What is a blepharoplasty, Cosmetic Eyelid Surgery, Eye Bag Removal Surgery?
- Blepharoplasty surgery, commonly known by various synonyms such as eyelid lift surgery, eye plastic surgery, cosmetic eye surgery literally means ‘refashioning of the eyelid’ and is an operation commonly performed to improve the appearance of the skin around the eye.
- In the UK, most blepharoplasty operations are performed to reverse the changes of ageing (often removing excess loose folds of skin from the upper eyelids or eyelid 'bags' from the lower eyelids) and are either performed for cosmetic improvement or for functional resons.
- A smaller proportion of patients, undergo different types of blepharoplasty surgery for other reasons e.g. Asian blepharoplasty/ double eyelid surgery, thyroid eye disease blepharoplasty, congenital problems etc.
- Although there are many types of operations to improve the appearance of eyelids, in general, the vast majority of patients who seek cosmetic eye surgery are usually enquiring about cosmetic blepharoplasty to reverse the signs of ageing.
- Contrary to popular belief, not all patients need to undergo surgery and indeed excellent results can be often achieved by non-surgical methods.
How do the eyelids age: Baggy eyelids? Drooping Eyelids? Eyelid bags? Heavy Eyelids?
As we all get older, changes in the structural of the tissues of the face begin to occur. For example, tendons become lax, muscles lose their tone, fat starts to shrink and skin loses its elasticity.
In the upper eyelids:
- excess skin develops leading to redundant droopy skin which can give rise to a melancholic appearance to the eyelid. Women often complain that they no longer have an eyelid on to which they can apply eye makeup. Patients remark that people comment on them looking angry, tired or frowning.
- Weakening of one of the middle layers of the eyelid allows for outward bulging of the fat of the eye socket leading to eyelid ‘bags’ known as steatoblepharon. Sometimes the fat behind the eyelid may start to descend leading to changing contour of the eyelid.
- Age related weakening of the main tendon involved in the lifting of the upper eyelid results in a skin crease that is less defined and sometimes a drooping upper eyelid (ptosis).
- Sometimes the tendons which keep the eyebrows in position may start to weaken leading to descent of the eyebrow itself, usually starting with the tail of the eyebrow (outer end)
Ageing eyelids (click to enlarge)
In the lower eyelid, similar changes occur with age related stretching of the tendons of the eyelid.
- The lower eyelid instead of having a youthful sharp contour starts to become more concave with greater exposure of the lower half of eye.
- Weakening of the middle layer of the eyelid results outward bulging of orbital fat and the appearance of eyelid bags or 'festoons'.
- The skin loses its elasticity and the muscles weaken leading to excess skin and wrinkles. As the tissues start to descend and shrink around the junction between the lower eyelid and cheek, the tear 'trough' or hollow starts become increasingly obvious and often one of the first complaints is of both men and women is of deep shadows or hollowness under their eyes.
Modern concepts of cosmetic oculofacial treatment
- Anatomical restoration of eyes and its surrounding structures: The upper face (forehead and brow) and midface (cheeks) are in continuity with the eyes. Thus ageing changes of the upper face and midface can alter the appearance of the eyes indirectly. Modern cosmetic surgery reflects this philosophy and many surgeons now advocate correcting structural changes in these areas simultaneously. For example, the forehead and eyebrows often descend with age and this may lead to the appearance of excess skin of the eyelids. In this case, it may be preferable to correct the descended forehead first with a brow lift. This would restore the eyebrows back to their normal position and at the same time reduce the amount of excess upper eyelid skin. Any residual excess skin of the eyelids may then be treated with a blepharoplasty/ eyelid surgery. For some patients, simultaneous brow lifting as well as blepharoplasty surgery are commonly required and this can be done through the same skin incision (transblepharoplasty brow lifting).
- Minimally invasive procedures: Not all patients require surgery and indeed, many patients do very well with simple quick non surgical techniques e.g. tear trough rejuvenation with injectable fillers, muscle relaxing injections or fillers to raise eyebrows. For the patients who do require surgery, most surgery now is performed through hidden minimal incisions with minimal dissection thus shortening recovery times and minimising the risk of scarring.
- Anatomical restoration: Other modern concepts include tissue volume replenishment e.g. fat grafts/ fillers to treat age related tissue deflation as opposed to standard excisional surgery.
What are the reasons for undergoing blepharoplasty? ( eyelid surgery/ eye plastic surgery/ cosmetic eyelid surgery)
There are two main reasons why patients undergo blepharoplasty surgery:
- Functional reasons: In some patients the hooding of their eyelids is so severe that their peripheral vision becomes very compromised or cause frequent blinking. These patients commonly have to exert their forehead muscles in an attempt to lift their eyelids out of the way in order to see properly. In such severe cases, upper eyelid blepharoplasty surgery may be funded by the NHS or patient's private medical insurance schemes since it is deemed that their surgery is not for cosmetic improvement but purely for functional reasons. Similarly but less commonly, patients undergoing lower eyelid blepharoplasty/ plastic surgery may have their surgery also funded by the NHS or via private medical insurance if it is deemed that their surgery is necessary for rehabilitative purposes e.g for thyroid eye disease.
Before (left) and after (right) pictures of blepharoplasty surgery to both upper eyelids. This lady's hooding was so severe that it was compromising her peripheral visual field. Thus upper eyelid blepharoplasty surgery was available on the NHS for functional reasons (click to enlarge).
- Cosmetic reasons: The appearance of one's eyes are central to their facial expression. As one ages, one's upper eyelids become more hooded and droopy, the lower eyelids often develop 'bags', the fat within the eye socket may start to bulge forward and under eye hollows may start to develop. Unfortunately, many of these normal age related changes can misinterpreted by others. Many patients who request blepharoplasty (cosmetic eyelid / eye plastic) surgery often do so because they are fed up of their peers commenting on them looking tired or angry. Cosmetic eyelid plastic surgery (cosmetic blepharoplasty) is therefore commonly performed to reverse these changes and is one of the most commonly performed cosmetic plastic surgery procedures worldwide. After blepharoplasty surgery, patients often remark that they look less tired, and even at times feel more energised in themselves. Although the majority of patients undergoing cosmetic eyelid surgery are women, increasingly men are also undergoing cosmetic eyelid surgery both for functional and cosmetic reasons. Indeed, cosmetic eyelid plastic surgery in men is one of the fastest growth sectors in cosmetic surgery currently in the UK and this may be due to the perceived importance of appearance in the workplace.
An upper eyelid blepharoplasty is performed for people with droopy, overhanging eyelids that look cause frequent blinking, impair vision or simply for cosmetic improvement. Upper eyelid blepharoplasty is sometimes performed at the same time as ptosis surgery or brow stabilisation/ lifting surgery via the same incision, thus reducing the need for unnecessary additional surgery.
Before and after pictures of combined blepharoplasty and eyelid ptosis surgery to both upper eyelids. This gentleman had marked upper eyelid hooding (dermatochalasis) and upper eyelid ptosis. Due to its severity, this patients surgery was available on the NHS for functional reasons. (click to enlarge)
Before (left) and after (right) pictures of Bilateral Upper eyelid Blepharoplasty - commonly referred to as an eyelid lift (click to enlarge)
A lower eyelid blepharoplasty is often requested by patients who are fed up with under eye 'bags' or puffiness. Similarly, lower eyelid cosmetic surgery can be combined with other procedures, sharing the same incision, thereby minimising the need for further surgery e.g. midface lifting.
Before (left) and after (right) pictures of blepharoplasty surgery to both lower eyelids (click to enlarge)
How is blepharoplasty/ cosmetic eyelid surgery performed?
Prior to any surgery, the surgeon should discuss with you what you wish to achieve, what is safely achievable and the risks and benefits of surgery. At the end of the consultation, the surgeon should be able to develop a surgical plan for that particular patient. Each patient is an individual, and the surgical plan reflects this. Prior to any eyelid operation, it is usually recommended that every patient should ideally undergo a formal eye examination either by the surgeon who is going to be performing the procedure or an impartial ophthalmologist.
Upper eyelid blepharoplasty/ cosmetic surgery is performed commonly as a day case procedure. Much like the word ‘haircut’, the term blepharoplasty describes refashioning of the eyelid in general. The procedure itself will have slight variations depending on the patient. Because oculoplastic surgeons perform more eyelid operations than any other type of surgeon, they are more equipped to offer the full repertoire of techniques to address different variations in patient anatomy. Like all types of eyelid surgery, blepharoplasty surgery, either for cosmetic or functional reasons, can be performed under local anaesthestia, local anaesthesia with mild sedation, or general anaesthesia.
For upper eyelid blepharoplasty, the surgeons will draw some lines on the upper eyelid. Surgery can be performed using either general anaesthetic or local anaesthetic. The vast majority of patients opt for local anaesthesia since its is quicker and very acceptable. Sometimes the anaesthetist may administer some sedation through a vein in the back of the hand to make relax the patient further. Removal of the excess skin is then performed using either a scalpel, carbon dioxide laser, or radiofrequency cutting device. The incisions are situated within the normal skin crease of the eyelid so that afterwards, the incision scar is hidden and becomes invisible. For those patients with bulging fat in the upper eyelid, the fat is then either sculpted away or repositioned. An oculoplastic surgeon can then perform any additional procedures as necessary , for example, correcting a droopy eyelid with eyelid ptosis surgery, repositioning a prolapsed tear gland, debulking of any prolapsing orbital fat or lifting/ stabilising the eyebrow position. The wound is then closed with sutures. Although their removal is required, non-dissolvable sutures are sometimes used, because of their more predictable cosmetic result.
Lower eyelid blepharoplasty is performed slightly differently to upper eyelid blepharoplasty. Again, depending on the nature of the cosmetic defect, different techniques may be used. For example:
-For patients excess skin causing wrinkles, the incision can be made in the skin just below the eyelash line so that the excess skin can be removed after the excess fat is addressed first. The incision is so close to the eyelash line that it becomes invisible within a few weeks of surgery. If there are eye bags ( which is usually caused by the normal orbital fat prolapsing forwards) this can be addressed at the same time through the same incision.
-In those patients where skin redundancy is not an issue and the only problem is eyelid bags due to bulging orbital fat, the incision can be made along the inside of the lower eyelid (transconjunctival approach) and the fat prolapse can be addressed resulting in sutureless scarless surgery. This results in a much quicker recovery time following surgery.
-There are various ways of addressing prolapsing fat in the lower eyelid and a good cosmetic surgeon should be able to discuss with you the most appropriate options. These include simple fat removal (debulking) to repositioning. In patients with a tear trough deformity, a popular technique which has gained popularity recently is to drape this fat over the edge of the socket and use it to replace the fat which has started to disappear on the rim of the orbit itself. Therefore, instead of simply disposing of the orbital fat, the surgeon is utilising it as a filler.
-Lower eyelid blepharoplasty is technically more challenging than upper eyelid blepharoplasty due to its slimmer margin for error and riskier potential complications. For this reason, many surgeons choose only only concentrate on upper eyelid blepharoplasty.
- The surgery performed will be individual to that patient. For example, eyelid tendons may need to be tightened, the bulging fat may be excised or redistributed, the midface/cheek may be lifted, some of the wrinkles may be removed, the hollows underneath the eyelids may be softened and filled. A good cosmetic surgeon should be able to discuss with the patient a personalised surgical plan: customised to the patient's anatomy, the patient's wishes and expectations.
Before (left) and after (right) pictures of blepharoplasty surgery to both upper and lower eyelids (click to enlarge)
How long do I need to stay in hospital following surgery? Most cosmetic eyelid surgery can performed quite safely as a day case procedure so that most patients go home the same day. It is advisable that someone you know can take you home and stay with you at least overnight just to be on the safe side. For some patients attending from outside the Midlands, particularly those undergoing complex surgery, Mr Cheung may advise staying overnight in the hospital or in a nearby hotel.
Recovery after cosmetic eyelid surgery/ blepharoplasty?
It is often advisable to have someone accompany you on the day of surgery, particularly if the surgery is performed as a day case procedure. Sometimes the eyes will be covered with pressure dressings, to help reduce the build up of any postoperative swelling. As the anaesthetic wears off, your eyelids may feel tight and sore, but this wears off quickly and is usually easily treated with simple painkillers. If the postoperative pain is severe, this may indicate a serious problem and patients should get in touch with their surgeon immediately.
You will advised to sleep upright and apply regular compresses to the eyelids to reduce the postoperative swelling. It is especially important to keep your wounds clean and dry. Eye drops are commonly provided to help soothe the eyes which can feel slightly dry due to temporary impairment of the normal blink reflex following surgery.
Recovery time following cosmetic eyelid surgery/ blepharoplasty?
-Swelling and minor bruising is normal and peaks about 24-48 hours after the procedure.
-However 90% of the swelling usually disappears by 10 days but minor swelling may still persist for 10-12 weeks depending on the complexity of the procedure. For example, most of Mr Cheung's patients who return to work after 10-14 days often comment that their work colleagues remark that they look fresher but often do not realise that any surgery has been performed.
-Most patients return back to work about 10-14 days after blepharoplasty surgery.
- The first clinic visit following surgery is usually scheduled for 1 - 2 weeks following surgery. Mr Cheung often personally removes any skin sutures with the aid of an examination microscope to ensure there is no retention of the fine skin stitches.
-Make up can be safely used usually from the 10th postoperative day.
- Most patients are usually discharged at 3-6 months following surgery.
Cosmetic upper eyelid surgery: Before and after pictures (click to enlarge)
What are the potential risks and complications of blepharoplasty/ cosmetic eyelid surgery?
As with any cosmetic procedure, the patient's part in expecting a realistic outcome and understanding the potential complications is probably more important than the skill of the surgeon. Any good surgeon will take the time to chat with the patient so that they have a good understanding of what to expect and what is realistically achievable. Patients with unrealistic expectations are likely to be disappointed no matter how skilled the surgeon or good the postoperative result.
Complications are extremely rare and the vast majority of patients are extremely satisfied following surgery. The complications of blepharoplasty surgery include:
- Eyelid Asymmetry: where one side does not match the other
- Undercorrection where insufficient skin/ orbital fat has been removed. It is important to be realistic about how much skin can safely be removed.
- Overcorrection-If too much skin is removed during upper eyelid blepharoplasty, the eyelid may not be able to close properly (termed lagophthalmos), which can be sight threatening. Lagophthalmos can be temporary from eyelid swelling, or permanent if too much skin from the upper eyelid was removed. The cornea (clear window on the front of the eye) may start to dry out due to the incomplete closure of the eyelid. This may be sight threatening since the cornea may ulcerate as a result. For severe cases of lagophthalmos, a skin graft or flap to replace the upper eyelid skin shortage may be necessary to allow the eyelid to function normally again.
- Temporary dry eye commonly occurs following upper eyelid blepharoplasty surgery and is commonly due to temporary impairment of the muscles involved in eyelid closure. Ocular lubricant drops are commonly prescribed for a few weeks following surgery for symptomatic relief. Less commonly though, permanent dry eye may result particularly particularly following excessive skin removal (both in upper and lower eyelid blepharoplasty) and in patients who have pre-existing problems with dry eye, tear film problems, previous refractive surgery and ocular surface problems. It is for this reason that the Dept of Health recommends that all patients undergoing any type of blepharoplasty surgery undergo a formal assessment by an ophthalmologist including testing ocular motility, tear film production and quality assessment.
- If too much lower eyelid skin is removed, the eyelid may look hollowed out, too concave or may cause the eyelid to turn outwards leading to ectropion formation. All oculoplastic surgeons are trained to avoid this by performing additional procedures if necessary e.g. eyelid tendon tightening such as lateral canthopexy.
- Scarring can also occur post-operatively, leading to a poor cosmetic outcome. Scarring following lower eyelid blepharoplasty can result in the lower eyelid being pulled out and downwards, leading to an unnatural appearance and ectropion. Corrective surgery may be necessary to address this. It can usually be avoided by meticulous dissection in the correct surgical planes and is rare in the hands of oculoplastic surgeons.
- Acute glaucoma is an rare but potentially blinding complication that can occur with any type of eyelid surgery and occurs when the internal pressure of the eye starts to rise as a result of some of the side effects of some of the drugs and injections utilised during eyelid surgery. Oculoplastic surgeons are trained to recognise and manage this complication through their general ophthalmology training. It is recommended in the US, that a formal ophthalmological assessment be performed prior to eyelid surgery to look for the potential risk factors for this complication.
- Bleeding into the skin, known as a skin haematoma, after the procedure is an uncommon complication and excessive bruising leading to a collection of blood within the tissue. It is critical to stop all tablets which may increase the risk of bleeding and your surgeon should advise you about this prior to surgery. In the first few days following surgery, you should avoid any vigourous activity such as lifting, bending, since this can worsen any bruising or swelling of the eyelids.
- Corneal abrasion is when the corneal surface is damaged either due to the inadvertent trauma. This complication is extremely rare in the hands of oculoplastic surgeons.
- Eyelid ptosis- Uncommonly the main tendon (levitator aponeurosis) within the eyelid may be damaged during cosmetic eyelid surgery causing the actual eyelid itself to descend and stay permanently low. This complication is extremely rare for oculoplastic surgeons since they routinely operate on this structure anyway and the most experienced in recognising the complex anatomy. Indeed, oculoplastic surgeons routinely perform ptosis surgery anyway and may recommend simultaneous ptosis correction/ repair in patients who already have a compromised eyelid tendon.
- Sunken eye (enophthalmos) and hollow eyelids- The fat within the socket (orbital fat) normally starts to shrink with age leading the the eyeball looking sunken over time. However, an artificially sunken eye can occur following excessive orbital fat removal. Similarly if excessive fat is removed the eyelids can look artificially hollow (sometimes known as skeletonisation). This complication occurs less commonly now surgeons have learnt to avoid it by being very conservative with orbital fat removal and performing safer techniques e.g. orbital fat repositioning.
- By far, the worst complication of blepharoplasty and thankfully the rarest, is an orbital haematoma. Uncontrolled bleeding, usually from a blood vessel from manipulation of some of the pockets of fat, results in compression on the optic nerve and its blood supply. If left untreated, permanent blindness can occur. Early diagnosis—recognised by severe eye pain or visual changes—is critical. Urgent reoperation may be necessary to stem the bleeding point and relieve the pressure on the optic nerve. It is for this reason, that eyelid plastic operations should ideally be performed by surgeons who are experienced in handling the fat of the eye socket to not only avoid this problem but also be able to manage it quickly and safely should it arise. Oculoplastic surgeons perform more operations within the orbit and around the eyelids than any other type of surgeon and are therefore best equipped to avoid and manage this rare but fearsome complication.
It is for all these reasons that Mr Cheung tends to err on the side of caution i.e. towards conservative blepharoplasty surgery to reduce the risk of complications and also give a more harmonious balance appearance, to try and avoid a 'plastic' unnatural look. Most complications can be avoid with careful preoperative examination, surgical planning and meticulous operative technique.
Advice Leaflets for Blepharoplasty Patients
Click here for the British Oculoplastic Society blepharoplasty advice page
Click here for the eMedicine blepharoplasty page
Cost of Self Funded Cosmetic Eyelid Surgery with Mr Cheung
The cost of cosmetic eyelid/ eye plastic/ blepharoplasty surgery (all inclusive) by Mr Cheung as a private patient is £2100-£4600 depending on the number of eyelids operated on, complexity of procedure, additional procedures performed, type of anaesthesia requested and length of hospital stay.
The vast majority of patients undergo their cosmetic eyelid surgery with Mr Cheung as a day case procedure (typical duration of attendance in hospital is 3 hours only) under local anaesthesia (numbing injections) with a typical cost of £2100 (all inclusive). The cost of the postoperative consultations including any suture removal by Mr Cheung are included within this initial cost.