughter line at the outer corner of the eyelids, although sometimes, if there is good skin and muscle tone, the bulging fat can be addressed through an incision on the inside of the eyelid (transconjunctival 'scarless' approach). Lower eyelid blepharoplasty is more involved than surgery to the upper lids, and is best done under either deep sedation or general anaesthesia.
At a blepharoplasty consultation
When you attend for a consultation, you will be asked about your medical history, current medications and allergies, as well as any previous treatment to the eyes and face, including non-surgical treatments such as fillers and Botox.
We will discuss what your main goals are from surgery, which procedures might be suitable, and what can be realistically expected from surgery.
As well as examining the eyelids and face in detail, you will have an examination of your eyes, including your blink and tear film.
Oculoplastic surgeon or plastic surgeon?
Oculoplastic surgeons are specialists who have advanced specialist training in surgery around the eyelids, brows and surrounding structures. Oculoplastic surgeons have also completed specialist training in the medical and surgical care of the eye itself (ophthalmology), and can identify issues which may affect surgical planning.
Plastic surgeons provide a broad range of operations, such as facelift, breast surgery and tummy tuck. Some plastic surgeons also undertake blepharoplasty surgery, but are not trained to examine the eye or to undertake more complex eyelid surgery.
On the day of surgery
When you arrive at the hospital our nursing staff will make sure you are comfortable and take you to our ward area. If you are having deep sedation or a general anaesthetic you will need to fast prior to your surgery. Our team will let you know in advance how long to fast for.
On the ward, you will see Mr Peden prior to your surgery, and have the opportunity to ask any further questions you may have. If you are having sedation or a general anaesthetic you will also see your anaesthetist, who will talk you through the anaesthetic process.
The surgery is carried out in our operating theatre, after which you will be taken back to the ward to relax and recover before going home later the same day.
After surgery
After blepharoplasty surgery you will have some bruising and swelling of the eyelids, which can extend into the upper cheek, particularly following lower lid surgery. This typically largely settles after 10-14 days in the case of upper eyelid surgery, or after 2-4 weeks in lower eyelid or combined surgery. In a small number of patients the swelling may persist longer than this. A good pair of sunglasses can be helpful to hide the swelling initially.
It is advisable to take measures to reduce the swelling, and in particular cool compresses such as ice packs should be applied for up to a week after surgery, at least 3-4 times a day for several minutes at a time. Keeping your head elevated with extra pillows in bed when you sleep will also encourage the swelling to settle more quickly. You should avoid strenuous activity for at least a week after the surgery, and ideally until the swelling subsides (gentle walking is fine).
You will be given some antibacterial ointment to apply to the incisions for 10 days to help them heal and to reduce the risk of infection. This ointment can also be applied to the eyes themselves, particularly at night, to help with any dryness you may be experiencing. It is also possible to use artificial tear drops if the eyes are feeling particularly dry (it is common to experience some dryness of the eyes initially following surgery).
For upper lid surgery it is usually possible to close the incision with a combination of dissolving sutures and glue, meaning in most cases no suture removal is necessary. Lower lid surgery usually requires removable sutures, which can be removed after 5-7 days. Make-up should be avoided for the first two weeks after surgery.
When washing, you should try to keep the eyelids dry for 48 hours after surgery. You can shower, avoiding the eyelids, or have a bath with your head out of the water. You can wash your hair if desired, trying to minimise getting water on the eyelids (small splashes are very unlikely to cause any problem). After 48 hours, you can wash the eyes gently if desired, but avoid any rubbing. After 10 days you can return to your usual washing routine.
It is possible to work from home with a computer as soon as you feel ready, typically after a few days. For most other work it is advisable to take 2 weeks off due to the swelling.
If desired, Bio-Oil or Dermatix can be applied to the incisions after 2 weeks to help the scars to fade, and following lower lid surgery it can help to massage the scar at the outer corner of the eye 2-3 times a day until it has fully settled.
Before upper lid blepharoplasty (above), and 8 weeks after surgery (below)
Before and after
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Before upper lid blepharoplasty (left), and 8 weeks after surgery (right)
Before lower lid blepharoplasty (above), and 5 weeks after surgery (below). Note mild residual post-operative swelling of the left lower lid.
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Before lower lid blepharoplasty (left), and 5 weeks after surgery (right). Note mild residual post-operative swelling of the left lower lid.
Risks and complications
Every operation has risks and potential complications. In the case of blepharoplasty, there will always be some bruising and swelling, and in some cases the swelling can be persistent. Infection is very rare, but is possible. There can be some bleeding from the incision after surgery, particularly when the adrenaline in the local anaesthetic wears off, but usually firm pressure with a clean tissue is enough to make this subside.
There will be a scar where the incision has been made (in the upper lid crease and/or below the eyelashes extending into a laughter line at the outer corner of the eye), and this tends to fade well with time. A small number of patients will have a reaction to dissolving sutures, which can cause swelling and inflamed lumps (granulomas) where the stitches are. If this occurs, these can be treated with steroid ointment or injections, along with removing the dissolving sutures if necessary.
There is often a degree of incomplete blink or eye closure immediately after the surgery due to disruption of the eyelid closing muscle, but in most cases this will resolve within 2-3 weeks. A small number of patients may experience a persistent problem with eye closure, which can lead to dryness and exposure of the eye, and may occasionally require further procedures to address.
There is an upper limit to how much tissue can be safely removed without compromising the function of the eyelids, and therefore there may still be some residual hooding or bags after the surgery, leading to disappointment in some cases. There can also be some asymmetry between the two sides, although careful measurements are taken to minimise this as much as possible.
There can be some numbness of the skin of the eyelids after surgery, which is sometimes noticed when applying make-up. This usually settles well, but can take several months to do so.
In the case of lower lid surgery, in some people there can be swelling of the conjunctiva (the clear layer over the white of your eye), which sometimes requires further treatment with drops or pressure dressings. There is also a risk of lower eyelid retraction, or the lower eyelid turning out (ectropion), and precautions are taken during surgery to reduce the risk of this.
Rarely, double vision can occur after blepharoplasty surgery, which may be persistent. There is also a very rare risk of damage to or loss of vision, for example from a bleed into the eye socket (0.0033% of patients having blepharoplasty suffered permanent visual loss in a large study, i.e. three in 100,000 patients).
How long does blepharoplasty last?
Blepharoplasty surgery is usually effective and long-lasting. However, it does not halt the natural ageing process, and therefore it is important to look after your skin with a healthy diet, sun cream, moisturiser and avoiding smoking. Any fat removed typically will not grow back, but skin can gradually stretch with time, and further fat can occasionally come forward. Most people find the effects of their blepharoplasty can last for 10-15 years or even longer.
I've had a blepharoplasty somewhere else, can you do revision surgery?
Revision surgery is usually possible, although it is less predictable than when there has been no previous surgery. Mr Peden is happy to see patients to discuss revision blepharoplasty (it is helpful to have as much detail about any previous surgery as possible).