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Eyelid Surgery (Blepharoplasty)

The skin loses its elasticity and our muscles slacken with age. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper lids and forms deepening creases in the lower lids. At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes.

What is blepharoplasty surgery?

Blepharoplasty surgery, commonly known as an eyelid reduction, is an operation to reshape the eyelids. An upper-eyelid reduction can improve your vision and make you look younger. A lower-eyelid reduction can help to reduce wrinkles and puffiness.

Why have an eyelid reduction?

With age, our muscles slacken and the skin loses its elasticity. For the eyelids, this results in folds in the upper lids and deepening creases in the lower lids. Also, the slackening of muscle beneath the skin allows the fat which cushions the eyes in their sockets to bulge forwards to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood.
Folds, creases and bagginess often seem worse in the morning, particularly after periods of stress and lack of sleep. This is because fluid that is normally distributed throughout the body when it is upright tends to settle in areas where the skin is loose, such as the eyelids, when a person is lying down.
The ageing process can also cause drooping of the eyelids, and folds of skin to gather in the upper eyelids. Sometimes there is so much skin that the upper lids hang over the eyelashes.

What will happen before my operation?

You will meet your surgeon to talk about why you want surgery and what you want. The surgeon will make a note of any illnesses you have or have had in the past. In particular, you should tell them if you have ever had any thyroid disease, high blood pressure, diabetes or eye disorder (such as a detached retina or glaucoma). The surgeon will also make a record of any medication you are on, including herbal remedies and medicines that are not prescribed by your doctor.
Your surgeon will examine your eyes, face and skin, and may take some photographs for your medical records. They will ask you to sign a consent form for taking, storing and using the photographs.
The surgeon will measure your height and weight to make sure that it is safe to do an operation. If you are overweight, pregnant or planning to become pregnant, your surgeon may suggest delaying your operation.If you would be having the surgery under a local anaesthetic, the surgeon will make sure that you can lie flat and still.The surgeon may want you to be checked out by an ophthalmologist.

How is the surgery performed?

Eyelid reductions can be carried out under local anaesthetic or general anaesthetic (in hospital only). In a typical procedure, the surgeon makes cuts that follow the natural lines of your eyelids – in the creases of the upper lids and just below the lashes in the lower lids (see the eye on the left of the diagram opposite). These cuts are extended a little way into the crow's feet (also known as laughter lines) at the corner of the eyes.

Through these cuts, extra fat, excess skin and sagging muscle are removed. If you have a pocket of fat beneath your lower eyelids without extra skin, the fat can be removed through the inside of the lower eyelid (see the eye on the right of the diagram opposite).All the cuts made will be stitched up.

Choosing a surgeon

If you decide to have an eyelid reduction, only go to a surgeon who is properly trained and on the specialist register held by the General Medical Council. They will talk to you about what is possible for you or might give the best results. Members of several different organisations do cosmetic surgery, so your general practitioner (GP) is the best person to advise you on who to see.You should talk to your surgeon before your operation about when and how to pay.Nobody needs an urgent eyelid reduction. If you are not given time to think about it, you should look elsewhere.

How can I help my operation be a success?

Be as healthy as possible. It is important to keep your weight steady with a good diet and regular exercise. Your GP can give you advice on this.If you smoke, stopping at least six weeks before the operation will help to reduce the risk of complications.Do not worry about removing hair near where cuts will be made, but do have a bath or shower during the 24 hours before your operation to make sure that the area is as clean as possible.

What is the alternative treatment?

Sometimes, a sagging forehead and eyebrow can make the eyelid look like it is sagging. Your surgeon may recommend an eyebrow lift instead of, or at the same time as, an eyelid reduction.
Only wrinkles in the skin which is cut away by the surgery will be improved. Folds of skin extending on to the cheek will not normally be improved. If you have wrinkles and saggy skin elsewhere on your face and neck, it may be useful to have a facelift or necklift (or both) at the same time as the eyelid reduction. A facelift can be used to not only lift the eyebrow and the upper eyelid, but also to lift and open the outer corner of the eye.
Although an eyelid reduction is the best way to reduce sagging of the eyelid, a laser can sometimes be used to burn the surface of your skin in a controlled way. This is called laser resurfacing and it can be carried out at the same time as the eyelid reduction to improve any remaining wrinkles. After laser resurfacing, the skin heals to be softer and less wrinkled. This improvement is not permanent, and the procedure does not work well on dark skin. It has no effect at all on dark circles under the eye.
Botox (injections of the botulinum toxin) can also be used to smooth out fine wrinkles.

What are the main risks and complications of an eyelid reduction?

As with all operations, there are risks involved in having an eyelid reduction. Although the risks are unlikely, it is important to weigh them up against the potential benefit of the surgery. Discuss each of them with your plastic surgeon to make sure you understand the potential complications and consequences.

Complications associated with the surgery

Scars There will be scars from the surgery. These will usually be red at first, then purple, and then fade to become paler over 12 to 18 months. Occasionally, scars may become wider, thicker, red or painful, and you may need to have surgery to correct them.
Bleeding Bleeding into the wound or the eye socket is unusual but possible, and you may need a blood transfusion or another operation (or both) to stop the bleeding. If there is bleeding into the eye socket, this is an emergency as increased pressure in the eye socket can cause permanent blindness. The risk of bleeding into the eye socket is higher if your surgeon needed to remove fat. It usually happens immediately after, or soon after, surgery. A build-up of clotted blood underneath the wound can delay healing or cause scarring, and you may need another operation to remove it. Before the surgery your surgeon will discuss any medicines that increase your risk of bleeding, and it is important to control high blood pressure.
Infection If you get an infection of the wound you may need antibiotics or another operation. This can affect the final result of the surgery.
Swelling, bruising and pain There will be some swelling and bruising around the eyes after the operation, and this can take weeks to settle. There may be long-term pain, but this is uncommon. The final result can take many months to appear, once the swelling has completely gone down.
Healing problems Sometimes, wounds take longer than expected to heal. This problem is usually put right by dressing the wounds, but you may need an operation to remove the tissue that has not healed. Smokers are more likely to have healing problems.
Sometimes, tiny white cysts can appear along the stitch line. These are nothing to be concerned about and your practice nurse can pick them out with a needle. If you tend to suffer from dry eyes or watering eyes, the surgery will temporarily make this worse. However, it should settle within six weeks.
Extrusion This is where deep stitches poke out through the skin. These can easily be removed.
Increased or reduced sensation After the surgery, the skin near the scar can be more or less sensitive. In rare cases, the change in sensation may be permanent.
Asymmetry This is where the eyes are not symmetrical. Almost everyone has a mild degree of asymmetry, and eyelid surgery may make you much more aware of this.
Eyelid position For the first day or two after the surgery it is quite common for the eyelash line of the lower lid to be slightly pushed away from the eye due to swelling. This will usually settle on its own or with simple dressings, but you may need another operation. If too much skin is removed, it can cause your eyelid to be so tight that you cannot close it properly. This can lead to the surface of the eye getting dry. If this is severe, you may need a small skin graft.
Damage to deeper structures Although rare, the surgery can damage deeper structures, including the eyes, nerves, blood vessels and muscles. This damage may be temporary or permanent. Blindness is an exceptionally rare complication. However, temporary changes in the film of moisture over the eyeball or pressure on the eye itself can affect your eyesight and may make you more aware of age-related deterioration in vision. Any temporary effect from the surgery will disappear within six months. Rarely, the surface of the eye can be scratched during the operation or by a stitch. If this happens you may need to use an antibiotic ointment for a few days. If the operation involved removing fat from a lower eyelid, there can be damage to eye muscle within the fat, which can cause double vision. This may be permanent and you would need to have a second operation.
Unsatisfactory result Sometimes, patients are not satisfied with the result of their eyelid reduction. This may be to do with the look or feel of the eyelids, or the shape of the eyelids not meeting expectations. It is very important that you talk to your surgeon, before you have the surgery, about the outcome you want, and whether this can be safely achieved with a good outcome. A very small number of patients need another operation to get the result they want.
Change over time The result of an eyelid reduction usually lasts for five to 10 years and can sometimes be permanent. The appearance of your eyelids will change as a result of ageing, sun exposure or other circumstances not related to your surgery. You may need more surgery or other treatments in the future to maintain the results of the eyelid reduction.
Allergic reaction Rarely, allergic reactions to tape, stitches or solutions have been reported. If you have an allergic reaction you may need extra treatment.

Risks of anaesthetic

Allergic reactions You could have an allergic reaction to the anaesthetic.
Chest infection There is a small risk of chest infection. The risk is higher if you smoke.
Blood clots Blood clots can form in the leg (called a deep vein thrombosis or 'DVT'). These cause pain and swelling and need to be treated with blood-thinning medication. In rare cases, part of the clot breaks off and goes to the lungs (called a pulmonary embolus or 'PE'). The risk of this is higher if you smoke, are overweight or are taking the contraceptive pill.
Heart attack or stroke A heart attack or stroke could be caused by the strain surgery places on your heart. You will be assessed for the risk of this before your surgery.
Death As with all surgery, it is possible to die as a result of the operation

What to expect after the operation

Eyelid reductions for the lower lid, or the lower and upper lids, are usually carried out under a general anaesthetic (so you would be asleep), or a local anaesthetic and sedation (where the whole area is numbed with injections and you are awake but sedated to keep you calm). Eyelid reductions for the upper lid only are usually carried out under local anaesthetic. The operation usually takes one or two hours.
You might be given antibiotics to keep the wound clean. You might go home the same day, or stay in hospital overnight. If you do go home on the same day, a responsible adult should stay with you for the night. Simple painkillers should be enough to keep you comfortable. After the surgery you should not drive or use machinery for at least 24 hours, until you have recovered feeling, movement and co-ordination.
It is common to have watery eyes after an eyelid reduction, partly because of swelling under the conjunctiva (the membrane that covers the front of the eye and lines the inside of the eye socket) and partly because the tear ducts are swollen and do not drain properly. This will last a few weeks. Your surgeon will give you eyedrops to help to ease the feeling of grittiness. After surgery, the eyelids might look and feel tight when closed because of the swelling and because skin has been removed. If you cannot completely close your eyes at night you should apply some eye ointment before going to sleep. This tightness will ease as the swelling goes down.

Dressings

The surgeon may apply some suture strips to support the eyelids. If these become crusted they can be replaced. Cleaning the eyes with water is useful, and the surgeon may advise you to use eye drops or ointment. Sleeping propped up will help reduce swelling and will help you stay on your back. Using cold compresses on your eyelids for one or two days can also help to reduce bruising and swelling. Do not put ice directly onto your skin.

Stitches

The stitches are usually removed after three to five days, and you will be able to use make-up soon after. You may be advised to use the suture strips to support the lower eyelids for a week or so.

Recovery

You will be out of bed on the same day as your surgery. You may have a little bleeding from your eyelids for the first day or two after your operation. Dab this away gently with gauze squares or a clean handkerchief. Activities that increase the blood flow in your face (for example, bending over, straining, lifting or taking a hot bath) may increase the chance of bleeding, so avoid these for the first week. Sleep with extra pillows to keep your head raised and be gentle with your eyelids for at least another month. You can gently clean your eyes with wet gauze.
You will be able to do light activities after one or two weeks. Most patients take at least two weeks off work after the operation, depending on their job. Do not lift heavy things for several weeks, and avoid sex for at least two weeks. With all activities, start gently. Do not drive until you feel safe and are comfortable wearing a seatbelt. Check your insurance documents if you are not sure.

Seeing the results

At first your eye skin may seem too tight and swollen, and you will have some bruising, which can be disguised with make-up and dark glasses. It can take a few weeks for the swelling to settle, and many months for the final result to appear.
The scars will be pink for a few months, but eventually they become almost invisible. The scars may also become tight after a few weeks, but this normally settles after four to six months. Most patients are pleased with the final result, but some find their new shape difficult to get used to. This may happen to you.

Your aftercare

To protect your body, and get the best result, look after yourself.
Avoid vigorous activities after your operation.
Protect your wounds as you are told to.
Putting on weight will affect the results. Maintain a healthy weight and level of exercise.

What to look out for

Bleeding after surgery can cause swelling, a change in colour, and pain, usually just on one side. If the bleeding is inside the eye socket it can cause headaches and affect vision. If this happens, go straight to your nearest A&E department.
The signs of an infection are pain, redness, swelling and pus in the wound, and you may also have a temperature.
A blood clot in the leg can cause swelling and pain in the calf. If the clot goes to the lung, you might be breathless or have pain in your chest.If the wound is not healing well, it may be sore and weep. If you have any worries after your operation, speak to a doctor or go to A&E.

Disclaimer:
This website is designed to supply useful information but is not to be regarded as advice specific to any particular case. It does not replace the need for a thorough consultation and all prospective patients should seek the advice of a suitably qualified medical practitioner. The BAAPS accepts no liability for any decision taken by the reader in respect of the treatment they decide to undertake.

This procedure is also commonly known as...

"blepharoplasty"
"reduction"
"transconjunctival blepharoplasty"