Download Eye bags and Blepharoplasty

Eye bags and Blepharoplasty
Condition
Eye bags refer to an excessive amount of eyelid tissue which can affect the upper
and/or lower eyelids with age. Eye bags look unsightly, can also impair vision where
the upper eyelids are affected. Eye bags are treated by reducing the amount of
eyelid tissue present. This operation is called a Blepharoplasty.
In Blepharoplasty excess skin is removed, together with a small amount of underlying
muscle (the oribicularis muscle) and occasionally with removal of protruding orbital
fat.
The medical term used to describe an excess of eyelid skin is Dermatochalasis. In the
upper eyelids this causes skin folds and hooding particularly with orbital fat protrusion
making the eyelids look bulky and heavy. Dermatochalasis can affect visual acuity.
The excess skin can sit on the eye lashes and cause heavy and lateral hooding and
excess folds of skin can interfere with the visual field and affect driving.
Patients of any age above 30 and up to 80 may request Blepharoplasty. The most
common age for Blepharoplasty is between 40-65 years old, both in men and
women. Upper eyelid Blepharoplasty is more commonly performed than lower
Blepharoplasty.
Psychological and functional effect of eye bags
The overall effect of eye bags is to age the face. If the upper eye bags are also
interfering with the visual function this can provoke headaches and exacerbate a
general feeling of fatigue, because the patient is using their eyebrows constantly to
try and lift their excess eyelid skin off the eyelashes and out of their visual field.
Towards the end of the day the forehead muscle called the frontalis muscles get
tired as they can no longer sustain lifting the eyelids all day long and an ensuing
headache and eye ache occurs. If the upper eyelid dermatochalasis is particularly
severe and the skin is touching the upper eyelashes, this can cause watering eyes
and irritation.
Asian Blepharoplasty
This is a specialised eyelid operation procedure which can be combined with
Westernisation, giving a higher more marked skin crease called the double eyelid
operation.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
Eyebrow Droop
Some patients may also have dropping eyebrows known at brow ptosis which may
also require surgery at the same time as Blepharoplasty.
Eyelid ptosis
Some patients may have associated eyelid droop called ptosis, which may also
require simultaneous surgery at the same time as Blepharoplasty.
Examination
The patient’s view
The patient will be asked how their eye bags affect them to determine whether the
problem is cosmetic or affecting visual function. It is very useful if the patient provides
photographs taken prior to them developing eye bags, for instance from two to five
years previously, in order to help the Oculoplastic Surgeon understand their
individual problem and how they looked before the eye bag developed.
Details of previous illnesses and surgery
The patient should bring along details of previous illnesses, current medication and
allergies. They should tell the Oculoplastic Surgeon if they are taking Aspirin, Warfarin
or any homeopathic tablets or vitamins as these may potentially affect bleeding
during surgery or the healing period.
Many patients have had periorbital and eyelid rejuvenation in the form of Botulinum
Toxin A injections, fillers such as Hyaluronic Acid gel or a previous Blepharoplasty. The
Oculoplastic Surgeon should be told about previous treatments and surgeries as it
may affect the outcome of Blepharoplasty surgery.
Prior to considering eyelid rejuvenation for functional or cosmetic reasons a full
ophthalmic and eyelid examination is performed. This includes checking visual
acuity, blepharitis, dry eye, eyelid laxity and other conditions that could be
exacerbated by a Blepharoplasty. The entire face and eyelids are examined.
Tests
A visual fields test may be required to determine the extent of the visual impairment
from the eye bags and/or associated eyebrow or eyelid ptosis. It is common for
photographs to be taken before and after Blepharoplasty.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
Consent for Blepharoplasty surgery
Blepharoplasty is tailored to the individual’s requirements The Oculoplastic Surgeon
will discuss the patient’s suitability for surgery, making them aware of both the risks
and the benefits.
They will also provide the patient with general advice with regards to diet, smoking
and skin care as well as other rejuvenation treatments such as Botulinum Toxin A or
fillers, which may either be complimentary to Blepharoplasty or replace the need for
Blepharoplasty surgery. They will be informed of the risks and complications of
Blepharoplasty surgery.
Treatment
A Blepharoplasty is either a rejuvenating (cosmetic) or functional surgical procedure,
depending on whether the excess tissue poses a cosmetic problem or interferes with
a patient’s visual function. The purpose of a Blepharoplasty is to remove the excess
folds of skin (dermatochalasis) and eye bags (orbital fat protrusion) or to reduce
lower eyelid festoons. Fine wrinkles can be treated with skin care, Retin A, a gentle
chemical peel, Botulinum Toxin A, filler or laser treatment. These non-surgical
treatments can be done either instead of Blepharoplasty or in addition.
Upper eyelid Blepharoplasty
The surgical incisions for upper eyelid Blepharoplasty are typically made in the upper
eyelid skin crease where they heal well and will remain hidden.
In upper eyelid Blepharoplasty an elliptical piece of skin and muscle is removed.
Occasionally the protruding orbital flat of the upper eyelid particularly the medial fat
pad may be excised in upper eyelid Blepharoplasty.
If there is an associated brow ptosis or upper eyelid ptosis then this may be operated
on during the same procedure as the upper eyelid Blepharoplasty. Usually either
discrete absorbable sutures or very fine non-absorbable sutures are used to close
the skin incisions which heal well leaving no visible scar.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
Upper eyelid Blepharoplasty
First with a pen, the surgeon marks out the
amount of skin to be removed
After an injection of local
anaesthetic the excess skin
is removed
An incision is made and the excess skin is
removed, occasionally with some of the
underlying muscle
The skin incision is then closed
using fine stitches that are
usually removed after 7-10 days
Lower eyelid Blepharoplasty
Patients must be aware that if they have mild eye bags or lower eyelid skin laxity,
then they may not require a Blepharoplasty. Instead they may achieve
improvement with a combination of skin care, Retin A, Botulinum Toxin A, chemical
peel and filler.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
If there are deep tear trough hollow regions and injection if Hyaluronic Acid gel such
as Restylane or Juvederm may be used in the cheek and periocular area in order to
increase the soft tissue volume. Once the Hyaluronic Acid gel has been reabsorbed
after several months a further or top-up injection is offered.
Lower eyelid Blepharoplasty
A lower lid Blepharoplasty is usually done
through an incision on the reverse of the
Lower lid (conjunctiva) to remove the
Excess fat. It excess skin removal is necessary,
Then a skin incision must be made.
After everting the lower lid, the
incision is made and the surgeon
dissects the tissue looking or the
fat that is causing the eyelids to
look baggy.
In lower eyelid Blepharoplasty it is most common for the incision to be done inside
the lower lid in order to remove or reposition. This is known as a transconjunctival fat
Blepharoplasty. The transconjunctival route is used only to access the fat. If excess
skin is going to be removed from the lower eyelids during lower eyelid
Blepharoplasty then a fine incision is made close to the eyelashes or a pinch incision
made a little further down which is then known as a Pinch Blepharoplasty.
Some patients prefer Sculptra® which is poly-L-lactic acid. The Sculptra® causes the
patient’s own body to form new collagen and thus increase facial and periorbital
volume. The injections are done over the cheeks, temporal and also helps the under
eye area appearance.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
Incision
Orbital fat
After everting the lower lid, an incision
is made on the inside of the lower lid
(the conjunctiva). The excess fat causing
the sagging appearance is located
and removed.
No stitches are needed after the
operation. Eye drops are
administered for a few weeks
after surgery.
When eyelid skin is removed from the lower eyelid, the lower eyelid needs to be
stabilised using a lateral canthal canthopexy at the corner of the eye. The
canthopexy serves to strengthen and sharpen the lateral angle where the upper
and lower eyelids meet. Usually either discrete absorbable sutures or very fine nonabsorbable sutures are used to close the skin incisions which heal well leaving no
visible scar.
A Pinch Blepharoplasty is just a small pinch of skin from either below the eyelashes or
a little down the eyelid is taken without touching the orbicularis muscle. Great effort
is made not to damage the orbicularis muscle in all forms of lower eyelid surgery as
this is important for eyelid blinking and lacrimal pump function, in order to maintain a
comfortable healthy eye surface.
Pinch Blepharoplasty
The skin of the lower lid is not always removed
removed in a Blepharoplasty. If a certain amount
amount of skin is going to be excised, we use the
use the “pinch technique”.
First, the surgeon pinches the skin with fine forceps
No muscle is cut using this technique, meaning
the risk of complications such as post
Blepharoplasty syndrome is avoided.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
After the skin has been pinched and
marked the surgeon removes it using
fine forceps and scissors.
Finally, the wound is closed with
some fine sutures. The lower lid
skin looks tighter and younger
after this technique. A pinch
Blepharoplasty is usually
combined with lower lid fat
removal.
Post-operative Care
After Blepharoplasty surgery the standard post-operative instructions for eyelid
surgery should be followed. Please see the separate information sheet which gives
general advice after eyelid surgery and provides you with information about how to
reduce swelling, how to clean the wound, how to put in eye drops and about the
eyelid sutures.
Complications
Blepharoplasty surgery is not without complications and the patient must be fully
aware of what they are committing themselves to having done and the risks of
Blepharoplasty surgery. Serious complications are extremely rare but may occur
even in the hands of well experienced and well trained Oculoplastic Surgeons. Every
effort is made to reduce the risk of complications during Blepharoplasty surgery.
However when the Oculoplastic Surgeon is taking consent the patient is asked to
sign that they have been informed about the possible risks and complications of
Blepharoplasty surgery.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
Bruising and swelling
This can last for up to three weeks.
Blurred vision
This can occur for a few hours or overnight. It is usually due to surface
ocular drying from effect of the anaesthetic. If this persists for more than
twenty-four hours, you should inform your Oculoplastic Surgeon.
Watery eyes
Reflex tearing commonly occurs for one to two days following surgery
due to mild ocular discomfort and surface dryness.
Dry gritty eyes
This can last for two to three weeks due to reduced blinking. You will be
prescribed artificial tears to take during the day (e.g. Hypromellose®,
Systane®, Viscotears® or Celluvisc 0.5%®) and an ointment at night
(e.g. Lacrilube® or ‘Simple Eye’ Ointment®) to ease this. Topical
antibiotics such as Chloromycetin are used for one week if surgery has
been done from inside the eyelid.
Scratched surface of the
Even minor injury to the eye surface can result in a small abrasion and
eye (corneal abrasion)
pain lasting twenty-four hours. If it persists or is severe, the Oculoplastic
Surgeon must be informed.
Bruising
Eyelid bruising or haematoma may occur and is easily visible. Bleeding
behind the eye, however, occurs rarely and is not always visible.
Haematoma is characterised by severe pain and it may cause loss of
vision if not dealt with urgently.
Blindness
This is very rare and is thought to be due to bleeding deep behind the
eye.
Acute glaucoma
Raised pressure within the eye. Specific treatment must be given and
review by a specialist ophthalmologist is necessary. This is extremely rare.
Wound infection
This may occur during the first seven to ten days after blepharoplasty
surgery.
Incomplete eyelid closure
The eyelids may feel stiff for one to two days and be unable to
completely cover the surface of the eye when closed. This usually settles
in a few days.
Asymmetry
There may be a minimally uneven skin crease or lid height. Asymmetry
may be noticeable if there is swelling. If the asymmetry persists after
three weeks, it is possible that it can be corrected with later surgery.
Scarring
This is rare in the periocular area. Scarring can usually be later revised
with ‘Z-plasty’ type surgery to break up and conceal the scar.
Repeat surgery
Patients should be warned of the need for further surgery if an optimum
result is not achieved.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
Questions and Answers
Q.
Is Blepharoplasty surgery carried out with the patient awake or asleep?
A.
The upper eyelids are usually operated on with the patient under local
anaesthetic, which means that they are awake. However, many patients
prefer local anaesthetic with sedation or general anaesthetic, particularly for
the lower eyelid Blepharoplasty.
Q.
Do I have to stay in hospital overnight after the blepharoplasty?
A.
This depends on the patient’s individual needs. It is easier to monitor the
postoperative course and the vision if the patient stays overnight after
Blepharoplasty surgery, particularly after a lower eyelid Blepharoplasty.
Q.
Do I have to stop Aspirin or Warfarin before the operation date?
A.
It is necessary to stop these but, in the case of Warfarin, it will be necessary to
check that this is safe with your GP. Aspirin should be stopped two weeks prior
to your blepharoplasty surgery date to reduce postoperative swelling.
Warfarin is usually stopped two days beforehand in order to reduce the risk of
bleeding in the orbit, which could reduce vision. INR will be checked on the
day of surgery.
Q.
Will I need simultaneous surgery for eyelid ptosis and eyebrow ptosis?
A.
This will be assessed and discussed with each individual patient. Eyebrows
that are particularly droopy and cause the skin to overhang the eyelashes
may mean that a brow lift surgery is indicated instead of or as well as a
Blepharoplasty.
Q.
Are there any risks of blepharoplasty surgery?
A.
You should read all this information thoroughly, which lists the possible risks.
You will be given a consent form to sign and the Oculoplastic Surgeon will
discuss these possible complications with you. Some complications are very
rare and some are more common.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk
If you do not understand what the Oculoplastic Surgeon is saying, you should
say so and ask any questions or discuss any worries you may have about your
proposed surgery before signing. Once you are satisfied that you understand
the aims of the Blepharoplasty surgery, what will happen and the possible risks
of Blepharoplasty surgery, then you should sign the consent form.
Q.
A.
What are the complications of Blepharoplasty surgery?
Serious complications are rare but may occur even in the hands of well
experienced and well trained surgeons. Please see the section on
complications which lists these in detail.
Jane M Olver
140 Harley Street London W1G 2LB UK
Phone: 020 7935 7990 Fax: 020 7486 7893
www.clinicalondon.co.uk