Blepharoplasty (eyelid tuck) Surgery Information

What is Blepharoplasty?
Blepharoplasty (eyelid surgery, eyelid lift, eyelid tuck) is a procedure to correct the sagging or drooping of the eyelids and the removal of excess fat, skin and muscle or even the herniated fat in the eye area. As we get older, most individuals start to see a difference in their eye area -- more laxity, bags below and above the eye; sometimes so much that the upper lid seems to disappear underneath the extra fatty area under the brow bone. This procedure can give a more youthful appearance to an otherwise older, more tired looking, face. It is a procedure than should be sought to be performed by a surgeon who is well skilled with its technique as experienced with numerous facial types and eye types. As with every surgery, there are risks and if your procedure is performed by an inexperienced surgeon this could prove disastrous.

excess skin fat and can be removed with blepharoplasty for a more youthful looking result

Blepharoplasty will not rid you of wrinkles around the eye area although it may make your eyes look smoother if you have considerable excess skin and the wrinkles are on the skin which is to be removed. What cannot be removed by blepharoplasty alone include crow's feet or other such wrinkles in the peri-orbital area. This procedure will not eliminate dark circles or lift your eyebrows. If a lifting effect of the eyebrows is what you are seeking a brow lift will better suit you. Please see this section for dark circles under the eyes.

This procedure can enhance your appearance and give your eye area a more awake look and can even remedy certain individuals' vision problems if they are caused by the excess skin blocking their vision. If the latter is the case, usually your insurance will cover the operation. Some of you may feel as if your eyes give the appearance of you being tired or angry. A Blepharoplasty can rid your eyes of its excess baggage and allow you to look as good as you feel.

Understanding the Eye Orbital Structure
In Standard Blepharoplasty procedures, the herniated fat and excess muscle are removed. As I have said before, what excess muscle is, is beyond me. What they mean is sagging, atrophied muscle -- not extra. Although many surgeons are no longer aggressively removing fat from the lower eyelid and tear trough area anymore -- many, still, are removing all the fat and muscle they can to create a wider, more alert eye. Which is, many times, their downfall.

Many reasons of an improper functioning eye post-op Standard Blepharoplasty, or even cosmetic deficiencies, results from too much tissue (be it fat, muscle or skin) being removed.

"The orbital septum, which lies deep to the Orbicularis, is a key structure and landmark in blepharoplasty. The septum is a thin sheet of fibrous tissue that originates along the superior orbital rim and hangs like a curtain across the lid. It joins the levator aponeurosis by interdigitating fibers at the upper edge of the tarsal plate. The septum keeps the orbital fat in its posterior position. Weakening of the septum with aging, hereditary predisposition, or trauma may cause protrusion of the orbital fat." 8

There is now a procedure dubbed Fat Re-positioning, which is sometimes better than removing. Removing, quite frankly is permanent -- for now. I mean, don't get me wrong you can replace fat and tissue by grafting it from other areas of your body but you cannot restore muscle function and the natural, untouched look of the eye area post excessive removal without the help of a specialized oculoplastic surgeon and that is only if your case is less than impossible to repair. It is easier to take away than to add, so be careful in your selection of a blepharoplasty surgeon.

Are You a Candidate for Blepharoplasty?
First and foremost, an individual must be in good health, not have any active diseases or pre-existing medical conditions and must have realistic expectations of the outcome of their surgery. Communication is crucial in reaching one's goals. You must be able to voice your desires to your surgeon if he/she is to understand what your desired results are. Discuss you goals with your surgeon so that you may reach an understanding with what can realistically be achieved.

You must be mentally and emotionally stable to undergo an cosmetic procedure. Cosmetic surgery is not getting a cavity filled. This is an operation which requires patience and stability in dealing with the healing period. There is sometimes a lull or depression after surgery and if there is already a pre-existing emotional problem, this low period can develop into a more serious issue. Please consider this before committing to a procedure.

Most individuals seek out Blepharoplasty starting in their mid to late thirties. However, if saggy or fatty eyelids are hereditary you may wish to go undergo this procedure at an earlier age. Only a qualified plastic surgeon can determine if you are a good candidate for Blepharoplasty.

Important! If you have Hyperthyroidism, or myxedema -- THINK THIS OVER! No amount of surgery will ever reduce your edema (swelling from fluid retention) of your eye -- ever. If you would like to hear more on this as well as from patients who have had negative outcomes regarding misdiagnosed situations, please visit our Plastic Surgery Message Boards and ask outloud. It could be a matter of your eyes never looking normal again. This is important. Please read the risks, complications and contraindications of Blepharoplasty.

"Blepharochalasis is a commonly misused term that should be reserved for a rare familial condition characterized by chronic, recurrent edema of the eyelids with subsequent breakdown of the tissues within the eyelids, including the orbital septum. This causes prolapse of the orbital fat, resulting in drooping of the lid. Blepharochalasis is a functional indication for a blepharoplasty. Dermatochalasis means relaxation of skin. It is associated with the aging process and variable amounts of fat herniation and prolapse. This is part of the normal aging process and is not a functional indication unless there is dermatochalasis causing "pseudoptosis" with superior visual field defect. Blepharoptosis, or the drooping eyelid is caused by a malfunction of the levator muscles. Levator function is measured by blocking the action of the frontalis muscle and measuring the excursion of the eyelid from downgaze to upgaze. Levator excursion from 15-18 mm is considered normal and 10-14 mm is good function." 8

What to Expect at Your Consultation
After finding a few certified and skilled surgeons (plastic, facial plastic or oculoplastic) you will want to schedule a consultation with each. It is best to get at least 3 opinions because not every surgeon is going to offer the same techniques nor have the same opinions of what will work for your needs. The surgeon's staff should ask for your complete medical history in your preliminary paperwork. It is advisable to go over any medical records to refresh your memory prior to your meeting with the surgeon. The paperwork should ask but if it does not, be sure to disclose any allergies that you may have, disorders, past illnesses and if you are a smoker. Be sure to advise the staff or surgeon of the medications, if any, you are taking. This includes, vitamins, herbal supplements, over the counter medications, etc. You should not take any aspirin-containing products at least 2 weeks prior to any surgery. See Medication & Supplement List.

You will also discuss the available anesthesia that will be used for your procedure. Most Blepharoplasty procedures are performed under Light Sleep Sedation or General Anesthesia. Please read the All About Anesthesia Page for more information.

Also so you will discuss the complications and risks of Blepharoplasty. If he does not discuss with you the risks of your surgery, you should be very wary. You will discuss where the surgery will be performed as well as after care and post-operative visits. Discuss with your surgeon your vision problems, if any and tell him if you wear contacts or glasses. He will discuss with you all of the aspects of surgery, if you should need all 4 or just the upper or lower eyelids only operated on. *You will also be taught how to clean your eyes post-operatively at your pre-operative visit. Usually a saline wash and application of some lubricating drops, however ask your surgeon for specific instructions.

He should advise if he feels as if you have excess fat, skin or even atrophied muscle that needs to be removed. You will discuss the incision placement, the realistic expectations you should have and what other options you may have instead of surgery.

You will also discuss fees, medication costs and any hidden costs that may arise. If your eyelids interfere with your vision, you may be able to get your insurance to cover Blepharoplasty.

Want more help on Consultations?

Preparing For Your Surgery
You will be given a pre-operative information packet that explains everything you should do and know before your surgery date. The packet should include a list of medications you should not take for up to 2 weeks before your surgery. These medications will include, but are not limited to, aspirin containing products. Would you like to view a typical Medication & Supplements List? Also, your surgeon may or may not advise you of the benefits of Arnica montana for swelling and bruising. Would you like to learn of the benefits of Arnica montana? Your surgeon may also advise of the use of Bromelain, drinking pineapple juice beginning 3 days pre-operative or the use of Vitamins A, C, and K. Please do NOT take any medication or supplement with the knowledge of both your surgeon and anesthesiologist. Ask your surgeon if he or she feels that Vitamin C taken post-operatively increases your chances of excess scar tissue as well.

It is quite possible that you will have preliminary blood work performed. This is normally an extra out-of-pocket expense that the patient must participate in to check your white and red blood cell count (complete blood count, CBC) to ultimately alert your surgeon to disease or disorders beforehand. So many things to do... so little time. Surgery will be here before you know it so visit the Preparing For Surgery page and relax. This section contains, printer-friendly pre-op lists, tips and advice as well as things you must do to prepare for your big day.

How Blepharoplasty Is Performed
Blepharoplasty normally takes from 1 to 3 hours to perform. If you are having upper and lower blepharoplasty the surgery will last closer to 3 hours. If this is the case, the upper Blepharoplasty will more than likely be performed first. Larger amounts of skin are excised for upper Blepharoplasty and the swelling is more intense than with the lower lids. The exception is when unusually large "bags" are present.

Before the surgery begins, your surgeon will mark the incision sites with a magic marker type pen (Sharpie), These incisions will follow along the natural lines and creases of the upper and lower eyelids. All efforts possible should be made in order to achieve inconspicuous scars. Although, the incisions may extend into the crow's feet area (aka smile lines) at the outer corners of your eyes.

First, you will have adhesive monitoring pads (electrodes) attached to you so that the surgical team can properly monitor your vital statistics before, during and after your operation. When you are brought to the operating room, these electrodes will be connected to the monitoring equipment. Or these pads may not be applied until you are on the table, a few minutes before your anesthesia is given. Your vitals are taken and when you are determined as stable and ready, the anesthesiologist will then be given your choice or your surgeon's preference in anesthesia as discussed prior to your surgery date. If you had been given an oral sedative or valium prior you will have less anxiety. They will more than likely insert an IV for a saline drip to keep you hydrated and have a vascular doorway for anesthesia, antibiotics, and other medications. If you haven't been given a sedative, it may be more stressful for some patients. If you feel that you may experience anxiety inquire beforehand regarding an oral sedative.

Having an IV inserted feels sort of like blood being drawn, but for a shorter period of time. It's the initial placement of the IV that may sting a bit. Some people get heir IV placed in the crook of the elbow, some the hand -- I personally like them in the crook of my arm rather than my hand. Hand IV's leave such an utterly horrid bruise, it is so sore afterwards, and everyone and their grandmaw can see you've recently had an IV. It all depends upon your veins though. So if your veins are not very prominent this can be a problem. Some patients eventually have to get their IV's in the neck when their veins elsewhere aren't cooperating.

After the needle is injected into the vein it is pulled out and a little plastic tube is left in your vein. This is called a catheter. The catheter is taped to your skin so it is not accidentally knocked or pulled out and is ready to be used as a sort of entryway for anything the surgical team deems necessary for your body. This is usually done before you get into the actual O.R. -- by a nurse -- and you have a saline bag hooked up to you. The medications will usually be given with a drip system with this saline. As said before, the saline will keep you hydrated both during and post-operatively. You are then brought to the O.R. if you aren't already on the table.

If you have chosen an IV Liquid Sedative, they may insert a hypodermic into your tube that you are attached to or they attach the bag of it with a drip system to add a few drops every few seconds and when they spring open the stopper and it starts heading towards your body. The effects of the anesthesia are felt soon after injection or opening the stopper -- a few seconds in fact. It may feel similar to a sensation of heat entering your arm or hand at the catheter site. It then feels as though it is creeping up your arm, then it jumps from your shoulder to a metallic-like taste under your tongue and then you are blissfully anesthetized. The anesthesiologist or CRNA will then determine if you are sedated properly, your stats are stable and if you are ready for the surgery to begin.

Your treatment area will be injected with a solution of Lidocaine for post-operative pain relief, and so your skin does not trigger its autonomic responses, plus epinephrine for vasoconstriction. Vasoconstrictors impede your skin's ability to bleed excessively by narrowing the bore of the blood vessels, this in turn prohibits mass absorption of the Lidocaine. Your surgeon then makes the incisions as predetermined with the Sharpie marker, unless there is a need for incision changes intra-operatively.

incisions for upper and lower blepharoplasty are placed within the natural
folds of the eyelids, in some cases they will extend into the "crow's feet" area.

The surgeon separates the skin from underlying fatty tissue and muscle and removes the excess fat or re-suspend some of it. Sometimes excess atrophied muscle or sagging muscle is removed or tightened. The surgeon then trims excess sagging skin.

After all of the necessary trimming, removing and tucking have been executed, the surgical team will perform a sponge, gauze and instrument check. The incisions are then closed with very fine, hair-like sutures. These sutures will be left in from 2 to 5 days. But more than likely closer to 3 days.

transconjunctival blepharoplasty incision; lower lid pulled down

In the case of fat removal only from the under eye area (bags) a transconjunctival blepharoplasty may be performed instead. With a transconjunctival blepharoplasty, a small incision is made within the inner portion of the lower lid (show as the blue line inside the lower lid in the above diagram). With this procedure, the fat is removed through this incision resulting in no visible scarring. Normally, this procedure is carried out in younger patients or patients where the skin elasticity is great. Also, the sutures used are of dissolvable type.

The surgeon will lubricate your eyes with an ointment and will perhaps apply a pressure dressing. Of course there may be differences in surgical technique depending upon the preference of your surgeon and the individual needs of the patient.

You are then gently awakened and brought into the recovery room where the recovery nurse will monitor your vital stats until you are ready to be released. This is dependent upon the individual but may take up to two hours or more. Your eyes may feel tight, hot and quite tender as the anesthesia wears off. If you feel any discomfort you may want to ask for a pain reliever which you will more than likely have been asked to bring with you. You may even feel emotional or upset -- this will depend upon your body's reaction to anesthesia. You may also experience rigors or shivering. This may feel uncontrollable and is usually from the medications - more than likely epinephrine that is used as a vasoconstrictor -- and the cold saline which will have been introduced into your system for the last few hours, and still may be. The fact that the operating room is usually very chilly, surely does not help matters in this regard. The recovery nurse usually has wrapped you in a warm blanket but if not, request one. It certainly makes things more tolerable. You may even be lucky enough to have heating lamps! Some surgical theaters are more like the dollar theater rather than IMAX -- so ask first.

Some patients feel nothing different than waking up from a good night's rest. Although if you have had General you may feel a little sick, hopefully your surgeon gave you something to lessen this. Your prescribed medication should alleviate any pain or discomfort. However, if you believe your pain to be out of the ordinary once you get home, call your surgeon or the on call staff immediately. You will be driven home by your spouse, significant other or friend as you will not be able to see, much less drive yourself home.

The Road To Recovery
Your will be instructed to keep your head elevated for several days. Two to three medium filled pillows should do the trick. Take your temperature regularly! An elevated temperature could mean an infection. Take those antibiotics ON TIME. And don't forget if you are taking birth control that some antibiotics can interfere so in the event that you do have relations, use another form of protection as well. You may be instructed to use cold compresses (or bags of frozen peas over a hand towel or thick paper towel) to keep swelling and bruising to a minimum. The amount of bruising varies with the individual. It will be at its worst during the first week. You may not swell and bruise too much directly after the surgery, but the next day and especially the third, you may feel as if the swelling and bruising is rather extreme. Some patients prefer cool Hydrogel masks for comfort such as the one depicted below from www.BioDermis.com:

You will begin cleaning your eye area as shown at the pre-operative visit. Your surgeon may recommend using eye drops or ocu-wetting solution to help with lubricating your eyes. It is quite possible that your tear glands will not be able to produce enough tears to lubricate your eyes properly for the first few days or even weeks. Although quite the opposite is possible as in excessive tearing. You may also experience light sensitivity and blurred or double vision. You may be instructed to wear a special hard mask over your eyes while sleeping. This type of mask is also utilized for post-operative care of LASER vision correction (LASIK) patients. This mask prohibits the patient from accidentally apply pressure or rubbing the eyes while at rest.

Your sutures will be removed after 2 to 5 days, more than likely 3 days. You swelling will begin to subside at the end of the week although it is known to remain for 3 weeks. You will instructed to not wear contacts (if your vision requires it). Even after the allotted time your contacts may give you discomfort while wearing them.

Most patients return to work in a 7 to 10 days. You should limit your sun exposure as your eyes will be sensitive to it as well as your incision sites; sun block should be used on the eye area. Make sure that the sun block is safe for eyes and will not irritate them.

Avoid too much movement for the first few days (about 5). Even if you are feeling better, you should take it easy while you are recovering. Do not participate is strenuous activates for at least 3 weeks. Definitely NO CONTACT SPORTS. Your bruising will subside within a few weeks and after your surgeon gives you the "go ahead" you may begin wearing cosmetics to hide residual bruising.

Risks and Complications Associated with Blepharoplasty
The minor complications that are associated with Blepharoplasty include double or blurry vision for a few days, temporary swelling at the corners of the eyelids, and milia (or tiny whiteheads) that can be removed by your surgeon by pricking them with a micro-needle. It is possible to develop asymmetry during healing or excessive scarring if you are prone to such a thing.

It is possible that you may experience difficulty in closing your eyes when sleeping. In rare instances this condition may be permanent. Also there is the rare possibility of ectropion. Ectropion is a condition where your lower lids are pull down or gape. If you should develop ectropion, further surgery will more than likely be needed to correct it. Which could lead to more risks and more cost to you, the patient.

If you have thyroid problems (hypothyroidism or Graves' disease) dry eyes or insufficient tearing, circulatory disorders or high blood pressure, having blepharoplasty may be more risky for you than an otherwise healthy individual who does not have such disorders. Grave’s disease is frequently associated with severe swelling of the periorbital tissues. This swelling may be misdiagnosed as excess under eye fat pads. If you are myxedematous* (in a severe state of hypothyroidism) you may have severe edema, or fluid retention, especially in the eye area; is a common symptom of hypothyroidism. The fluid filled tissue areas are often misdiagnosed as excessive fat in the eye area and when removed can lead to disastrous results. As your edema subsides and your fluid levels level out, after removal the eye area will look very sunken in. Ascertain that your surgeon establishes whether or not your eye bags are caused by fat or chronic edema prior to your Blepharoplasty. Edema will not be corrected by blepharoplasty surgery -- ever.

However, some surgeons are capable of disguising the symptoms of some of these disorders such as Grave's Disease and the wide eye look with surgery or other treatments. They can perform surgery or use Botox to relax the muscles and lids of these patients. Please research more on the web with the use of Google.com and "oculoplastic surgeon + grave's disease + eyes" or "oculoplastic surgeon + hyperthyroidism + eyes"

Other disorders that may increase your risks are myasthenia gravis, cardiovascular disease, diabetes, a detached retina or glaucoma (and other high pressures of the eye), poor circulation and poor elasticity. Please disclose all disorders or concerns with your plastic surgeon -- you're health and well-being might depend on it.

Sometimes the eye area will not heal correctly and you just may have to have an additional surgery to correct it. The surgeon normally does not charge any additional fees if another surgery is necessary. I think the doctor shouldn't charge you but you may not be that lucky.

There is also the risk of a doctor cutting & removing too large of an oval of skin for your eye size, resulting in smaller eyes. Completely changing your appearance rather than rejuvenating it. There may be a need for eye spacers to open up the eyes more. I am not even completely sure how these work but I will attempt to gather more information of this.

Quite the opposite is the fact that over-suturing or removing too much tissue can result in an open, wide look that is completely unnatural. BUT, this sometimes happen during the healing phase and will relax as time goes on so don't get freaked if you look a little wide-eyed at first.

There is also the risk that your doctor may completely remove the fat from under your eyes. More and more, doctors are discontinuing this as they are finding an increasing amount of patients suffering eye abnormalities with this practice. Patients are complaining of sunken eyes, eye hollowness and a tired, aged look.

Yet another possible risk is dog ears at the incision lines, dropping of the eye or lack of muscle function, temporary or permanent, post-operatively.

Of course there are risks related to anesthesia as well -- please read the Anesthesia Information Section for more on this subject.

*myxedematous: severe hypothyroidism characterized by firm inelastic edema, dry skin and hair, and loss of mental and physical vigor. (Merriam-Webster dictionary)

The Least You Need To Know

What: Blepharoplasty (eyelid surgery, eyelid lift) is a procedure to correct ptosis (sagging or drooping) of the eyelids and the removal of excess fat, skin and muscle or even the herniated fat in the eye area.
Why: As we get older, most individuals start to see a difference in their eye area -- more laxity, "bags" below and above the eye; some times so much that the upper lid seems to disappear underneath the extra fatty area under the brow bone. This procedure can give a more youthful appearance to an otherwise older, more tired looking face.
When: from late 20's to 70's, usually.
Who: Research your doctor very well! He should help you decide which technique would be best for you and discuss this openly. Do not rule out oculoplastic surgeons.
Where: Accredited Surgical suite or hospital
Risks: READ THEM!
incisions/scars: scars are placed within the natural crease of the eyelids
Anesthesia: IV Sedation (Light Sleep) or General. Read All About Anesthesia
Duration: 1 to 3 hours
Pain Factor: mild, pain meds should alleviate any discomfort. If not, call your surgeon immediately.
Swelling: Moderate to Medium, depending upon individual. I suggest Arnica Montana, however check with your surgeon before using any homeopathic or unprescribed medication.
Bruising: Moderate to Medium, depending upon individual. I suggest Arnica Montana, however check with your surgeon before using any homeopathic or unprescribed medication.
Post-operative instructions: Have someone there to help care for you during your recovery, keep elevated -- even when sleeping. A recliner works best. Cold compresses for first 48 hours are suggested. As well as cleansing of the eyes after your pre-operative visit. You shouldn't try to read or watch television, at least for long periods of time or avoid it altogether for up to three days post-operatively. Do NOT wear contacts for at least 2 weeks post-operatively. Try not to rub your eyes in the weeks following your surgery. This action could further irritate your eyes. Some surgeons offer a metal or hard plastic face mask (coated with a soft material) to keep wandering hands and fingers away during healing times. Patients having undergone LASIK are familiar with these face masks.
1st Post-op visit: day 2 to 5 (more than likely day 3) for suture removal.
Return to work: 7 to 10 days
Activity: No exercise until at least 3 weeks post-operative. Be careful not to raise your blood pressure for several weeks, you don't want to inhibit proper healing or get an infection. You should remain generally inactive for 3 to 5 days. Check with your surgeon!
Sun exposure: UV light may cause hyperpigmentation in some patients around the incision lines. D
End result: The swelling and proper positioning of the eyelids post-op may take several months.
Loss of Sensitivity: It is possible to lose sensation along the incision lines. Long term or permanent loss of sensitivity is possible.
Anything Else? Possible eyebrow and eyelash loss from medications and also near incision lines. Possible asymmetry as well. Possibility of hypertrophic scarring that may be treated early with paper tape, silicone gel or Kenelog injections.
Longevity: the skin is still subject to aging, especially with photo-aging. You may wish to seek laser treatments or chemical peels for the finer wrinkles. Botox around the crow's feet are also helpful.
But Wait, There's More! Disclose all your medical background. This includes if you are a smoker, if you are taking medications, or if you have any other medical concerns. Have realistic expectations about your results. If you are 50 years of age and you choose to undergo Blepharoplasty, the procedure will not give you the eyes of 20 year old. Besides this look would not suit your face and appear "done". NO plastic surgeon can perform miracles, he can only try and improve upon what you have beforehand.
The average prices for a Blepharoplasty: both upper lids, $1,545. - $4,850.; both lower lids, $1,594. - $4,000.; both upper and lower eyelids, $2,739. - $5,500.

References:
Goldberg, Robert Alan; MD, FACS; "Lower Blepharoplasty Is Not About Removing Skin and Fat";
Goldberg, Robert Alan; MD, FACS "SOOF Lift Helps Rehab Eyelid Complex Fat Relocation Rather Than Removal Is The Name Of The Game In Today’s Lower Lid Blepharoplasty" *R. Goldberg can be reached at the Jules Stein Eye Institute, 100 Stein Plaza, Los Angeles, CA 90095-7006; (310) 206-8250; fax: (310) 825-9263.
Illustrations. Fig. 888. Gray, Henry. 1918. Anatomy of the Human Body.
8 Greenberg, Jayson, M.D.; Baylor College of Medicine. The Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences. Blepharoplasty February 4, 1999

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