Upper Eyelids – Blepharoplasty I
As one ages, the upper lid tissues begin to relax and stretch. The skin becomes thinner, wrinkled and redundant. Sun exposure, allergies or recurrent swelling may accelerate these nonspecific changes in the tissue. In some individuals, this process may be hereditary. The result is an excess of eyelid skin referred to as “dermatochalasis”. Stretching and relaxation of the eyelid tissues (orbital septum) will also allow migration of the orbital fat into the eyelids (fat prolapse). As a result, a “fullness” of the upper eyelids develops, which often progresses with time. The excess lid skin and fat bags create a tired look, cause the patient to look older than they are, and may cause a heavy feeling or weight on the lid. Eventually, the excess tissues hang over the lid margin and cause a restriction of the superior visual field. Having eyelid surgery to remove the excess skin and fat is referred to as “Blepharoplasty”. Blepharoplasty can restore a younger; more rested appearance as well as removing any visual field restriction.
Eyebrow position requires assessment in every candidate interested in upper eyelid surgery. Like the eyelids the eyebrows also change with age, gradually moving in a downward direction. As the brows move downward, the eyelid skin appears droopier than it actually is. Some individuals will require brow elevation as well as blepharoplasty to obtain an improvement in their appearance and/or visual field.
Goals of Upper Blepharoplasty
Blepharoplasty surgery will remove the bulges created by fat herniation as well as the excess, redundant skin that is hanging downward (Figure 1 and 2). Patients often request as much tissue be removed as possible. It is extremely important to leave enough skin to allow proper eyelid opening and closing. If too much is removed and the eyelids do not close, dry irritable eyes will result and create a great deal of discomfort. If too much fat is removed, a sunken appearance of the lid may develop.
The goals of surgery therefore, are to remove enough tissue to restore a younger, healthier, more rested appearance and any associated visual field defect, yet leave enough lid tissue on the eyelid to allow proper eyelid opening and closing, and without any distortion or change in the natural almond-shaped eyelid contour.
A preoperative eye check is important to assess the visual acuity, tear film, strength of lid closure, symmetry of eyelid openings and status of any other eye problems. The pre-existence of dry eyes, facial nerve palsy, a drooping eyelid due to a weak muscle in the lid (ptosis) etc., will have a bearing on the amount of tissue removed during the lid surgery.
65 year old pre-op.
42 year old pre-op.
3 months post upper blepharoplasty.
3 months post upper blepharoplasty.
Upper blepharoplasty surgery is an out-patient procedure performed in the office, surgi-center or hospital, under local anesthesia with oral sedation. The excess skin is carefully marked out and the eyelids are infiltrated with a local anesthestic. Incisions are made in the natural folds of the upper eyelid and the excess skin is removed. A small amount of fat may also be removed. Bleeding vessels are gently cauterized with a cautery machine. Skin edges are closed with absorbable sutures or occasionally non-absorbable sutures which are removed in one week. The incision blends into the natural eyelid crease line. With normal tissue healing and a little make-up, it hides nicely by 10 days. The incision gradually matures, settles and becomes barely noticeable by 3 months.
Following surgery, rest with cool compresses (frozen peas, ice, gel packs, etc.) over the eyelids 4 to 6 times daily for 30-60 minutes is required for about 3 days. Patients are able to get up and walk around but are cautioned to avoid heavy lifting, straining and excess activity to prevent any stress on the eyelid incision and potential bleeding. Discomfort is usually minimal and relieved with acetaminophen (Tylenol). Most individuals will have swelling and some degree of bruising in the first week. It is best to be off work and away from social events for about 1 week. Makeup can be applied after one week. Complete tissue healing usually occurs by 2 to 3 months.
The eyelid blink rate may temporarily slow down following eyelid surgery and, as a result, the eyes may have a gritty or sandy feeling. Artificial tears during the day and lubricating ointment at night are commonly used to keep the eyes moist during the healing process. Blurry vision may occur during the healing period as a result of the decrease in eyelid blink rate or ointment getting into the eye but returns to normal over the next few weeks. Infection, excessive pain, and bleeding into the eyelid tissue with hematoma formation are very uncommon. If infection develops, antibiotics may be required either orally or intravenously. Pain should be minimal if any. If pain is present and severe, it is important to notify the physician who did the surgery, or the physician “oncall” for further assessment. Bleeding with hematoma formation is very uncommon. Most hematomas settle on their own. If they are large and prevent the eyelid from opening, drainage is sometimes required.
Once the healing process has settled (3 months), if there is any lid asymmetry, a touchup procedure may be required in less than 5% of patients.
The potential complications associated with upper blepharoplasty surgery are eye related. It is important to have the surgery done by someone who has a thorough knowledge of the eye and is prepared to manage the potential eye problems that occasionally occur.
Will OHIP cover the Upper Eyelid Surgery?
OHIP will only cover upper eyelid surgery if there is a 50% visual field restriction, making it very difficult for patients to get covered. If the eyebrows are low and require elevation, OHIP will not cover this.
Your eyes are the first thing people notice about your face and are an important aspect of facial attractiveness. With age, the upper eyelids become “droopy” or “baggy” in appearance, making one look “more tired” or “older” than they really are. Upper blepharoplasty surgery provides both functional and cosmetic improvement with minimal risk of serious problems. It is commonly performed under local anesthesia as a day patient and is a straightforward procedure in experienced hands.