Seeing Eye to Eye

Created on 02nd March 2009

Blepharoplasty explained: top cosmetic surgeon, Patrick Mallucci of London Plastic Surgery Associates, provides a general introduction to eyelid surgery. Next issue, he discusses his own personal surgical philosophy and explains how blepharoplasty can be combined with other facial surgeries for the best possible result

Blepharoplasty relates to correction of the upper and lower eyelids - hence the terms upper lid blepharoplasty and lower lid blepharoplasty. As part of the ageing process significant changes can occur to the eyelids affecting either the upper lid or the lower lid or both. The problems occurring in each are very different and they should probably be considered separately even though improvement of the whole orbital complex is paramount in achieving optimal aesthetic results.

The upper eyelid

With age the position of the brow above the eyelid often drops a little, resulting in more skin 'crowding' into the upper eyelid. Also the eyelid skin itself thins over time and appears excessive and more lax. The effect of these changes is that the skin on the eyelid gives an impression of heaviness, often sitting on the eyelashes and obliterating the natural space seen on the upper lid in a more youthful eye. In extreme situations there is a feeling that the visual field becomes impaired as the excess skin hangs over the eyelid into the field of vision. Occasionally the fat behind the eye also bulges forward producing a 'puffy' appearance. The onset of these changes is very variable from individual to individual but excess skin in the upper lid can commence relatively early (30s and 40s) and is seen as a stigma of ageing.

Surgery to this area is aimed at correction of these changes. In general, this involves removal of the excess skin along the natural crease of the eyelid. This is normally combined with removal of a strip of loose muscle sitting just below the skin, and occasionally removal of any pockets of bulging fat if these are deemed to be problematic. Because of the importance of the brow position, sometimes it will be recommended that brow elevation should be part of the improvement of the upper eyelid.

For isolated surgery to the upper eyelid this is a relatively straightforward procedure. It is often performed under local anaesthesia with the patient fully awake. This has the advantage of avoiding anaesthetic and minimising 'downtime'. The procedure is literally a 'walk in, walk out' procedure. Patients are told to expect some bruising for the first week or so and sometimes there is a feeling of slight tightness during this time, however, this resolves quickly and normality is restored soon after. Sutures are removed after four or five days.

The results are generally very gratifying, and with minimal complications. The eyelid surgery can be carried out as an isolated procedure or as part of general facial rejuvenation.

The lower eyelid

As part of the 'orbital complex' the overall appearance of the eyelids is important and as mentioned earlier it might be that one lid or both lids are affected and need correction. The main effect of the ageing process on the lower eyelid is the appearance of 'bags' underneath the eye as well as excess skin below and to the side of the eye producing 'wrinkly' skin. The eye bags are not only ageing in appearance but people will often be told that it makes them look tired or grumpy.

Because gravity acts on the lower lid, as the elasticity in the tissues diminishes with age, the position of the lower lid can also drop slightly, replacing the more youthful appearance of a better supported eyelid. Surgery to the lower lid is generally more challenging than to that of the upper lid, largely because of gravity - any over-correction can be exacerbated as a result, leading to malposition of the eyelid, with an uncomfortable eye often characterised by the eyelid being pulled downwards exposing the white of the eye. This phenomenon is referred to as an ectropion of the eye and is to be avoided. Surgery therefore has to be delicate and precise.

The principles of surgery are to deal with either the bags under the eye or the wrinkly skin or both. When it is deemed necessary to remove skin as well as the eye bags - the approach to the lower eyelid is usually via an incision just below the eyelashes, the skin of the lower eyelid is lifted giving access to the eye bag area which consists of bulging fat. The fat can either be removed or often it is retained but simply put back into the eye in order to retain a youthful full appearance without the bulge. Once the fat has been corrected, any excess skin can be carefully removed to reduce the wrinkles.

The scar, like in the upper eyelid, is very well disguised and heals impeccably. Sutures are often placed in the corner of the eye and anchored to the bony rim in order to protect against the downward pull of gravity - this is known as a canthopexy.

When it is not necessary to remove skin and only the fatty component needs to be corrected, the eye bag area can be approached via an incision on the inner aspect of the eyelid so that there is no external visible scar. The aim is to produce a smooth transition between the skin of the cheek and the junction with the lower eye lid, avoiding any hollowing or puffiness in the lower lid.

Most problems relating to the lower lid are as a result of an imbalance between trying to achieve correction and improvement on the one hand while not maintaining the delicate relationship and position of the elements of the lower lid that keep it from being pulled out of position.

Correction of the upper and lower eyelids is of paramount importance in overall rejuvenation of the face as the eyes are potent transmitters of appearance. Done delicately this surgery can be very rewarding.