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Understanding
the Eye Orbital Structure
In Standard Blepharoplasty
procedures, the herniated fat may be removed or re-situated and the atrophied
muscle is lifted and tacked with a very fine resorbable suture material.
Although many surgeons are no
longer aggressively removing fat from the eyelid and tear trough areas
anymore. However, some may still be removing all that they can to create a wider,
more alert eye. Which is, many times, their downfall. Many causes of an improper functioning eye
after Blepharoplasty, or even cosmetic deficiencies, results from too much
tissue (be it fat, muscle or skin) being removed, or from ligaments being
sutured too tightly.
"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
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 which may inhibit wound
healing. You must also have realistic
expectations of the outcome of the surgery. Blepharoplasty surgery is
not without scars and not everyone will scar as well as the next
patient. There are treatments which can lessen the appearance of
scars,
but the pre-existing disposition to scarring well is preferred.
This may depend upon your health, heredity, eating habits, if you smoke,
your post-operative protocol and your surgeon's ability.
An ideal
patient would have very elastic skin. Then again, if we had skin elasticity THAT
good, we wouldn't need the blepharoplasty in the first place, now would
we? Nonetheless, good elasticity certainly helps!
You must also 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
mental 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.
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
Most individuals seek out Blepharoplasty
starting in their
mid to late thirties, but most commonly in the mid to late forties.. 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.
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 should also cease consumption of
alcohol the week before surgery. Please discuss any stimulants and illegal
drugs with your surgeon and anesthesiologist. Your life may depend upon it
as many drugs may interact with anesthesia.
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. 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 lifting of the upper or lower eyelids only. *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.
Your surgeon should
advise if he feels as if you have excess fat, skin or even atrophied muscle that
needs to be removed and why he or she feels that this is necessary. 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, vitamin E, stimulants, Ibuprofen, etc. Would you like to view a typical
Medication
& Supplements List?
Your surgeon may also advise of the use of
Bromelain, drinking pineapple juice beginning 3 days pre-operatively,
arnica montana, or the use of Vitamins A, C, and
K. Please do NOT take any medication or supplement without 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 1/2 to 3 hours to perform, depending upon
the level of correction that must be made.
If you
are having both 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 (a single sue surgical
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 at the outer corners of your eyes.
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 hteir 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 in the world can see you've recently had an IV (or
worse).
It all depends upon your veins though. So if your veins are not
very prominent this can be a problem.
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. where you will 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-suspends it. Sometimes excess
atrophied muscle
or sagging muscle is removed but it is usually only re-suspended to lower the
occurrence of abnormal muscle movement. 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 or re-suspension to only 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
very good. The sutures used are of dissolvable type, irritation to the
sclera (the white part of the eye) is possible.
Upper Blepharoplasty is also able to be
performed through an incision in the brow, however, the scar can be apparent and
also cause hairloss. This is only for fat re-suspension or removal and/or
functional surgery that requires no excess skin removal.
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 which may be 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
or a heated air blower (which I have had).
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. This is really important! I have seen
patients (my own mother!) swell considerably simple because they toss the
pillows on the floor in the middle of the night. Keeping a pillow under the
backs of your knees can help you from flipping over, sleeping on your face, or
moving much. However, I think your best bet would be to sleep in a recliner.
That way you have no way to turn and you remain upright regardless if you want
to or not--short of sleepwalking!
Take your temperature regularly! An elevated
temperature could mean an infection. Take those antibiotics ON TIME. And don't
forget that if you are taking birth control that some antibiotics can interfere so in
the event that you do have relations once you feel well, 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. These masks are actually amazing! They feel cool, even though they are not
refrigerated. Plus they are very soothing. They feel like a strong
mask made from Jell-O which never melts and doesn't easily tear. They a
\re also great for laser resurfacing and post-chemical peels.
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. Te
asymmetry during your healing period may also be caused from asymmetrical
swelling and is not indicative of your end result.
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 using the keywords "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 may have to have an additional surgery to correct it.
The surgeon
normally does not charge any additional fees if another surgery is necessary.
Well, I don't think the
doctor should charge you but you may not be that lucky.
There is also the risk your eyeshape changing
and, 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.
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 with abnormal scleral (the white part of your eyes) show
between the lids and the iris. 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 remove
too much 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.
There are also 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, and 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 usually placed within
the natural crease of the eyelids
-
Anesthesia: IV
Sedation (Light Sleep) or General. Read
All About Anesthesia
-
Duration:
1 1/2 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.
-
Bruising: Moderate
to Medium, depending upon individual.
-
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. After your incisions have closed, if you expose your face to UV
(sunlight) you should wear a high SPF sunblock even when you will be wearing
sunglasses.
-
End result:
The swelling and proper positioning of the eyelids post-operatively 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 Kenalog 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 is
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 or she 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. - $6,500.
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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