Blepharoplasty (Eyelid Surgery) & Browlift
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Significant facial aging changes usually begin around the eyes. The goal of aesthetic eyelid surgery is to restore a fresh appearance to this area. This is accomplished by selecting one or more of the following procedures: removing excess skin and fat from the upper eyelids; treating the lower eyelids by removing excess fat or repositioning it; removing excess skin; smoothing the lower eyelid skin texture with a chemical peel; and either removing the muscles that cause vertical furrows between the eyebrows, lifting the eyebrows, or both. Each component procedure is optional but has an additive beneficial effect. The proper combination of these procedures will produce a clean and fresh look around the eyes without actually changing their shape in any way. The face looks less tired without showing any telltale signs of surgery.
Upper eyelid scars are placed within the natural eyelid crease and are generally not visible with the eyes open. They are permanent like all scars but typically are very subtle after healing is complete. Lower eyelid problems in younger surgical candidates are often due to just fat pouches without loose skin. These fat pouches can be removed through an incision placed inside the lower eyelid. This procedure is called a transconjunctival approach. It avoids a scar under the eyelashes and simplifies postoperative care. Others that have loose lower eyelid skin in addition to fat pouches require an incision placed just under the eyelash line in order to remove the excess skin. This incision also heals extremely well and is difficult to detect.
Some individuals have deep vertical furrows between their eyebrows and heaviness of the inner eyebrows that together convey an angry look. This is due to chronic over activity of the small corrugator muscles located underneath the inner part of the eyebrows. This problem can be treated by Botox injections. Botox smooths this area by temporarily paralyzing these muscles. While effective, these injections are expensive, can be painful, and must be repeated every four to six months to maintain the effect. A more permanent alternative is to actually remove these muscles surgically. This can be done through an upper eyelid incision at the same time as eyelid skin removal. There is no significance to removal of these small muscles other than the fact that it prevents making an angry expression with the eyebrows.
Sometimes hooded upper eyelids are due primarily to sagging eyebrows, a condition best treated with a combination of upper eyelid surgery and a browlift. Although a browlift is more involved than eyelid surgery it will contribute to producing a better and more natural result than the alternative of radical removal of excess upper eyelid skin alone. It is usually accomplished through a one-inch incision within the scalp above the hairline on each side. The forehead skin is then loosened and lifted. Small plastic anchors are attached to the bone through the incisions and used to hold the lifted forehead skin in place. These anchors slowly dissolve in a number of months and do not require removal. It is not necessary to remove any hair to perform a browlift like this. This method is essentially a simplified endoscopic technique.
A more traditional type of browlift called an “open” browlift is reserved for those who are usually over 60 years of age and have more extensive sagging of the forehead. It is also useful for those with deep horizontal forehead lines. An open browlift requires a long incision in the scalp extending over the top of the head between the ears. This procedure includes removing a strip of scalp skin to adequately raise the forehead. Dissolvable anchors are also used as in the more limited type of browlift. Those with thinning hair or a high forehead to begin with are not ideal candidates for an open browlift. A variant of this procedure, in which the incision is made at the hairline, is useful for those with a high forehead because it will not raise the hairline further. Open browlift methods are rarely required but are very effective if needed.
There are some associated conditions of the eyelids that are treated by ancillary procedures. Deep smile lines (“crow’s feet”) can be treated most effectively with Botox injections and less effectively with peels. Crepey lower eyelid skin exhibiting fine wrinkles can be treated with a chemical peel using dilute trichloroacetic acid (TCA). This method removes the top layer of skin. The deeper layers then regenerate a new epidermis that is smoother and softer in appearance. Light crusting is present for about one week and then the skin remains pink for another week after a TCA peel. Make-up can be effectively used to conceal redness during the healing process. Dark circles are more difficult to treat successfully but in some cases are amenable to a chemical peel.
Older individuals with weak lower eyelids and younger individuals with especially prominent eyes may have a white space visible between the bottom of the colored cornea and the top of the lower eyelid. This often makes the eyes look sad but more importantly may cause symptoms of dry eyes because eye protection is compromised by low eyelid position. These individuals may require a tightening procedure in addition to skin and fat removal of the lower eyelids. This will prevent or improve dry eye symptoms and also improve the shape of the eye opening by raising the eyelid. This procedure is normally accompanied by a temporary Asian appearance to the outer part of the eye that resolves after about one month.
Some individuals have decreased tear production and are at risk of developing chronic eye irritation after surgery. Those with suggestive symptoms such as tearing or itching will be tested prior to surgery. Surgery can be performed conservatively in those with minimal symptoms but is not recommended in others more severely afflicted. It may be necessary to perform upper and lower eyelid surgery in two separate stages for maximum safety in patients with symptoms suggestive of dry eyes.
Aesthetic eyelid surgery is performed in the office as an outpatient procedure. It usually takes about one hour. More advanced conditions may require two hours and a browlift, if necessary, adds another 45 minutes. All surgery is performed entirely by Dr. Hidalgo. General anesthesia is usually not necessary unless eyelid surgery is combined with another cosmetic procedure done elsewhere on the body. This issue can be discussed with the anesthesiologist prior to surgery.
Ice compresses are applied to the eyelid area after surgery and are continued for 24 hours. The eyes are not bandaged. There is usually slight discomfort following surgery but many patients do not require pain medication. Vision is normally slightly blurred for the first few days after which reading may resume. Browlifts may cause more discomfort. The scalp feels tight due to swelling and portions of the forehead and scalp may feel numb. These symptoms resolve with time.
Eyelid sutures are generally removed by five days and browlift clips by one week. Swelling and discoloration is expected following surgery and usually resolves in two weeks. A light cover-up may be applied to the lower eyelids beginning one week after surgery, or by two weeks if a chemical peel has also been performed. For women, other facial and eyelid makeup including mascara, eye shadow, and eyeliner may be conservatively applied beginning one week after surgery.
Most individuals are able to resume most of their normal activities one week after eyelid surgery, and by two weeks if either a browlift or chemical peel has also been performed. This includes going to work if residual bruising or skin redness is not objectionable. Jogging, aerobics, bicycling, and other non-contact and non-ball sports can be slowly resumed beginning three weeks after surgery. Ball sports should be avoided for six weeks.
Eyelid and brow surgery is seldom associated with complications and are among the safest aesthetic procedures performed. Infection or eye irritation can occur but typically are self-limited problems. Although blindness in one eye following blepharoplasty has been reported in the plastic surgery literature, this is an extraordinarily rare occurrence. Permanent nerve injury is possible with browlifts but is also a rare occurrence. The open method can cause hair loss adjacent to the incision that is usually quite minor. Skin darkening can occur with a chemical peel but this is treatable with bleaching cream and is not permanent.
The beneficial effects of eyelid surgery last for decades. Browlifts rarely need to be revised or repeated. While some individuals slowly develop a small amount of additional excess upper eyelid skin after many years, most patients have only one operation and remain pleased with the appearance of their eyes.
Copyright © 2007 David A Hidalgo, M.D.
