Prior to blepharoplasty surgery, a full ophthalmic examination is necessary. This includes checking visual function as well as undertaking tests to exclude eyelid and eye surface conditions such as blepharitis, dry eye, eyelid laxity or any other conditions that could be exacerbated by a blepharoplasty. The patient’s entire face and eyelids are examined during the consultation.
A visual field test may be required to determine the extent of visual impairment from eyebags or other conditions.
It is common for photographs to be taken both before and after the blepharoplasty procedure.
The patient will be asked how the eyebags affect them, determining whether the problem is cosmetic or also affects vision. It is also useful for the patient to provide photographs taken prior to the eyebags becoming noticeable, for instance from two to five years younger, to aid in understanding the individual cases and to plan their blepharoplasty.
A blepharoplasty can be done for cosmetic purposes or to improve vision. The purpose of a blepharoplasty is to correct excess folds of skin (dermatochalasis) and drooping eyelids (eyelid ptosis), or to reduce baggy lower eyelids. Fine wrinkles can be treated with laser resurfacing or a gentle chemical peel if desired. A periocular and facial trichloracetic acid peel can be performed at the same time as blepharoplasty surgery. Regular tretinoin treatment can greatly improve the quality of the skin.
Upper eyelid blepharoplasty
Upper eyelid blepharoplasty incisions are typically made in the upper eyelid skin crease, where they heal best and scarring remains well hidden.
The blepharoplasty incision is made along the natural eyelid skin crease a few millimetres above the eyelashes. The height of the blepharoplasty incision varies in men and women and is commonly placed lower in Asian blepharoplasty patients who have a naturally low skin crease unless ‘Westernisation’ is requested.
The blepharoplasty consists of an elliptical piece of skin and muscle being removed using a blade and a Colorado needle, which greatly reduces bleeding and helps keep tissue damage to a minimum. The blepharoplasty skin incision is then closed using delicate sutures.
A drooping brow ptosis or eyelid ptosis may be operated on during the same procedure. It is also possible that underlying fatty tissue may be removed during the blepharoplasty surgery to get rid of upper bulges, particularly at the inner corner of the upper eyelid.
Lower eyelid blepharoplasty
Patients with only mild eye bags or mild lower lid skin laxity, fine lines or discolouration may not require a blepharoplasty. Instead, they may be able to get a noticeable improvement from revised skin care, laser resurfacing or a chemical peel with trichloracetic acid (TCA peel).
If there are deep tear troughs, an injection of a hyaluronic acid gel filler (eg. Restylane® or Juvéderm®) may be used in the periocular region in order to increase the soft tissue volume. Once the hyaluronic acid gel has reabsorbed after several months, a further injection can be offered. Some patients can proceed with an autologous fat transfer (also known as a Coleman fat transfer).
If a blepharoplasty is required, the incision is often done from the inside of the lower eyelid, which causes minimal swelling and leaves no visible scarring from the outside. This is known as a transconjunctival blepharoplasty. The transconjunctival route is used if a small amount of fat needs to be removed or repositioned into the tear trough.
If skin is going to be removed from the lower eyelids themselves during blepharoplasty, a fine incision is made close to the eyelashes, known as an infra-lash incision. At the same time, the eyelid can be tightened and stabilised using an orbicularis muscle flap and canthopexy. Discreet absorbable sutures are used to close the skin incision, which heals well usually leaving no visible scar.
A pinch blepharoplasty consists of an excision of a small pinch of skin from either immediately below the eyelashes or a little lower down the eyelid, without removing the orbicularis muscle.
Blepharoplasty patients with dry eye may have punctal plugs inserted to reduce dry eye symptoms after surgery.
N.B. Aspirin should be stopped two weeks prior to your blepharoplasty surgery date to reduce the risk of pre- and postoperative bleeding which could affect the vision.
Similarly, warfarin is usually stopped two days beforehand. We aim to reduce the INR to around 2, however, if you have for instance a prosthetic heart valve, this may not be possible and you should check with your cadiologist or your GP first.