Blepharoplasty

What is a Blepharoplasty (Eyelid surgery)?

As we get older, the upper and lower eyelid skin loses tone and contains less elastin.

This loss of elasticity allows the skin around the eyes to sag, and fat appears to bulge out. In the lower eyelid this causes “bags” and in the upper eyelid it manifests as a saggy and tired appearance. As this worsens, the visual field is affected, and the eyes can become dry and water all the time.

Upper and lower eyelid tightening can be performed together or separately. Upper eyelids are normally corrected under a local anaesthetic (when you are awake, but the area is numb) in the clinic room, whereas lower eyelid surgery is usually performed under a general anaesthetic (when you are fully unconscious) in the hospital.

Upper eyelid: In upper eyelid surgery, small incisions are made within the natural crease of your eyelids. Through these incisions, skin and sometimes fat or muscle are removed. The incisions are closed with fine sutures, hiding the scar in the natural fold of your eyelids. This opens the upper eyelid and corrects any bulging. The sutures are dissolvable and do not need to be removed.

If the eyebrow has dropped or flattened, then an eyebrow lift can be performed, through the same incision as an upper eyelid blepharoplasty, without any additional scars or signs of surgery. This procedure is useful to restore the natural arch to the eyebrow.

The procedure is often performed under local anaesthetic (you are awake, but the area is numb). However, it can also be performed with sedation (you are awake but drowsy) or under general anaesthetic (when you are fully unconscious) if you prefer.

The surgery takes 45 minutes as a day case, and you can return to work the following day. It takes about 3 weeks for bruising or swelling to disappear.

Lower eyelid: In lower eyelid surgery, the incision is placed just underneath the eyelashes. There are 3 fat pads in the lower eyelid that can bulge outwards, as the orbital septum, which holds them in place weakens. This gives an appearance of “bags” in the lower lids. At the same time, the fat pads on the cheek that normally cover the orbital bone slide downwards creating a depression. This depression accentuates the bulge above it.

A lower lid blepharoplasty allows the bulging fat to be repositioned to fill the groove under the eye and the septum is tightened to prevent its recurrence. Any excess skin is excised, and the incision is closed with dissolvable sutures.

The surgery takes approximately 2½ hours and is normally performed under a general anaesthetic (when you are fully unconscious), due to the length of surgery and proximity to vital structures. The surgery can be performed as either a day case or an overnight stay in Hospital.

When you wake up you may experience a slight throbbing or tenderness around the eyes. However, a blepharoplasty is a minor procedure, and most patients require minimal pain relief.

As a precaution, you should arrange for someone to take you home and stay with you for the first night if you have had a general anaesthetic.

Having cosmetic surgery should be a very positive experience. Complications are infrequent and usually minor. However, any surgery has risk, and it is important that you are aware of possible complications. All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, please do not hesitate to discuss them with me. Decisions about cosmetic surgery should never be rushed.

These risks can be divided into those specific to the surgery and those that relate to the anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

  • Unintended intraoperative awareness, which is very rare.
  • Dizziness and nausea.
  • Sore throat.
  • Damage to teeth or mouth.
  • Nerve injury due to body positioning.
  • Allergic reaction or anaphylaxis.
  • Malignant hyperthermia, which is a rare life-threatening condition.

The anaesthetist will go through these risks in more detail prior to your surgery.

Scars: Scars on the eyelids tend to settle remarkably well and are usually barely perceptible. However, some patients heal with noticeable thickened, thin or stretched scars.

Bruising and swelling: This is very common and may take a couple of weeks to settle. Many patients wear dark sunglasses to conceal this.

Infection: This is rare, as the eye area has good circulation. However, if there are signs of infection, antibiotics will be prescribed.

Asymmetry: Scars are never identical under each eye. This is because our faces are asymmetrical, and the scar is tailored to each eye.

Watery/dry eyes: Following surgery, your eyes may be watery, or your vision blurred for the first 2 days and then dry and gritty for 2 to 3 weeks thereafter. You will be prescribed artificial tears to use during the day as this settles.

Patients who tend to have dry eyes or blepharitis before surgery, may find that blepharoplasty can make this worse and may possibly become permanent.

Ectropion: This is where the lower eyelid is pulled down, which can lead to dry or watery eyes and may need further treatment. Patients with lax lower eyelids are prone to this.

Lid lag: If too much skin is excised from the upper eyelid, this could lead to problems with closing the eye at night. This may require further treatment.

Scleral show: This is when the white of your eye can be seen above your lower eyelid. This can occasionally occur following lower lid blepharoplasty and may require further surgery to correct the problem.

Milia: Sometimes, tiny, white cysts appear along the stitch line. However, if this does happen, they can be easily removed with a fine needle at your clinic appointment.

Retrobulbar haematoma:  This is an exceptionally rare complication. It occurs when fat behind the eye bleeds, putting pressure on the optic nerve. If this is not recognised and treated, it can possibly lead to blindness.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and move to your lungs. If the blood clot is large enough it could prove fatal. To reduce any risks of this, we give you special stockings to wear in bed and a blood thinning injection if you are not mobile.

All the risks outlined above, as well as others, will be discussed in detail at your consultation with me. However, if you have further questions or concerns, please do not hesitate to ask.

There are no sutures to be removed as they are dissolvable. I will prescribe you lubricating eye drops for the first 2 weeks post-operatively.

Following surgery there may be some temporary blurring of vision due to the swelling. If you have increasing pain or sudden blurred vision, then please contact me or the Hospital for advice.

Before you are discharged from Hospital you will be given a follow up appointment to see the nurse after one week post-operatively, to check your incisions.

I normally see you in clinic 2 weeks following your procedure.

You will not be able to drive yourself home from Hospital and, ideally, you should have someone to stay with you for the first few days to assist you. If you have any concerns during this period, please contact the clinic for advice.

Scar advice
Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection.

The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

When you get home, you should take things easy for the first week or so. Recovery times vary from one person to another. Most patients return to work after one week. It takes approximately 12 weeks for everything to settle, as eyelids are very prone to swelling.

Surgical fees are a combination of the hospital or clinic costs, the surgeon and anaesthetic fees and any consumables such as implants. In breast reconstruction patients, the fees are normally cover by your health insurance. However, most patients have a co-pay of 20% and certain policies only cover one breast and half of the other breast. This means you are likely to have to pay towards the cost of your surgery. Any fees will be calculated, and you will be informed of the potential fees at your consultation.

Blepharoplasty - Nicotine and Surgery