COSMETIC EYELID

Blepharoplasty surgery involves the removal or redistribution of eyelid tissue. These tissues include skin, muscle and fat, all of which undergo changes with aging and in some disease processes.

AGE CHANGES IN THE EYELIDS

With aging, the skin loses its natural elasticity. This, combined with the effects of gravity, tends to cause ‘drooping’ of the eyebrows and the appearance of redundant skin in the upper and lower eyelids. Muscles around the eye may also become thickened (hypertrophic), particularly in smokers.

In addition, many people lose fat around the eye (atrophy), resulting in a sunken appearance. The connective tissue layers in the eyelids may thin out, causing fat to move downwards and form ‘bags’ under the eyes. Loss of elasticity and subcutaneous fat often leads to an increase in wrinkle formation (rhytid) and permanent lines such as frown lines.

COMMON REASONS FOR EYELID SURGERY

The results of these changes produce the cosmetic concerns many have regarding the eyelid region, the most common of which include:

• overhang of upper lid skin

• puffy looking eyelids

• the appearance of ‘bags’ in the lower lids

• hollowing associated with the ‘tear trough’

• ‘dark circles’ around the eyes

Most of these concerns can be addressed by surgical or non-surgical means. The ‘dark circles’ are more problematic as they relate to the specific anatomy of the lower eyelid skin which is devoid of sub- cutaneous fat and therefore allows colour changes from the underlying vascularity to show through very easily. There is no useful surgical treatment for this issue.

SURGICAL EYELID TREATMENTS

UPPER BLEPHAROPLASTY

Upper eyelid surgery is often recommended for functional or cosmetic reasons or a combination of the two. Brow surgery may also be recommended, although this is far less commonly indicated. Most medical insurance companies will cover upper blepharoplasty surgery if the conditions for functional visual impairment are met.

Generally, surgery involves excision of some redundant skin, underlying muscle and if necessary, excess fat. The skin crease is an important structure in the upper lid as this determines the position of the fold which drapes the upper lid.

The skin crease is typically higher in women than men and lower or absent in most oriental races. Loss of the skin crease can contribute to the overhang of skin and often reformation of the crease is indicated during blepharoplasty surgery.

Upper blepharoplasty is the most common cosmetic surgical eyelid procedure performed. There is a very high satisfaction rate amongst patients and it should achieve a significant cosmetic improvement in the upper lids while still maintaining a natural appearance.

LOWER BLEPHAROPLASTY

This surgery involves removal of skin and removal or redistribution of fat. There has been a move away from skin excision in recent years as this is more likely to result in lower lid retraction or ectropion formation. Another trend has been towards reducing the removal of fat in the lower lid, as this can skeletonise the face, ultimately hastening the aging process.

A prominent hollowing (termed the “tear trough”) can occur at the junction of the lower lid and cheek, and this usually relates to a combination of loss of fat over the rim, fat prolapse above this and cheek descent. Fat may be redistributed into the tear trough to address this condition though more recently tissue fillers have been found to give very good improvement and now are often the treatment of choice.

The current approach to lower blepharoplasty is to assess whether to remove, reposition or replace tissue (refer below).

HOW LONG DOES THE SURGERY TAKE?

Bilateral upper or lower blepharoplasty generally takes only 60 to 90 minutes and the majority of cases are performed under local anaesthetic as an outpatient, although some patients choose intravenous sedation (or very occasionally a general anaesthetic).

WHAT IS INVOLVED?

In upper lid surgery the incision is made through the skin crease and following removal of excess tissue, the resulting wound is sutured. These sutures are removed within five to seven days. In lower lid surgery the incision is made just below the lashes if skin is excised, but in cases where only fat is removed, the incision is made from inside the lid through the conjunctiva. These sutures dissolve without the need for removal.

HOW SOON WILL IT HEAL?

Following surgery, your eyes needn’t be padded, but it is recommended that you apply ice masks regularly to help reduce bruising. Swelling and bruising can vary and while it will generally settle within two weeks of surgery, in some cases it may take longer. Due to gravity, the swelling and bruising will often appear in the lower lids or cheeks even with upper eyelid surgery.

POTENTIAL COMPLICATIONS

With well-performed surgery, these procedures rarely have significant complications. The eyelash region may be numb for a number of weeks following division of the fine sensory nerves, but with time this returns to normal. Significant scarring is unusual around the lids because of the fine skin and excellent blood supply in the area.

Patients are often aware of an altered blink following surgery, which may affect the tear film and impact on the vision a little, although this is generally only present for the first couple of weeks after the procedure. Loss of vision has been reported in rare cases (particularly with lower blepharoplasty) and this has a 1:40,000 chance of occurring. By using meticulous technique, performing surgery under local anaesthetic and avoiding post operative padding, this complication is further reduced.

ASSOCIATED CONDITIONS

Ptosis

Some patients may have pre-existing ptosis (low eyelid position) of their upper lids, and this should be corrected at the time of blepharoplasty surgery.

Lid laxity

In the lower lid, any laxity should also below addressed, particularly where skin is removed in an effort to prevent post operative eyelid malposition.

NON-SURGICAL TREATMENTS

Botox® and fillers

Recently there has been increased awareness of the benefits of less invasive, non-surgical treatments such as Botox® and dermal fillers for some cosmetic eyelid conditions. Many patients prefer these non-surgical options as ones face changes over time and treatments can be tailored to match these changes.

Botox (botulinum toxin) is a natural purified protein and has been used successfully in many millions of cases with a very high safety profile. Botox® has been used in the eyelids for functional problems over the past 25 years and more recently for cosmetic reasons.

Dermal tissue fillers

Dermal fillers such as Restylane® are made from a substance which occurs naturally in the body’s joint spaces called Hyaluronic Acid. It is gradually resorbed after injection but can often last for nine to eighteen months.

Fillers are in many cases the treatment of choice for lower lid fat prolapse particularly in the presence of a prominent ‘tear trough’. The case below demonstrates this as the lids were treated non-surgically with dermal fillers only.

WRINKLES

Ptosis

Lines and wrinkles around the eye are most effectively treated with non-surgical procedures. Botox® is best used in the treatment of dynamic lines (those lines produced with facial expression). Used properly, it softens the lines and helps maintain a natural appearance with facial movement. Static lines are present permanently (although they can worsen with use of the facial muscles) and are largely unaffected by Botox® injections. If these lines are deep, the injection of tissue fillers can give a nice improvement.

SUMMARY

Ptosis

The issues involved in cosmetic eyelid procedures are complex and this is a very specialised area to deal with, particularly when surgery can affect the comfort or function of the eye. Treatments may be surgical or non-surgical and the variations in anatomy of different genders and races need consideration, as do the changes naturally occurring with aging. The variety of treatments now available means most areas of concern can be appropriately managed with a high degree of patient satisfaction.