What is Blepharoplasty?
The term blepharoplasty has originated from the Greek word blepharon, a synonym for eyelid and plasse in that refers to form. Blepharoplasty refers to the surgical correction of defects, malformation and impairments of the eyelids; for the purpose of aesthetic modification of the eye region. This transforms the person’s appearance as well as the visual function. The changes that occur in the eye and the mid face region are generally the prime aesthetic complaint of an aging patient. With advancement in age, the globe of the eye descends within the eye socket consequently causing protrusion of the orbital fat and forming a double convex contour of the lower eyelid. Multiple approaches and interventions have evolved for their correction such as noninvasive techniques and invasive techniques. Fillers, lasers and chemical resurfacing are the common options available under noninvasive techniques. Whereas invasive technique produce comparatively permanent results as seen with blepharoplasty or midface lift procedure.
Indications for Blepharoplasty:
- Age related changes such as overhanging of excessive skin
- Overstretching or loosening of skin over the eyelid
- Hypertrophy of the orbicularis which is the muscle that functions to close the eyelids
- Protrusion of the orbital fat tissue
- Festoons formed in the malar or cheek region
- Sinking of the midface region displaces the buccal pad of fat in the cheek forming a tear trough deformity
- Hollowing of the infraorbital rim
- Appearance of volume loss in the midfaceregion
- Dermatochalasisor baggy eyes encroaching the visual axis and interfering with peripheral vision
- Ptosis or drooping of lash resulting in irritation of the ocular surface
- Severeinflammation of the eyelid or blepharitis
- Cosmetic indications such as unesthetic dermatochalasis and upper eyelid fullness
- Bags or circles are formed under the eyes giving a chronically tired look
- A thorough medical history and detailed evaluation of the periorbitalregion are crucial for a successful blepharoplasty procedure. All the prevailing health conditions such as hypertension, diabetes mellitus, bleeding or clotting disorders, thyroid disorders should to be duly noted. It is imperative to stop anticoagulants at least 2 weeks before the surgery.A comprehensive ocular history is taken followed by carefully examining the visual acuity and analysis of any ocular surface disease or conditions. If the patient had undergone a refractive procedure in previous years such as laser epithelial keratomileusis or photorefractive keratectomy, then in such cases blepharoplasty ought to be postponed for at least six months after the refraction correction procedure as these patients are more prone to dry eyes. Quantitative tear assessment is performed via Schirmer’s test. Cases of dry yes are managed with artificial tears and by pharmacological management using immune modulating drugs. Smoking has perilous effects on the ophthalmic condition and can lead to formation of a tear film that predisposes to an ocular disease. Hence, it is strictly advised to stop smoking and preoperative counseling is given for the same. Medications such as niacin, Echinacea and kava need to be discontinued as these drugs increase the chances of an ocular surface disease. Preoperative photographs aid in documentation and evaluation of the surgical procedure.
- Examination of the eyebrows: This is an indispensible step in evaluation of a blepharoplasty patient. It involves documentation of the shape and position of the brow. As a general variation, eye brows in females are more arched while in males it is comparatively lower and flatter. Dermatochalasis refers to redundant orbital tissue seen with age and in such patients compensatory brow elevation is a common phenomenon.
Tests for ophthalmic evaluation
- Shirmer’s Test: The purpose of this test is to measurethe amount of tear secretion thus identify patients at risk for dry eyes. It is performed with paperstrips that are placed inside the patient’s lower eyelid for 5 minutes and the amount of moisture absorbed on the paper is recorded. Values more than or equal to 15 mm are considered to be normal and values below 5 mm point towards lack of tear production.
- Visual Field Testing: This test is performed to analyze visual areas for obstruction by paralysis of eye muscle. It is done in two steps. In the first step the assessment is done while the lids are in normal position while during the second step measurements are taken using tape to secure the fold of excess skin tissue above the margin of the eyelid.
- Jones Test: Both Jones I and Jones II tests are conducted to assess the patency of lacrimal ducts. In Jones I test evaluates the flow of fluorescein dye which is injected into the lacrimal sac. Measurements are taken after 5 minutes and the test is considered to be positive if the dye persists that indicates open ducts. In negative cases, the Jones II test is performed. The lacrimal glands are irrigated using a lacrimal syringe and subsequently the intranasal opening is probed. If the dye is able to flow through then the test is considered to be positive and indicates towards a functional problem associated with the drainage apparatus of the lacrimal glands. If no flow of the dye is witnessed then a mechanical obstruction within the lacrimal irrigation system is suspected.
Treatment steps in Blepharoplasty:
- Skin markings: This is an indispensible step for a successful blepharoplasty. The eyelid crease is measured as the fusion part of levatoraponeurosis with the orbital septum, which shows occidental and gender variations. In Asians, the height of the eyelid crease is 4 to 6mm centrally in males and 6 to 8 mm in females while higher values are observed in non-Asians males and females. Generally in males, eyebrows are flatter in shape as compared to women in whom normally the eyebrows are more curved. Modifications are to be made in the surgical approach in patients with an unusually high or asymmetric eyelid crease where levator resection is performed known as blepharoptosis. In cases with hooding of eyes the crease marking needs to be extended beyond the lateral canthus of the eye.
- A pair of toothless forceps is used to pinch the redundant skin tissue at the skin crease for incision. There might be minor eversion of eyelashes. Skin markings are made centrally, medially, and laterally along a curvilinear arch outlining the natural appearing curve of the eyebrow. In patients where general anesthesia is not used, he/she is asked to open and close eyelids to make the eyelid skin markings. After confirmation of the markings, excess ink is blotted with gauze in order to prevent diffusion of the ink.
- Anesthesia: Under standard conditions, Blepharoplasty is a routine outpatient procedure performed under local anesthesia and does not require monitored anesthesia care. An anesthetic mixture of lidocaine and bupivacaine along with epinephrine is preferred in most of the cases which is injected subcutaneously. In combined cases that involve the forehead as well as the face, general anesthesia can be used. Additionally, sodium bicarbonate can also be used to reduce patient’s discomfort. Superonasal anesthesia can be given to further minimize patient’s discomfort while sculpting the pad of nasal fat.
- Surgical incision: Multiple modalities can be utilized to make the surgical incision such as a surgical blade can be used or carbon dioxide laser and also radiofrequency needle is a suitable option. Irrespective of the type of incisional instrument used, it is imperative to place a corneal shield to protect the patients’ eye. Skin incisions are made using surgical blade preferably number 15 blades. Following this the redundant tissue is removed using either surgical scissors or cautery instruments. Adjoining eye muscles such as orbicularis oculi are preserved to prevent postoperative complications pertaining to eyelid closure. On the contrary, in Asian patients a minimal cuff of approximately 1-2 mm of this muscle is incised which will allow an enhanced aesthetics giving a more natural appearance of the eyelid crease. Cautery is used to achieve hemostasis.
- Fat tissue removal: In subjects where orbital fat is to be selectively removed, there a nasal approach is performed wherein the orbital septum is entered medially to identify the nasal fat. Care is taken to prevent inadvertent injury to the trochlea and superior oblique muscle juxtaposed in this region. Slight pressure is applied in the region of the globe for the estimation of nasal fat prolapse. Subsequent to fat sculpting, hemostasis is carefully achieved. In cases with a prolapsed lacrimal gland,prolene suture is used forits fixture with the periosteumsuperlaterally. Accordingly an anterior or posterior approach is performed for the management of upper eyelid ptosis.
- Skin closure: Vicryl sutures are commonly used for reapproximation of the eye muscles whereas prolene sutures are used for the closure of skin incisions.
Types of blepharoplasty approaches
- Transcutaneous approach: The two main types of transcutaneous blepharoplasty for the lower eyelid are the skin flap method and the skin–muscle flap technique. In the skin flap method, a subciliary incision is made and the eyelid skin is elevated from the orbicularis muscle till the infraorbital rim using surgical forceps. The advantage of this method is the removal of redundant orbital tissue in a conservative manner that preserves the underlying eye muscles. On the other hand, the skin–muscle flap technique is a more aggressive approach hence it is preferred in young patients who have eye muscle hypertrophy and redundant skin in the lower eyelid. In this technique, orbital tissue is dissected between the orbicularis and the orbital septum and additionally the suborbicularis oculi fat is also elevated. A simultaneous midface lift can also be performed.
- Transconjunctival approach: This approach was developed to minimize external scarring and also provides access to orbital fat tissues. It is a preferred approach in patients who have minimal lid laxity but present with pseudoherniatedinfraorbital fat, hence are unsuitable for the transcutaneous approach. In this technique, the skin incision is made along the lower conjunctiva inferiorly to the tarsus. This allows easier access to the inferior periorbital fat while also preserving the anterior lamella. The two methods to approach the infraorbital fat is via the pre- or thepostseptaltechnique. In the former a 4mm incision is made inferior to the tarsus, which allows proper visualization of anterior septum.
Complications/Risk factors associated with Blepharoplasty
- Asymmetry: It is one of the frequently encountered complication post upper eyelid blepharoplasty surgery. Persistence of residual skin as such is not considered as a complication hence a revision surgery can be planned postoperatively.
- Lagophthalmos: Lagophthalmos or inability to close eyes completely and resultant dry eyes are also one of the common complications associated with blepharoplasty. Early and temporary lagophthalmos may be the result of edema post-surgery or partial paralysis of orbicularis due to anesthesia or an inadvertent surgical trauma. It can be treated with lamellar supplementation from a suitable donor site. In cases with inadequate orbicularis muscle graft that predisposes to continued lagophthalmos, loading the upper eyelid with a weight may be required.
- Canthal Webbing: When the incisions are extended too far medially, hollowing of the skin can occur which is aesthetically displeasing. It may or may not be noticed by the patient and/or surgeon. Surgical revision with Z-plasty is a suitable option for its correction.
Am I a Good Candidate for Blepharoplasty?
Patient selection is of prime concern in cosmetic procedures. It is imperative that the patient, who desires to undergo blepharoplasty, should be otherwise healthy with absence of any chronic disease or systemic condition. He/she should have realistic and legitimate expectations and motives from the procedure as though blepharoplasty is a suitable cosmetic procedure yet like every surgical procedure it has its own limitations. Most of the patients are over 35 years of age but can be younger as well. Patients with family history of baggy eyelids, it is advised to opt for blepharoplasty, comparatively sooner.
Recovery time and aftercare
A combination of antibiotics and a steroid ophthalmic ointment is advised to the patients. These are to be applied twice daily on the skin incisions. Eye drops or artificial tears are recommended to prevent dry eyes. Additionally, ice packs or ice cubes are advised which are to be applied at intervals of thirty minutes daily and continued for the first 3 postoperative days. Patient is instructed to only use clean washcloths and towels for wiping the face. Painkillers as recommended by the physician can be used for alleviation of pain. Care is to be taken to not use Advil, Naproxen and aspirin as these drugs potentiate the chances of bleeding. The patient is instructed to sleep with their head elevated at approximately 30 degrees and pillows can be used for the same. Patient is advised to visit their doctor at week post-surgery. The prolene skin sutures are removed at the 1-week postoperative visit.Generally, patients start to look normal after approximately two to three weeks post-surgery. But that is variable as some patients might heal faster while others might take longer. Immediately after surgery, the crease is high, and gradually settles to the desired position as the swelling resolves. It may take six weeks to six months to appear better. At duration of one year, the final results would be evaluated. Nevertheless, at two weeks’ time, the patients’ path of recovery can be assessed. Few patients might experience dry eyes post-surgery; nevertheless it does not last for more than two weeks. In rare cases, if it does then contact your doctor immediately.
Success Rate of Blepharoplasty
Blepharoplasty surgery has been highly successful in patients who werehealthy and had legitimate expectations; and were properly educated regarding the procedure. It is important that patient should have realistic expectations as it plays a huge role in the success of the procedure. Within standard limits, loose sagging tissue of the eyelids and protruding pads of fat can evidently be removed. Usually three months post-surgery, most patients achieve approximately 90% of their final result.
Benefits of Blepharoplasty
- Aesthetic enhancement
- Removal of redundant and lax tissue
- Lifting of drooping eyelid
- Visual improvement to some extent
- Youthful appearance
- Reduction of facial lines
The cost of blepharoplasty is influenced by multiple factors such as expertise of the surgeon, complexity of the case, type of hospital, level of expectation of the patient from the procedure, etc. Cosmetic procedures are on a surge in recent years which has proportionately increased the exposure of surgeons to these interventions. India being the hub of advanced medical facilities provides ample treatment options to the patients.
Why Choose MedcureIndia?
We at MedcureIndia take pride in providing world-class medical facilities to our patients. We not only guide our patients to opt for the best suited treatment plan for their condition but also assist them throughout the procedure intraoperatively as well as post-operatively. We have liaisons with highly proficient team of surgeons and physicians who are working round the clock to provide standard medical facilities.
• Are the results of Blepharoplasty permanent?
It has been reported that results of upper eyelid blepharoplasty surgical intervention can last for at least five to seven years, while lower eyelid blepharoplasty lasts even longer and rarely needs a repetition surgery. This does not imply that aging changes would not occur; the patient should be educated that aging is an inevitable physiological process hence his/her eyes will still age following blepharoplasty. In cases, which present with sagging of eyelids again, a forehead lift procedure can be performed.
• How should I prepare for Blepharoplasty?
The patient is instructed to arrange for their pick and drop from the hospital post-surgery. It is also advised that the patient should make arrangements for a relative or friend to accompany them for the night after surgery. It is recommended to preplan stipulated leave from work as he/she would have to stay at home and limit their daily activities for some days after surgery until the eyelids heal.
• What are the alternatives to blepharoplasty?
At present, there are no other suitable medical alternatives to blepharoplasty that can adequately reposition or reshape the eyelids. It is advisable to consult your doctor to help you overcome concerns associated with appearance, and guide you in choosing the right option.
• Can Blepharoplasty remove wrinkles and dark circles?
It might be feasible to achieve all of these results with Blepharoplasty. Wrinkles around the eyes might fade away as the skin tightens after the procedure but the finer ones might still persist. Patients who present with more redundant tissues around the eyes might experience some improvement in the dark regions of the eyes but in most of the cases skin darkness below the eyes does not fade away completely.
• Can I opt for Blepharoplasty post PRK or LASIK procedure?
Yes, such patients are suitable candidates for blepharoplasty.
• Does blepharoplasty surgery leave scars?
No, blepharoplasty does not leave scars in most of the cases as the healing completes. Care is taken during the surgery to place skin incisions within the natural folds of the skin and these fade away with the healing process, gradually becoming inconspicuous.
• How long does the blepharoplasty surgery take?
Marking the skin incisions are an indispensible step of the procedure and the surgeon may spend half an hour discussing it with the patient so as to achieve satisfactory results. Following that the surgical intervention might take approximately an hour or so, but it varies depending on the complexity of each case.