Dr. Dirk Lazarus, Plastic Surgeon, Cape Town, South Africa

Blepharoplasty is done to remove or reposition excess skin, fat and muscle from the upper and/or lower eyelids. Eyelid surgery can correct drooping upper lids and puffy bags below your eyes - features that make you look older and more tired than you feel, and which may even be interfering with your vision. It will not, however, remove crow's feet or other wrinkles, or lift sagging eyebrows. Blepharoplasty can be done alone, or in conjunction with other facial surgery procedures such as a facelift or brow-lift

Who is a candidate for blepharoplasty?

The best candidates are men and women who are physically healthy, psychologically stable, and realistic in their expectations. Most are 35 or older, although you may require surgery earlier if you have strong family history of baggy eyelids.

A few medical conditions make blepharoplasty more risky. These include thyroid problems such as hypothyroidism and Grave's disease, dry eye or lack of sufficient tears, high blood pressure (uncontrolled) or other circulatory disorders, cardiovascular disease, and diabetes. A detached retina or glaucoma is also reason for caution.

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The consultation

At the first consultation, I like you to tell me in your own words what it is that worries you about your eyelids and to define the problem(s) as you see them. It is important to be honest and forthright as surgery is tailored around the problem(s).

Since the function of the eyelids is to protect the globe or eyeball, it is important to establish that your visual function is normal. I need to know if your vision is normal or if you use or have had correction (glasses, contact lenses, refractive or laser surgery). I also want to know if you suffer from dry eyes, excess tearing or any other vision related problems. Your motivation, goals and expectations with regard to the surgery will also be discussed.

Your eyes and lids will be carefully examined to assess the quantity of excess skin and fat, the quality of the muscle and the bony relations to the eyeball. Your suitability and fitness for surgery will be evaluated. Routine pre-operative photographs will be taken which form part of the medical record.

Following assessment, we will discuss all available options and formulate an operative plan, including type of surgery and anaesthesia to be used, venue for surgery and costs. In consultation, we will decide whether all four lids require surgery or just upper or lower. Other facial procedures may in addition be advisable for a harmonious result. Risks and complications will also be discussed.

It is important that prior to surgery you are clear as to what surgery will entail. A well informed patient will cope better with surgery. You have a right to ask any question you want and I feel that I have an obligation to answer with honesty and without the use of jargon. Consent for surgery will also be taken. If your goals are realistic you will be more satisfied with the final result of surgery.

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Venue for surgery and length of stay afterwards

I always perform blepharoplasties in an operating theatre. I usually do the procedure as a day case in the morning, allowing you home later that afternoon.

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Anaesthesia

I usually perform blepharoplasty under local anaesthesia with supplementary sedation administered either by myself (usually the case if blepharoplasty is the only procedure you are having) or by an anaesthetist (usually the case if blepharoplasty is combined with some other procedure, especially facelift).

Preparing for surgery

Very little preparation is necessary for surgery. If you are well informed and know what to expect, if you are fit and healthy, if your reasons for surgery are good and your expectations realistic, you should get through the procedure with the minimum of problems.

Smoking is generally unhealthy, but in particular it interferes with normal blood flow and wound healing. I would therefore recommend that for any surgery, blepharoplasty in particular, you stop smoking a week or two before hand and you refrain from smoking for about three weeks afterwards. Although nicotine replacement products such as the spray, patch or gum are of great assistance, these products also adversely affect wound healing and should be avoided for the same period.

You should arrange for someone to bring and collect you from the clinic and there should be a responsible adult to look after you on the night of surgery. Hospital admission can be arranged for this or domicillary nursing care if you require it.

Do not apply make up on the day of surgery. On the day of surgery, you should be healthy and not suffering from flu or any other illness. All cosmetic surgery is elective and it is better to delay surgery than to tempt problems. You should arrive at the clinic on the morning of surgery having fasted and being nil by mouth for six hours.

Your eyelids will be bruised and swollen after surgery and you might find that your eyes are sensitive to light. It is a good idea, therefore to bring a pair of good quality sunglasses to wear afterwards.

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What does the surgery entail?

One pair of lids (upper or lower) usually take me about one to one and a half hours; All four lids, usually about two and half hours, depending on the extent of surgery. If I do all four lids, I usually do the uppers followed by the lowers.

After infiltration of the local anaesthetic, once the tissues are numb, the incision is made. This follows the natural lines of your eyelids - in the creases of your upper lids, and just below the lashes in the lower lids. The incisions usually extend into the crow's feet or laugh lines at the outer corners of your eyes. Working through these incisions, the skin is separated from the underlying fatty tissue and muscle and excess fat is removed or repositioned, depending on requirements. The skin is then re-draped over the lid and any excess removed prior to closure. Closure is done using a fine suture which is removed on day 3 to 5.

Adjuvant procedures may be performed especially in relation to the lower lid. These include lower lid horizontal tightening if the lid has a tendency to fall away from the eyeball and malar fat suspension if you suffer from dark rings below the eye. Some patients have very little lower lid skin excess and their problem is predominantly an excess of fat. In these cases a transconjunctival blepharoplasty may be performed in which the incision is made on the back of the eyelid, leaving no visible scar.

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What can one expect after the operation?

After surgery an antibiotic eye lubricant is usually applied and a light dressing placed over the incisions. As the anaesthetic wears off, your eyelids may begin to feel tight and sore, but you can control any discomfort with the pain medication that will be prescribed. In most cases the pain is mild and tolerable. If the pain is severe, this indicates a problem requiring treatment.

You should avoid straining and bending following surgery and plan to take things easy for the first week afterwards.

Swelling and bruising varies from person to person, usually peaking during the first week, and mostly gone by three weeks after surgery. To diminish swelling and bruising, you should keep your head elevated for the first few days after surgery. This means sleeping or resting in a slightly sitting up position. Cold compresses and ice packs will also help tremendously and they will be soothing on your eyes. Your eyes may be gummy for a week or so, or they may feel dry, hot or itchy. For the first few weeks you may also experience excessive tearing, sensitivity to light, and temporary changes in your eyesight, such as blurring or double vision.

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How long does it take to get back to normal?

You should be able to read or watch television after two or three days. However, you will not be able to wear contact lenses for about two weeks, and even then they may feel uncomfortable for a while.

Most people feel ready to go out in public (and back to work) in a week to 10 days. By then, depending on your rate of healing, you will probably be able to wear makeup to hide the bruising that remains. You may be sensitive to sunlight, wind, and other irritants for several weeks, so you should wear sunglasses and a sunblock when you go out.

Try to keep your activities to a minimum for three to five days, and to avoid more strenuous activities for about three weeks. Your body needs to heal! It is especially important to avoid activities that raise your blood pressure, including bending, lifting, and rigorous sports. Try and avoid alcohol since it causes fluid retention.

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What are the risks of eyelid surgery?

When eyelid surgery is performed by a qualified plastic surgeon, complications are infrequent and usually minor. Nevertheless, there is always the possibility of complications, including infection or a reaction to the anaesthesia.

The minor complications that occasionally follow blepharoplasty include double or blurred vision for a few days; excess swelling and bruising of your eyelids; and a slight asymmetry in healing or scarring. Tiny whiteheads may appear after your stitches are taken out - these can be removed simply with a very fine needle.

Following surgery, some patients may have difficulty closing their eyes when asleep; in rare cases this condition may be permanent. Another very rare complication is ectropion, a pulling down of the lower lids. In this case, further surgery may be required.

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Are the results permanent?

Healing is a gradual process, and your scars may remain slightly pink for six months or more after surgery. Eventually, though, they will fade to a thin, nearly invisible white line.

On the other hand, the positive results of your eyelid surgery - the more alert and youthful look - will last for years. For many people, these results are permanent.

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