Blepharoplasty is a surgical procedure to rejuvenate droopy eyelids through the removal of excess skin, muscle, and fat. As we age, the tissues of the eyelid weaken and loosen, resulting in sagging soft tissue that can crowd the eyes. This contributes to an aged appearance, and in some cases can also partially obstruct ones vision. An upper eyelid blepharoplasty can make a person look younger, more rested, and in some cases improve their vision.
Upper eyelid blepharoplasty can be a very effective way to achieve a more rested, youthful, attractive appearance.
Anyone with excess or droopy skin, or puffy eyelids may be a candidate for this surgery. It is usually performed as an outpatient with local anesthesia and possibly intravenous (IV) sedation. Thus, the candidate must be healthy enough to undergo a surgical procedure.
It is common for patients seeking blepharoplasty to notice heavy, excess skin of the outer portion of the eyelids. This is an area that is not always able to be corrected with blepharoplasty alone. A simultaneous browlift is often recommended in such cases and others. The combination of the upper lid blepharoplasty with the browlift is often necessary to achieve the greatest improvement. The surgeon should discuss and demonstrate with each patient how these issues relate to their own particular anatomy.
It may be performed with only local anesthesia, with IV sedation, or under general anesthesia. Upper eyelid blepharoplasty is often performed at the same time as other procedures, such as browlifting, lower lid blepharoplasty, or facelifting.
The incision in the eyelid is made to lie within the existing eyelid crease, in most cases. It extends outward toward the corner of the eye, and often is made to trail upward at the outermost end.
The excess skin is removed conservatively. If too much is removed, then the patient could have trouble closing their eyes normally. Most surgeons then also remove some of the underlying muscle. If bulging fat is noted, then this can also be removed too. This is performed by carefully by opening up the fat containing compartment, and teasing out the excess fat.
The skin is then sutured closed. Surgeons differ in how they do this. Some use a suture that requires removal in 4-7 days. Others prefer to use dissolvable sutures, or even tissue glue.
The eyelids look bruised for about one week. During this time, heavy lifting and strenuous activity is to be avoided. The incisions initially look quite conspicuous, but typically heal very well over the course of several weeks.
Patients with a history of dry eye problems need to be careful about having upper eyelid blepharoplasty. The blepharoplasty alters the blink mechanism for some time, and after these procedures it is possible to have some dryness of the eyes. In patients with a pre-existing problem with dry eyes, this can become a serious problem.
Complications are possible with any surgical operation. These include bleeding, infection, separation of the incision edges which can require re-suturing, and noticeable scars. The eyelids may look asymmetric after the operation, or fail to show the desired improvement. If too much skin is removed, it may restrict the ability to close the eye, which can be very problematic. Visual changes are not uncommon temporarily. These usually resolve, but in rare cases a permanent change in vision can occur. A rare complication of blepharoplasty is vision loss. This can occur if significant bleeding occurs behind the eye, putting pressure on the optic nerve.
Upper eyelid blepharoplasty is a very common, and typically very effective, technique to reduce sagging, drooping, and bulging upper eyelids. The benefits of a more youthful and rested appearance can be quite dramatic. It is not without risk, and for this reason it is important to think very carefully about any risk factors (dry eye, previous surgery) and choose your surgeon very carefully.
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Lower blepharoplasty is an operation of the soft tissue in and around the lower eyelids. The operation aims to create a smooth contour to the skin immediately below the eyes. Common reasons that motivate patients to undergo lower blepharoplasty include under-eye wrinkles, puffiness, dark circles, or some combination of the above. These unsightly characteristics create an aged or tired appearance in many individuals.
As with any cosmetic surgical procedure, lower blepharoplasty aims to alter the anatomical causes of the problems in order to improve the appearance. For this operation there are two main ways in which a smoother contour is attained. First, uneven or wrinkled skin is treated to create smoother skin. This can be thought of as treatments to smooth out the surface. Second, unevenness of the deeper tissues of the under eye area can be altered in order to create a smoother contour. This can be conceptualized as smoothing out the infrastructure of the under-eye. Several options for treatment exist within these two categories of treatment and are discussed below.
Historically, excessive amounts of skin in the lower eyelids have been treated with surgical removal. The incision is placed 1-2 millimeters below the margin of the lower eyelid so that it will be hidden below the lashes and within a crease that naturally forms there. This is called a subciliary incision. A parallel incision is then made some distance below the upper incision and the intervening skin is excised and removed. Care is taken to preserve much of the underlying muscle beneath the skin so that the supporting sling of the lower eyelid is not weakened. The amount of skin removed depends on how loose and wrinkled the skin is prior to surgery. Over-aggressive excision can lead to retraction of the lower lid, in which the lid pulls downward causing a rounding of the eye from its normal almond shape. In severe cases, this retraction can cause dryness and eventual damage to the eye. Therefore surgeons tend to be conservative with the amount of skin excision. Through this skin incision, the fat in the lower eyelid can also be accessed and treated (see below).
In some cases in which there is not much extra skin, or there is only crêpey wrinkling of the skin, the skin may be treated with a laser or chemical peel to make the skin inherently tighter (see section on resurfacing). Chemical peels or laser resurfacing may be performed by the surgeon on the area to tighten the skin and smooth fine lines in the area. In some cases, a conservative amount of skin removal is combined with post-operative resurfacing in order to get the benefit of combination therapy.
Traditionally, the most common target of lower blepharoplasty has been the bulging fat under the eyes. Fat normally resides under the eye, serving to cushion the eyeball within the bony eye socket. With age, the membrane which contains the fat within the eye socket (called the orbital septum) weakens, allowing the fat to bulge forward. This causes puffiness or fullness under the eyes that can make the person look tired. Although fat is often the main component of this fullness, water retention (edema) can also contribute to the puffiness. This explains why the eyes can appear more swollen after sleeping, eating salty food, drinking too much alcohol, etc. Nonetheless, for decades, fat removal served at the mainstay surgical treatment to reduce fullness under the eyes.
The fat pockets can be accessed either from the incision just below the eyelashes described above, or through an incision on the inner surface of the eyelid, behind and below the eyelashes—the so-called transconjunctival incision. The choice of incision depends on whether or not the skin needs to be removed. In the past, it was customary to remove a large amount of fat in order to create a large reduction of the fullness in the lower lids. While this approach can lead to smoothing of the contour, in many cases it can lead a gaunt, hollow appearance of the under eye appearance. In recent years, the approach has become less popular, with surgeons instead opting for options to create a smooth contour while preserving or even adding volume to the area.
In the past several years, there has been a change in the approach to lower eyelid contour, favoring preservation of volume. Modern surgeons agree that fullness or volume signifies youthfulness and that by reducing volume, one may cause an aged appearance rather than a rejuvenated look. For this reason, techniques have evolved in which the volume of the under eye area is re-oriented, rather than reduced, in order to smooth contour. Fat transposition is one increasingly popular way to achieve this end. With this technique, the fat under the eye is not removed, but rather transposed into a nearby area in which there is a lack of volume. The tear-trough, which is a natural hollow area under the eye within the facial skeleton, is a common target for fat transposition. The tear trough represents an area of depression under the eye which leads to shadow formation, contributing to an appearance of circles or tiredness under the eyes. “Transposition” implies that the fat that is moved is loosened or mobilized, but is still partially connected to its natural foundation. This allows some of the blood vessels which nourish the fat to remain intact, thus increasing the chances that the transposed fat will survive and endure in its new location. This is essentially a procedure in which fat is moved from an area of excess to an area of deficiency so as to improve contour.
Other methods of volumization are available for the lower lids. One option is the injection of transferred fat, in which fat is completely removed from an area in the body and injected into the desired target site, such as the tear troughs. One criticism of fat transfer is that not all of the fat will survive in the recipient site which may lead to temporary results or even uneven outcomes requiring revision touch-up procedures. Injectable fillers (Juvederm, Restylane) are also options to fill the under eye areas. At this point, the commercially available fillers for use in the US are “off-label” for application in the under-eyes. Nonetheless, the practice is commonly performed with a high satisfaction rate. The down-sides are that these fillers are not permanent and will re-absorb within a year and in the short term can lead to bruising under the eyes.
TRADITIONAL LOWER BLEPHAROPLASTY: IS ADDITIONAL SUPPORT NECESSARY? A 30 YEAR REVIEW. Maffi TR, Chang S, Friedland JA. Plast Reconstr Surg. 2011 Mar 10
Fat Repositioning in Lower Lid Blepharoplasty: The Role of Titrated Excision. Aakalu VK, Putterman AM. Ophthal Plast Reconstr Surg. 2011 Mar 16.