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Eyelid Surgery (Blepharoplasty)

Introduction

Ageing of the upper half of the face includes changes in the forehead, eyebrow, upper eyelid, lower eyelid and cheek or mid face area. The skin becomes thin and you lose volume of subcutaneous tissue. The continuous movements and contraction of muscles cause transverse creases at the forehead, vertical creases at the area between the eyebrows and creases also appear at the crow’s feet area.

With the effect of ageing and gravity the tissues on the forehead and upper face move downwards. The eyebrows descend with a reduction in distance between the eyebrows and upper eyelashes and also leads to an excess skin fold on the upper eyelid. The normal fat in the socket can protrude and cause a bulge at the medial part of the upper eyelids. Sometimes normal structures, like the lacrimal gland, can descend and cause a bulge at the outer part of the upper eyelid.

Bags are caused by an accumulation of fat and with age the skin stretches and the muscles around the eye weaken.

Bags are caused by an accumulation of fat and with age the skin stretches and the muscles around the eye weaken.

The lower eyelids become loose and lax and the white part of the eyeball becomes visible below the darker area, called “scleral show”. The skin of the lower eyelid becomes loose and lax. The youthful lower eyelid is shorter in height but the ageing lower eyelid becomes longer in length because the tissue of the cheek descends due to gravity. It also causes deep lines between the eyelid and cheek called “tear trough deformity”.

The amount of fat normally present around the eyeball in the socket is variable due to laxity of the normal retaining tissue of fat in the orbit in the area of the lower eyelid. Prominent bulges appear, which are called “eye bags”. The fold on the side of the nose at the cheek, called naso-labial fold, also becomes prominent. All these age related changes on the upper face give a person a tired or an aged look. Both non-surgical and surgical remedies can help to rejuvenate the upper face. The surgical procedures for the upper face include, eyebrow lift, temple lift, browpexy, upper blepharoplasty, lower blepharoplasty, and mid face or cheek lift. 

The skin loses its elasticity and our muscles slacken with age. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper lids and forms deepening creases in the lower lids.

At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes.

The problem often seems worse in the morning particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day tends at night to settle in areas where the skin is loose, such as the eyelids.


Upper blepharoplasty

Most patients come with a complaint of a tired look to their face due to a hooded appearance of their upper lids with no show of normal skin fold on the upper eyelids. Some female patients have a complaint of not being able to apply makeup on the upper eyelids as there is a continuous overhanging fold of skin pressing on the eyelashes. Mr Riaz will make an assessment of the underlying problems at the time of consultation.

The eyebrows have to be at a suitable position in relation to the upper eyelashes to give a youthful fresh appearance. Some patients require a temple lift or browpexy to be performed at the same time when upper blepharoplasty is performed. The procedure of upper blepharoplasty mainly addresses the appearance of the upper eyelid. The assessment of excess skin on the upper eyelids and any excess fat with abnormal protrusion giving rise to bulges and position of lacrimal gland is assessed. 

In a typical eyelid reduction operation incisions lines follow the natural lines of the eyelids.

In a typical eyelid reduction operation incisions lines follow the natural lines of the eyelids.

PROCEDURE

A pre-operative marking of skin to be excised is marked in the sitting position with the eyebrows held at a normal location over the upper orbital bony margin. The skin incision is marked in the natural crease about 1.0cm from the eyelashes and it also extends outwards over the crow’s feet area then the upper margin of excision of excess skin is marked. It is important not to over-excise skin and muscle in upper blepharoplasty so that the patient can have normal eye closure with no risk of dry eye syndrome.

Some patients have ptosis of the upper eyelid which is droopy upper eyelid causing partial blockage of the field of vision. This can be addressed at the time of upper blepharoplasty. At operation the skin is excised as marked. A strip of loose muscle is excised. The excess fat in the two compartments of the upper lid is excised if required. Browpexy is repositioning of the outer part of the eyebrow, which can be performed through the same incision. This procedure gives control on repositioning of the eyebrow and is usually suitable for patients who have mild to moderate saggy eyebrows.

The structures are then closed in layers. Sutures from the skin are usually removed at 5-6 days from the operation. In patients who have no skin fold on the upper eyelids or it has a weak attachment, then an anchor blepharoplasty is performed by recreation of this fold to give a youthful appearance. At the same time we can keep a nice and full appearance of the upper lids. 


Lower blepharoplasty

The traditional lower blepharoplasty is skin and a strip of muscle excision only which leaves a scar close to the eyelashes extending to the crow’s feet area. This technique is notorious to have a slight pull on the lower lids leaving a visible white part of the eyeball below the dark area, called “scleral show”.

Mr Riaz likes his individual approach to the lower eyelid and mid face or cheek area. His technique addresses excess skin, loose muscle and tightening of the deep layer of the lower eyelid with repositioning of orbital fat over the lower orbital margin and also moving descended and saggy cheek tissue upwards over the bone.

This technique also uses tightening of the lower eyelid to prevent eversion or ectropion of the lower lid. This technique changes the aged look of the lower eyelid and cheek into a youthful fresh appearance of the mid face with a shorter height of the lower lid and full cheeks. It also corrects laxity of the naso-labial fold.

 

Procedure

An incision is placed close to the eyelashes extending to a variable distance in the crow’s feet area. Skin and muscle flaps are raised separately to expose the third deep layer and depending on the individual patient’s orbital fat, if not in excess, then the orbital septum is plicated to change its loose and lax baggy appearance into a nice and tight flat sheet.

Transconjunctival blepharoplasty- incision made inside.

Transconjunctival blepharoplasty- incision made inside.

If there is an excess of fat then the orbital septum is opened up to remove some fat if the cheeks of patients are nice and full but if the cheeks are thin then normal excess fat of the orbit is re-draped over the tear trough area or lower orbital margin and it is extended into the cheeks to get fullness of the cheeks.

In this technique the orbital septum is still plicated. The fat is transfixed to the peri-osteum over the lower orbital margin. The normal deep fat below the orbital margin is brought on top of this re-draped fat. Mr Riaz uses a deep cheek lift suture to move the bulk of the cheek and hitch to the outer bony margin of the orbit.

Mr Riaz also uses a canthopexy stitch to tighten the lower eyelid against the eyeball. The canthopexy stitch also helps to relocate the position of the margin of the lower eyelid in relation to the dark area. It also helps to create youthful almond shaped eyes. Last but not least, the muscle of the lower eyelid is hitched upwards above the cheek bone to a fixed point of temporal fascia to move the cheek further upwards. It also supports the lower eyelid.

A small strip of muscle is excised before hitching the muscle and lastly, excess skin is re-draped and excised so that skin margins are closed without any tension. Mr Riaz’ lower blepharoplasty technique includes full rejuvenation of the mid face and cheek. A corneal shield is used during the operation to protect the cornea.

Ice packs are used in the post-operative period. Sutures are usually removed after 5-6 days. 


Endo brow lift

This procedure is performed through keyholes inside the hairline to lift the forehead and eyebrows. This procedure is not very popular these days because of a possible end result of a surprised look due to a too high position of the eyebrows. 


Asian blepharoplasty

Asian Blepharoplasty is the aesthetic or cosmetic procedure for creating an upper eyelid crease in Asians who lack this anatomic feature.  In general, the Asian upper eyelid differs significantly from its Caucasian counterpart not only in size but also in the shape of the crease when present.  

Upper eyelid surgery in Asians is certainly more challenging, here we share the result of one of our female patients.