Eyelid Rejuvenation (Blepharoplasty)
Heavy or hooded upper lids can be corrected with an upper blepharoplasty.
Lower lids may have excess skin, fat pouches, deflation with a tear trough deformity or a combination of these issues. The correct combination of surgical manoeuvres is required for lower lid correction.
Eyelid rejuvenation (blepharoplasty) is performed under sedation and local anaesthesia. It is done as day case surgery (in and out on the same day) in my own clinic. The upper lid pair take about 40 minutes, lower lid surgery, depending on what is required, can take 30 to 90 minutes. When skin is removed closure is achieved with a running suture in the skin (deep to the surface) and this suture is removed at 5-7 days. Recovery from blepharoplasty is relatively quick. Bruising and swelling are usually not severe and take about 10 days to 2 weeks to subside. Complications are rare and the results from blepharoplasty are usually very satisfactory and long lasting.
The lower lids may have excess crepey skin, fat pouches, hollowness (deflation), or a combination. Correct treatment depends on the problem. The lower lid is responsible for only 5% of eye closure. Its main function is to support the eyeball. It is important to bear in mind this function when performing any lower lid rejuvenation procedure. Excess skin removal or interference with the supporting structures (the muscle in the middle), can result in lower lid droop (ectropion) which can not only accentuate an aged appearance but also cause other issues. Lower lid rejuvenation requires a problem orientated and cautious approach.
Excess skin can be removed with a pinch blepharoplasty – the excess is pinched and excised leaving usually an inconspicuous scar running just beneath the lash margin. Sometimes it might be feasible to tighten the skin and improve a crepey look with resurfacing, thus avoiding a scar.
Because I like to leave the middle supporting layer intact, I prefer to remove fat pouches through the back of the lid. This is a trans-conjunctival blepharoplasty. The lid is drawn forward and one or two small incisions are made in the conjunctiva on the back of the lower lid through which the fat is removed.
Tear troughs, a deep junction between the lower lid and the cheek and easily felt bone are signs of deflation of the lower lid. This is a common and early problem of facial aging, often under-recognised by patients. There are a number of reasons why I prefer to correct lower lid deflation with fat grafting rather than fillers. Fat grafting provides sufficient volume – typically about 3 ml per lid as opposed to half a syringe, 0.5 ml, per lid with filler. Fat grafts are the richest source of adult stem cells which I believe and have observed to improve the texture and appearance of the lower lid skin. Fat grafts provide a greater degree of permanence than does filler and this works out to be more cost effective over time. The fat that is used for grafting is your own fat, usually present in abundant amounts, and harvest, with a small liposuction, may provide some donor site improvement. Lower lid droop occurs with age and many surgeons like to put a fine suture from the lower lid to the bone to elevate the lower lid (canthopexy). I find that the fat grafts provide some support to the lower lids which can help push them up into a more normal position. Finally, if I am doing fat grafts to the lower lids, it is a small thing to extend the fat grafting to other areas of the face (temples, cheeks, around the mouth) so as to provide a more effective general rejuvenation of the face. See more on fat grafting here.
Although complications are rare, whenever fat is added or taken away from the lids, asymmetries, lumps, dents and other contour irregularities are possible. Scars can vary in position and quality. With any lid surgery, ectropion (a pulled down lid) can be an issue, as can dryness of the eye, redness and irritability.
Upper Blepharoplasty is performed primarily to remove excess droopy skin. After skin removal, the muscle is tightened with cautery. Occasionally excess fat from the fat pocket nearest the nose is removed. Rarely fat may be removed from the rest of the upper lid – rarely because one does not want to create aged-appearing hollow upper lids. A full lid appears youthful and is preferable. Sometimes, fat is added to the lid to create a youthful fullness.
The primary function of the upper lid is to close the eye. Complications after upper blepharoplasty include difficulty with eye closure and associated problems: dryness; itchy, scratchy, red eyes. The scar from upper blepharoplasty usually heals as a fine inconspicuous line hidden in the lid crease, but sometimes the scar can be more visible, especially early on, as the wound heals and settles. Upper blepharoplasty should be one of the ‘winner’ procedures in cosmetic surgery. The results are long lasting. Your eyes will appear fresher, more open and you will look more awake.
Watch my vlog on upper blepharoplasty below.
The video below demonstrates more or less how I do my upper upper lid blepharoplasty. Some differences: I mark my patients beforehand in the ward while they are sitting up. This gives me greater precision and accuracy in determining how much skin to remove. I use a device called a surgitron to cut and remove the skin. This uses radio frequency and is similar to laser. The advantage of this is that there is less bleeding. I rarely remove muscle, but I do cauterise it to shape it and to minimise intra-operative bleeding and post-operative bruising. I am also very conservative with fat removal and hardly, if ever, remove fat from the middle compartment. Sometimes, if there is bulging, I do remove fat from the inner part of the lid. Sometimes I add fat. As he says, it depends on the patient’s desires, but it also depends on the anatomy of the lid.
Blepharoplasty can provide a long lasting rejuvenation to the window of the soul.