Blepharoplasty is a surgical procedure for removing redundant skin, muscle and fat from the eyelid. It is sometimes performed in combination with eyelid ptosis repair. Although blepharoplasty is performed by practitioners from many disciplines, an ophthalmologist is best placed to look after your eyes during and after the procedure.
Upper eyelid blepharoplasty is performed through a skin crease incision, through which excess fat can be removed if necessary. There are two fat pads in the upper lid, themedial and central. The lateral compartment is occupied by thelacrimal gland. It is very important to avoid surgical interference with the lacrimal gland to prevent dry eye post-operatively.
Lower eyelid blepharoplasty is generally carried out through a trans-conjunctival incision with the emphasis on fat removal. There are three fat pads in the lower lid, the medial,central and lateral. The inferior oblique muscle lies between themedial and central, and must always be positively identified duringlower lid fat removal. It is important to avoid srgical interference with the inferior oblique muscle to avoid vertical and torsionaldiplopia (double vision) post-operatively.
Wrinkles due to excess skin lessen due to skin contraction in the post-operative phase, or they can be treated by resurfacing techniques.
Blepharoplasty does not treat skin pigmentation, venous show-through, wrinkles or large fluid bags.
The skin type should be considered and any skin conditions treated to prevent problems with wound healing.
The appropriate aesthetic parameters must be discussed with, taking account of age, race and gender. In Caucasian patients, an arched brow with a deep upper sulcus and a well-defined skin crease are considered attractive in females, whereas in males in a straight brow perpendicular to the nose with a low, subtle skin crease is often considered more masculine.
Oriental blepharoplasty
In Hong Kong and Singapore, an eyelid with no crease is known as a “single eyelid” and eyelid with a skin crease as a “double eyelid”. These are literal translations from the Chinese ideograms. When South East Asian patients request a blepharoplasty, they are often requesting the surgeon to form a skin crease and a "double eyelid". They rarely wish removal of excess skin or of their epicanthic fold. The surgeon should remember that Asian skin is prone to the formation of hypertrophic scars.
The essence of the surgical technique is the incision of the skin at the site of the desired skin crease, and the closure of the skin with sutures which involve the levator aponeurosis or tarsal plate. Scar formation produces the desired skin crease.
Complications of blepharoplasty
Visual loss
This is the most devastating complication of blepharoplasty. The frequency of this complication has been estimated at 0.04%. The cause is thought to be orbital haemorrhage, which increases intra-orbital and intra-ocular pressure, compromising the ocular circulation, and causing ischaemic optic neuropathy and central retinal artery occlusion.
Risk factors such as hypertension, aspirin, Ginko
biloba and anticoagulants must be stopped a full two weeks before
surgery if the underlying medical condition allows, and with the
agreement of the patient’s GP or physician.
The source of haemorrhage is thought to be the orbital fat pads; for this reason, meticulous surgical technique is critically important, and I use bipolar cautery after careful clamping of the fat to minimise these risks.
Strenuous exercise is prohibited for two weeks following surgery.
Diplopia
The inferior oblique muscle is most frequently involved in blepharoplasty, and the author recommends that it the positively identified during lower lid fat excision. Injury to the superior oblique has also been described. Secondary blepharoplasty appears to carry a higher risk of diplopia.
Lacrimal gland prolapse
This can be recognised prior to surgery and the lacrimal gland resuspended during blepharoplasty. It rarely appears as a postoperative complication.
Reduction of eyelid closure
To a minor degree, this is expected after eyelid surgery, and exposure can be prevented with ocular lubricants, particularly at night.
I avoid over-zealous excision of skin with the pinch test, making sure that the lids remain closed, during surgery when the intended excision marks are brought together with forceps.
Lower eyelid malpositions
Lid retraction and ectropion are the result of undiagnosed horizontal lid laxity or excessive lower lid skin removal. These can be avoided by tightening the lower lid at the time of surgery and avoiding skin removal by using the trans-conjunctival approach.
Treatment of the round-eyed, tell-tale appearance of the inexpert lower eyelid blepharoplasty is by lateral tightening with or without lower eyelid grafts.
Dry eye
I search for this pre-operatively and recommend the routine use of lubricants post-operatively. Infection
This is extremely uncommon due to the excellent vascular supply of the eyelids. Gentian Violet solution has been found to be contaminated with bacteria and the I recommends the use of disposable skin marking pens. Wound infections should be treated in the normal way, with bacteriological sampling and broad spectrum antibiotics. Necrotising fasciitis has been described following blepharoplasty, which emphasizes that no procedure should be entered into lightly by patient or surgeon.
John Pitts is an oculoplastic surgeon in full-time private practice in London and Barbados following a substantive NHS consultant position. He graduated MB ChB from Glasgow University in 1983 and, in 1987, after working in pathology and neurology, he trained in ophthalmology in Glasgow, Nottingham and London. He has travelled extensively, working in centres of excellence in Los Angeles, New Orleans, Melbourne, Barbados, Brunei and Vancouver. He has undertaken Fellowship training in oculoplastics at Moorfields Eye Hospital.
