Tuesday, 15 June 2010 00:13

Upper and Lower Eyelid Surgery (Blepharoplasty)

Upper and Lower Eyelid Surgery (Blepharoplasty)


As we age the delicate skin around the eyes tends to sag as the underlying structures in our skin weakens and often sags along with the skin. The appearance is a tired, haggard-looking face that often results in low self-esteem and a poor self-image. This is hardly surprising when you consider that the eyes are one of the first things people notice about you. In fact, people you encounter form their first impressions of you within seconds of meeting you and, rightly or wrongly, aging eyes tell them a story that perhaps may give them an incorrect impression of who you are, what knowledge you have and what is important to you. Most often wrinkling and sagging can be the result of the normal aging process.

However, they can also reflect an erratic lifestyle, as well as smoking, drinking, too much stress, too little sleep as well as skin allergies causing eyes to puff up. Quite often premature aging can be alleviated by upper and lower eyelid surgery. While all surgery carries a certain amount of risk, surgery to correct aging eyes is a remarkably safe procedure that carries a particularly high level of satisfaction to the patients who undergo surgery. It is important to mention that not all surgery for upper and lower eyelids is done for cosmetic reasons. Sometimes sagging eyelids occur as the result of skin allergies or from kidney illnesses, as well as blepharitis which is an inflammation along the rims of the eyes. Surgery is sometimes needed to correct problems caused by these conditions.

Anatomy and Physiology of the Eye

As you will be aware, you have an upper and lower eyelid to each eye, each one lined with eyelashes. As our bodies are in 3D, as it were, your eyelids have an edge along which upper and lower eyelids meet. The edge of the eyelids is known as the eyelid margin, with an internal margin and an external one. Your eyelashes are attached to the outside edge of the margin. When your eyelids are open your eyeballs are exposed so that you can see what is around you. The open gap between upper eyelid and lower eyelid is referred to as the palpebral fissure. When you close your eyes together your eyelids meet together.

The line along which they meet is known as the commissures, with the medial commissure being nearest to the nose and the lateral commissure being the one furthest away from your nose. At the medial commissure eyelid margin your eyes drain into the tear ducts known as the lacrimal puncta. Below the skin, lying on top of the bone of your skull is the soft tissue, collectively known as canthi. Each canthus would be muscle, epidermis which is the lower level of skin, tendons, and fat. The medial canthus and the lateral canthus each extend for half an inch either side of your eye. A large muscle that completely encircles each of your eyes is the orbicularis muscle which allows your eyelids to close, with the levator muscle opening your eyes.

The levator muscle originates deep inside your eye socket and extends towards the top of your eye, where it meets the flap of your eyelid. Here it has evolved into the levator aponeurosis tendon that physically attaches the muscle to your upper eyelid. Meanwhile, the frontalis muscle lies across your forehead, enabling you to pull up each of your eyebrows and wrinkle your forehead. Horizontal wrinkles are the result of skin between each eyebrow being pulled by the procerus muscles. If you decide to wrinkle your nose up and push up the skin between each of your eyebrows you will be utilising your corrugator muscles. The only muscle involved with the movement of your actual eyeball itself is the inferior oblique muscle that may be disturbed when the fat from your lower eyelid is removed, although there are actually six muscles that your eye relies upon to control movement.

Your eyelids are supported by a layer of thin cartilage strung from lateral to medial corners of each eye. This is the tarsal plate that is attached to either side of your eye by tendons that attach it to the bone of your skull, at your orbital rim. The medial side by the nose is called the medial canthal tendon whilst the lateral canthal tendon is found at the outside edge of your eyelid. In other words, to put it more simply, you have the tarsal plate along the inside of your eyelid, attached at each side by a tendon, in a hammock-like construction known as the tarsoligamentous sling. A similar system operates the top eyelid, similar to that of the lower eyelid.

  • Medial Canthal Tendon anchoring lids to bone
  • Lateral Canthal Tendon anchoring lids to bone
  • Upper Tarsus or Tarsal Plate. This is stiffens like cartilage
  • Lower Tarsus.
  • Levator muscle as far as tendon. Main opening muscle of upper lid
  • Superior Oblique tendon – this moves the eyeball
  • Inferor Oblique muscle – also moves eyeball
  • Lacrimal Gland – otherwise known as the tear gland
  • Lacrimal Sac – part of tear drainage system
  • Fat Orbital – extends into eyelids
  • Orbital rim – bony socket

Your eyeball is cushioned from contact with the inside bony surface of the orbital socket with a padding of fat covered by a thick fibrous membrane called the orbital septum. This connects with the tarsoligamentous of the lower eyelid and attaches up to the bony rim of the orbital socket. Meanwhile, the orbital septum for the upper eyelid extends as far as the bony rim above the eye. These orbital septa cover the pad of fat the covers the levator aponeurosis tendon. In the upper eye there are two fat pads whilst there are three fat pads in the lower orbital area, referred to as the temporal, middle and nasal pockets.

Meanwhile, your eyelid crease is formed from extensions of the levator aponeurosis tendon. The capsulopalpebral fascia is a set of small muscles and tendons that make small movements to your lower eyelids possible whilst the deepest muscle of all within your eyelid is the Muller’s muscle. This is not touched during upper and lower eyelid surgery. Other important structures that tend to be involved in surgery on your upper and lower eyelid include the suborbicularis oculi which is a layer of fat at the lower end of your orbicularis muscle as well as another fat pad known as the malar fat pad which extends from below the base of the orbital bone towards your cheeks.

Why Do Your Eye Lids Begin to Sag?

Basically, a lot of this is determined by your genes and, if your parents suffer from sagging skin around your eyelids, you will be more likely to as well. However, the physiological effects of drooping eyelids, baggy pouches and a general sagging is due to the effect of aging on the face, exacerbated by the effects of gravity. As you age your eyelids begin to stretch as elasticity in the skin is lost, causing an overhang in the upper eyelids. Your skin is particularly thin around the area of your eyes so, as collagen begins to lose some of its natural fluids, wrinkles develop. As skin continues to thin more of the orbital fat is revealed, often making it look as if it has herniated through the protective support fascia even when it hasn’t.

As time progresses fat continues to be absorbed from the face, resulting in skin that increasingly sags. In fact, loss of fat from the face tends to be considered as one of the primary causes of sagging skin around the eyes.  As fat becomes absorbed and skin starts to stretch due to the aging collagen, the orbicularis muscle also gets stretched. This makes it thinner and more prone to stretching itself due to less strength in the muscle fibres. The whole result is the slow collapse of the support system around each of your eyes.

As if this wasn’t enough, your brow begins to lower due to the loss of elasticity in the frontalis muscle. This is the ultimate cause of the skin of your eyelid rolling over. There is a section in your face just slightly lower than you bottom eyelid. This is referred to as the tear trough. As the aging process continues all the soft tissue begins to gravitate through this small area as gravity exerts a force more powerful than the lost elasticity of muscle fibres, eventually allowing the bony orbital rim to be revealed around the eyes, a process known as skeletization. Another quite noticeable condition might be a mound of fluid around the lateral corners of your bottom eyelids. This is known as the malar mound. If often appears as a purple color and is often associated with a diet too high in salt.

Pre-Surgical Consultation

The idea of upper and lower eyelid surgery is to remove the fatty pads that have prolapsed through the orbital septum, as well as to remove the loose and saggy skin that gives a droopy impression prior to surgery. Pre-surgery consultation needs to take place with the surgeon or a member of the operating team. This includes a complete medical examination. The kind of questions your doctor will ask you will be whether you suffer, or have suffered from any chronic illnesses such as kidney disease, diabetes, congestive heart failure or thyroid disease as any one of these could have a potential effect on the tissues around your eyes.

If everything is in order and you are declared fit for surgery you will usually be given an operation date within 2-4 weeks. You will be advised to make sure you get plenty of sleep so you feel fresh and fit for your operation.

What the Surgery Involves

If you are intending to travel abroad to have this surgery carried out you need to ensure you are prepared to allocate at least 10-14 days for the surgery to be completed successfully. This includes the initial consultation, any imaging or tests necessary, the operation and immediate post-operative period and the start of your period of recuperation, including having your stitches removed. The surgeon is careful to ensure that the scar is well concealed amongst natural eyelid folds.  Any loose skin and prolapsed fat will have been removed and you will begin to look and feel better as soon as the bruising and initial swelling subsides.

The operation for both upper and lower eyelid surgery can usually take up to three hours. During upper eyelid surgery the incision is made along the line of the natural eye crease while the incision for the lower eyelid is just below the eyelashes. If you are just having excess fat removed beneath your lower eyelids, without skin removal, the surgeon will often carry out a transconjunctival blepharoplasty, where an incision is made, the fat is removed and the incision is closed with tiny sutures. Overall, this is a minor operation that is habitually done under local anesthetic, although an intravenous line is usually inserted to provide you with sufficient sedation so that you are completely relaxed during surgery.

Once surgery is formally finished you will have your eyes lubricated with an ointment containing an antibiotic to prevent infection. Once your anesthetic wears off you might find your eyes feel sticky from the eye ointment will be sore and rather blurry, although the actual suture line will remain numb. Your eyes will be sensitive to light and, for around 10 days following your operation, your eye area may be swollen and bruised.

What to Expect During Recovery

You should hardly notice the incision after about two to three months, although it may remain pink for quite a few months. Any stitches are usually removed by about the 5th day and, by the 10th day you are usually ready to resume your normal lifestyle.  Your eyes will be very sensitive for some weeks so make sure you protect your eyes with some good UV sunglasses. If you wear contact lenses, you will need to leave them out for a few weeks until your recovery has progressed enough that it is safe and comfortable enough for you to re-insert them.

Risks Associated with Surgery

There are very few risks associated with upper and lower eyelid surgery, apart from the risk of infection. However, patients sometimes report dry eyes and double vision during recovery and, very rarely, delay in wound healing.

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