The skin loses its elasticity and our muscles slacken with age. For the eyelids this results in an accumulation of loose skin which collects as folds in the upper eyelids and forms deepening creases in the lower lids.
At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes. The problem often seems worse in the morning particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day tends to settle at night in areas where the skin is loose, such as the eyelids.
Drooping of the eyelids is also an effect of the ageing process and aggravates the accumulation of the skin in the upper eyelids. Sometimes so much skin accumulates in the upper eyelids that they hang over the eyelashes, obstructing vision.
What can be done?
An eyelid reduction (blepharoplasty) removes the surplus skin and protruding fat to produce a more alert appearance and reduce the morning swelling. Sometimes it is only necessary to reduce the skin, sometimes the skin and the fat, and sometimes just the fat. If only the fat is being removed from the lower eyelids, this can be removed from the inside of the lower eyelid avoiding an external incision (transconjunctival blepharoplasty).
Who are the best candidates?
People who have the familial problem of bags underneath the eyes may well undergo surgery in their 20’s. Ageing effects of the skin are apparent earlier in the eyelids than elsewhere. A reduction of the skin can be carried out from the age of 35.
Patients with thyroid disease often develop eye signs which can be helped by surgery. Where there is reduced secretion of thyroxin (hypo-thyroidism) there is an increase in fat and where there is an increase in thyroxine (hyper-thyroidism) there is often so much increase in fat that the eyes protrude. An extended eyelid reduction (Olivari’s procedure) can treat this satisfactorily.
Both upper and lower eyelid surgery can be carried out under local anaesthetic or under general anaesthesia in a hospital. In a typical procedure the surgeon makes incisions following the natural lines of your eyelids; in the creases of upper lids and just below the lashes in the lower lids. These incisions are extended a little way into the crow’s feet or laughter lines at the corner of the eyes. Through this incision surplus fat, excess skin and sagging muscle is removed.
If you have a pocket of fat beneath your lower eyelids without surplus skin then the fat may be removed through the inside of the lower eyelid (transconjuctival blepharoplasty). There is then no external scar. Sometimes surgeons prefer to use lasers to cut the skin or conjunctiva, but it is essentially the same procedure.
The resurfacing laser can be used at the same time as a transconjunctival blepharoplasty to tighten the external skin and reduce wrinkles. Although there is no external scar there is residual redness in the skin which will last a few months.
Following surgery it would be best to keep your head elevated for a few days to reduce swelling. Cold compresses can also help. The surgeon will normally apply some suture strips or steri-strips as support to the eyelids after surgery, and if these become crusted they can be replaced.Cleaning the eye clean with water and using Clinisept™ spray will help with the healing process. The sutures are usually removed after 7 days and soon after you will be able to use make-up. Sometimes you will be advised to use the suture strips or steri-strips as support to the lower eyelids for a week or so.
The closure of the eyes appears tight after surgery because of all the swelling and because skin has been removed.If closure is not complete at night then applying a small amount of coconut oil should help. The sensation will settle as the swelling goes down. The eyes appear watery after surgery, partly because of swelling under the conjunctiva (chemosis) and partly because the tear ducts are swollen and do not drain readily. This will last a few weeks. Although there is bruising it can quite readily be disguised with make-up and dark glasses. The scars will be pink for a few months but they should become less visible with time.
What are the risks?
All surgery carries some uncertainty and risk. When eyelid surgery is performed by a qualified Plastic Surgeon complications are infrequent and usually minor. You can check that your surgeon is on the Specialist Register kept by the General Medical Council (telephone 020 7915 3638). All members of the British Association of Aesthetic Plastic Surgeons (BAAPS) are on the Register.
You can reduce the risks by closely following your surgeon’s instructions both before and after surgery. You should tell him of any thyroid disease, high blood pressure, diabetes or eye disorder such as detached retina or glaucoma. It may be that he/she will wish you to be checked by an Ophthalmologist.
Occasionally a pool of blood can collect under the skin after the operation has finished (haematoma). This usually disperses spontaneously over 2 or 3 weeks bit it may need to be drained if it is large. Quite commonly the margin of the lower lid is slightly pulled away from the eye during the first day or two after surgery owing to swelling. This will settle on its own or with the help of suture strips or steri-strips. Very occasionally another operation is necessary.
Sometimes tiny white cysts can appear along the stitch line. They are nothing to be concerned about but can be pricked out with a needle. Blindness is an exceptionally rare complication.
What Are The Limitations?
It is important for you to understand that the only way the wrinkles which are in the skin which is cut away will be removed. We are only treating the eyelids within the bony margin of the orbit (eye sockets). Folds of skin extending onto the cheek (festoons) will not normally be improved. Wrinkles in the area of the crow’s feet will remain and although the skin is much tighter it is still necessary to be able to open and close the eyes freely. The skin has less elasticity with age and for proper closure of the eye the upper eyelid will need to have surplus skin when it is open.
Descent of the eyebrow can be helped by endoscopic brow lift and en extension of this, the deep facelift, can be used not only to lift the eyebrow and the upper eyelid, but also to lift and open the outer angle of the eye.
Sometimes residual or recurrent wrinkles are suitable for treatment by chemical peeling or laser resurfacing. The operation has no effect at all on the dark colour of the lower eyelid.
ARNICA tablets will reduce swelling. These can be bought at any CHEMIST. These should be started a few days before surgery and continued for several days afterwards.
We now tend to use surgical glue in places of sutures following this procedure.
You must wash your face as normal by using Johnsons Baby Shampoo or Baby Soap, as these products are very gentle.
You should sleep on two or more pillows. This will reduce the swelling in your eyelids.
Ice packs can be applied if desired. They should ideally be GEL EYE PADS rather than ice. ICE SHOULD NEVER BE APPLIED DIRECTLY TO SKIN. If ice packs are used, you should wrap the ice cubes in a towel before applying
Scarring is always an issue and hopefully your scarring will be acceptable. If scarring is an issue we will endeavour to correct this.the surgeon may not charge for this but there will be a small facility fee to pay. Any corrective surgery will only be undertaken when post operative swelling settles which may be after 9 – 12 months.