A Second Look

Created on 15th May 2009

Blepharoplasty explained: top cosmetic surgeon, Patrick Mallucci of London Plastic Surgery Associates, concludes his look at eyelid surgery by detailing his own personal surgical approach to this often tricky and delicate procedure

The upper eyelid

The aim of surgery to the upper eyelid is to create a more youthful appearance by removing excess skin and soft tissue in order to remove some of the heaviness that appears with time. Depending on the situation, this might be predominantly skin or also some of the deeper structures such as muscle and fat.

The operation involves placing an incision along the natural eyelid crease and removing the required amount of excess skin above the incision. Once excess skin has been removed a small layer of underlying orbicularis muscle is also removed as this too can be lax and contribute to bulging in the upper lid.

Beneath the muscle lie the fat pockets and if it is determined that there is a significant amount of bulging of the upper lid, this is often due to protruding fat pockets. The pockets can be carefully opened and some of the fat removed in order to reduce the amount of bulge.

Once all the required skin and muscle/fat has been removed, sutures are used to close the incision on the lid. The sutures normally remain in place for 4-5 days before they are removed.

The operation itself can be carried under local anaesthetic (patient awake) as a day case procedure or for those who want to be less aware as a general anaesthetic day case.

Recovery is rapid although swelling and bruising for 7-14 days is normal and to be expected.

Scarring on the eyelid is generally excellent - the eyelid skin is the thinnest in the body and once the healing process is complete scars are barely perceptible.

The main complication of upper eyelid surgery is related to excess removal of skin resulting in difficulty with eye closure. This is thankfully rare and with careful planning and discussion should be avoided.

The lower eyelid

Surgery to the lower eyelid is more complicated than that to the upper lid. This is mainly due to the fact that the anatomy of the lower lid is vital in its design to maintain good eye function and protection. Any significant disturbance or imbalance of this design can result not only in a poor aesthetic outcome but also in problematic, uncomfortable eyes.

It is also complicated by the fact that gravity acts on the lower lid and so intervention during surgery can lead to unwanted lowering of the lid - a phenomenon known as ectropion - if measures are not taken to protect against this.

Surgery to the lower lid needs to respect these challenges, but carried out precisely can lead to dramatic improvement of the eye region as a whole - particularly in those who have unwanted ‘bags'.

The surgery seeks to correct any excess skin giving rise to wrinkles on the lid as well as trying to correct the eye bags themselves. The latter are caused by bulging fat pockets which are not held properly in place by ageing lax membranes.

There are two strategies to deal with these; either to remove any excess fat or to replace and tighten the membranes that should be keeping the fat in its proper position.

My preference has always been to maintain the fat and to refashion the membranes in order to reposition the fat whence it came from. My reason for this is twofold: removal of fat from the lower lid can lead to hollowing of the area - a look which is not rejuvenating - and, secondly, retention of the fat placed in its correct position gives an aesthetic fullness to the eyelid region, a feature of the youthful eye.

An incision is made just below the lash line, then skin and a layer of muscle are raised in order to access the fat membranes, these are then tightened and repositioned, and finally any excess skin/muscle are removed subtly and the incision is closed beneath the lashes.

In order to protect against lower lid descent, sutures are placed from the outer corner of the eyelid to the bony orbit at the side of the eye to effectively ‘anchor' the lower lid into position minimising any risk of lid lowering (ectropion). This is known as a canthopexy and is an important manoeuvre in trying to avoid the problems outlined at the beginning.

Occasionally, when there is no excess skin and the problem is mainly due to the fat bags, these can be approached from the inside of the lid without going through the skin.

As with the upper lid, the scars from this surgery heal very well and are barely noticeable over time.

Bruising and swelling usually last a little longer - between ten and fourteen days - and during this time it is not uncommon for the eyes to feel a little irritated. Once this period is over recovery is rapid with return to normal activity.

The operation is generally carried out under a general anaesthetic as it is slightly more involved than that of the upper lid, but can be carried out under local anaesthetic also.

Patients need to be warned about the bruising and swelling and initial discomfort as well as the rare possibility of lid malposition as described. During the initial recovery period excess tearing is also seen occasionally which settles as the swelling resolves.

While, as with all surgery, it is important to understand the risks and the benefits of any procedure, good preparation and a thorough understanding of the problem area will result in a successful outcome
CS&AM