It has been said that the eyes are the windows to the soul. Whether or not this is true, the eyes are certainly one of the major focal points of the face. Changes caused by aging can lead to a tired, unrested appearance and detract from the beauty of the eyes. Blepharoplasty, or "eyelid lifts", as they are more commonly called, can result in a more refreshed, well-rested, youthful appearance.
As we age, eyelid skin tends to sag and fatty tissues around the eye begin to bulge, causing bags under the eyes. As the eyelid muscle thickens, ridges and creases develop around the eyes as well. Eyelid lifts are usually performed for cosmetic reasons, but occasionally the upper eyelid skin becomes so droopy that it obstructs vision and in these cases, eyelid surgery is done to correct this problem.
As a cosmetic surgeon, I perform countless eyelid surgeries. Below, I describe the process of getting an eyelid lift, from the initial decision to get the surgery, through the recovery process.
Anyone considering an eyelid lift should see a board certified surgeon from one of the following surgical specialties: facial plastic surgery, otolaryngology/head and neck surgery, ophthalmology, or general plastic surgery. The surgeon should have extensive training and experience with eyelid surgery, and it is advisable to request to see examples of before-and-after photographs of the surgeon's work. It is also a good idea to speak with some of the surgeon's prior patients. Doing your homework before you decide to go ahead with the procedure will help ensure that you receive the best care possible.
Assessing patient goals
The consultation gives the surgeon an opportunity to listen to the patient describe his or her goals. As a surgeon, I want to know that the patient has thoroughly examined his or her own reasons for wanting the surgery, and I want to make sure that the patient has realistic expectations.
Eye assessment and surgical plan
The consultation also includes an eye examination, and the development of a surgical plan. I ask about the patient's general health and then about any problems with the eyes such as dry eyes or visual problems. During the exam, I test visual acuity, eye movements and tear production.
When examining the patient for an eyelid lift, I look at the eyes, forehead and brows. I examine the eyes to determine if there is excess skin, fat and/or muscle around the eyes. I also test to see if there is any laxity of the lower eyelid, which may need to be addressed during the surgery to prevent the lower eyelid from being pulled down.
To achieve optimal results, I often recommend that patients get a browlift in addition to an eyelid lift. The brows can be repositioned to their original, youthful position at the same time as the eyelid surgery.
I use computer imaging to show patients the cosmetic changes that are possible, and how they will look. It is important to note, however, that the computer-simulated photographs are only an estimation of the desired outcome. Although the actual result usually approximates the computer-simulated images quite closely, no surgeon can guarantee to what extent this will be the case.
There are a number of different settings where this surgery can be performed, including hospital operating rooms, surgicenters and outpatient office operating rooms.
If patients are having surgery performed in an office operating room, they should make sure that the anesthesia is administered by a licensed anesthesiologist or nurse anesthetist, and that all of the same monitoring equipment present in a hospital operating room, such as EKG and blood oxygen level monitors, will be in the office for their surgery.
There are a number of different techniques in blepharoplasty.
The upper eyelid
The standard approach to the upper eyelid is through an incision in the eyelid crease, which camouflages very well after surgery. Through this incision, excess upper eyelid skin, muscle and fat are removed to give a tighter, smoother upper eyelid.
The lower eyelid
The lower eyelid can be approached through an external incision immediately under the lashes or through an internal incision inside the lower eyelid, which is called the transconjunctival approach. The external incision allows the surgeon to remove excess skin and muscle as well as excess fat. The incision inside the lower lid is useful when the only problem is excess fatty tissue-not excess skin or muscle. An upper and lower blepharoplasty takes about two hours.
If a browlift is done at the time of an eyelid lift prodedure, the browlift is done first. Doing the browlift first allows the surgeon to remove the correct amount of upper eyelid skin, as raising the brows decreases the amount of upper eyelid skin.
The browlift requires a few small incisions hidden in the scalp hair. The surgery is performed with very specialized instruments and a tiny video camera, called an endoscope, which allows the surgeon to watch the procedure on a video screen. In addition to raising the brows, the browlift gets rid of the deep vertical creases between the brows and the horizontal creases across the forehead. (see photos x,y,z)
Once the browlift is completed, excess skin, muscle and or fat are removed from the upper and lower lids to give a smooth eyelid contour.
Some visual examples of blepharoplasty, before and after surgery:
Patients are usually given medications to place them in a comfortable drowsy state during the surgery, though they remain awake. This is known as "sedation". An alternative to sedation is general anesthesia, in which the patient is put to sleep for the duration of the surgery. Sedation, however, is considered safer and has a quicker recovery then general anesthesia.
After surgery there is usually minimal pain, and it is easily controlled with a mild pain reliever such as Tylenol with codeine. For the first day and a half after the surgery, I ask that patients place gauze pads soaked with ice water on the eyes, and replace them every twenty minutes while awake. This keeps discoloration and bruising in the eye region to a minimum, and is soothing to the patient. I also have patients keep their eyes moist with saline eye drops and antibiotic ointment for at least one week after surgery.
The black and blue usually resolves by the end of the first week. Removing stitches from the eye region usually takes place five to seven days after the surgery. The incisions heal very quickly in the thin eyelid skin and are usually very difficult to see after the first month. Any redness around the incisions can be camouflaged with makeup immediately after the stitches are removed.
It is important for patients to avoid strenuous activities for the first two weeks after surgery in order to limit the possibility of postoperative bleeding. It is also important for patients to sleep with their head elevated on a few pillows for the first week, to allow gravity to aid in reducing swelling.
All surgery is associated with risks. For patients who do not have significant medical problems, the risks are minimal. Any surgery can result in an infection, a bleeding problem or an allergic reaction to anesthesia medications, but these problems are extremely rare.
Overaggressive excision of skin can lead to difficulty with eyelid closure and dry eyes, and post-operative bleeding can cause pressure on the eyes and decreased vision. These complications are extremely rare in experienced hands.
The surgical fee for blepharoplasty varies from doctor to doctor and cost will depend on the extent of the surgery. A range of $3000 to $5000 is typical for upper and lower blepharoplasty.
Occasionally, when the upper eyelid skin excess is significant enough that it obstructs vision, insurance will cover the cost. If the procedure is done for purely cosmetic reasons, it will not be covered by health insurance.