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Eyes

As we age, it is common to develop hooding of skin on the upper eyelids also a bulge of fat towards the inner aspect of the upper lid. Skin excess on the upper lid is caused by the tendency of the forehead and brow to drop over the years due to the effect of time and gravity. In women, the presence of a skin fold on the upper eyelid can make it awkward to apply cosmetics and can leave the lids looking tired. In the most dramatic cases, skin may even project beyond the margin of the upper lid and begin to impair the field of vision.

Changes in the lower eyelid, with age and time are partly a product of gradual loss of support of the eyelid structures and also descent of the cheek fat down away from the lid, once again due to the effects of gravity. Typical appearances are fine wrinkling of the skin, a bulge of the lid itself and then a trough that develops between the eyelid and the cheek, which accentuates the bulging of the lid itself. There is a tendency for the lower lids to develop shadowy rings with the junction of the cheek and to give an impression of tiredness.

The surgery: Solutions to upper lid ageing changes vary from patient to patient. In the simplest cases effective treatment can be provided by removing skin with or without resection of a small amount of fat. For patients in whom the forehead has dropped it maybe better to manage the problem by elevating the brow to its more youthful position, which will enhance not only the aesthetics of the forehead but also improve the appearance of the upper eyelid. For some patients with dramatic descent of the brow and very marked skin excess on the upper eyelid the best results come from a combination of repositioning the brow and also upper lid blepharoplasty.

Upper lid blepharoplasty on its own can be performed under local as well as general anaesthesia and is typically a daycase treatment. Surgery involves resection of skin excess from across the upper eyelid and closure of the wound using fine sutures and also supportive tape.

Lower lid blepharoplasty is typically performed under general anaesthesia. The operation involves making an incision just below the eyelid margin, which extends out to the side of the eye. Surgery addresses fine wrinkles by cautious excision of the skin and addresses the bulge of the lower lid by careful tensioning of lid supporting tissues and redistribution of fat. Wounds are typically closed with a combination of sutures and external tape.

Brow lifting is carried out as an endoscopic procedure through a series of small incisions made within the hairline. Using endoscopic instrumentation, the brow is released and elevated and then held in its new position by suspensory internal sutures. Brow lifting is an effective way of elevating the brow and also of smoothing out forehead creases if these have contributed to the ageing changes of the upper face.

Recovery

All patients are advised to have a non-stressful physically calm schedule for the first few days after surgery and should spend several hours each day resting with moistened eye pads to help swelling and bruising resolve. Some patients find the application of diluted Witch Hazel soothing whilst others prefer to use cool water. I routinely advise patients to take Arnica, which can be purchased at most health care shops and is typically commenced before surgery and continued until bruising has settled.

Lower lid blepharoplasty and/or endoscopic brow lifting normally require a one-night hospital stay with follow up arrangements to be seen a week later for review and removal of sutures.

Risks and Complications

Recovery after upper lid blepharoplasty alone is usually very straightforward. It is typical for the lid margins to become bruised and swollen but this usually settles over 10-14 days. The eyelid margin can feel numb for several months following surgery and recovery of sensation may be accompanied by a pricking, tingling feeling, which settles with time. Scars from eyelid surgery typically heal extremely well although no guarantee can ever be given about the final quality of scars in any given case.

It is common for surgery to be accompanied by a few days in which the eyes feel watery. This is typically due to swelling and settles without any specific treatment. Occasionally the watering (and sometimes accompanying discomfort) can last somewhat longer, which may be due to persistent oedema of the conjunctiva over the front of the eye (chemosis). The latter usually responds very well to treatments with drops and ointments but can in some cases last for several weeks and occasionally requires more active management.

Infection is very uncommon for patients undergoing surgery to the eyelids but would typically present with redness, swelling, pain/grittiness in the eyes, fever, feeling unwell and ultimately discharge from the wounds. Most infections would respond to early treatment with oral or topical antibiotics.

Post-operative bleeding is a risk for all surgery. Following blepharoplasty the concern is bleeding into the wounds, which can tend to cause significant swelling, discomfort and difficulty opening the eye. Minor haematoma (blood collection) can often be dealt with by simply removing one or two sutures and re-dressing the wound, whereas more significant haematoma may require further surgery to remove any blood collected from the wound and to arrest any active bleeding occurring (this is extremely uncommon). Severe bleeding is a very rare cause of blindness.

In older patients, with relatively poor support to the lower eyelid, surgery carries a greater risk of the lid falling away from the eye or dropping down, which may, in turn, require additional surgical treatment.

Key Points

• Blepharoplasty surgery aims to remove excess skin from the upper and lower eyelid and to reduce or remove bulging across the lower eyelid.
• Surgery for the upper eyelids is performed under local anaesthesia.
• Surgery for the lower eyelids is typically performed under a general anaesthetic and requires a 1 night stay in hospital
• Bruising and swelling are normal round the eyelids and tend to settle quite quickly
• A restful schedule for the first 5-7 days after surgery is important to initiate good wound healing