These tissues include skin, muscle and fat, all of which undergo changes with aging and in some disease processes.
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.
The results of these changes produce the cosmetic concerns many have regarding the eyelid region, the most common of which include:
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.
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.
Pre-op upper blepharoplasty (front view)
Post-op upper blepharoplasty (front view)
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.
Pre-op upper blepharoplasty (oblique view)
Post-op upper blepharoplasty (oblique view)
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.
This procedure goes by a number of names but the term "double eyelid" is often used by the patient and refers to eyelid skin being seen above and below a crease. The surgery involves the creation of a skin crease in the upper lid in patients with a particularly low or absent skin crease. Attention needs to be paid to the significant differences in the Asian and Caucasian eyelids, as well as variations within Asian races.
Patient born with left skin crease but absent right crease
Following right upper lid skin crease reformation
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.
Lower lid fat prolapse
Lid following fat removal
The current approach to lower blepharoplasty therefore is to assess whether to remove, reposition or replace tissue (refer below).
Fat prolapse and obvious tear trough
Appearance after reposition of fat pad
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.
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.
In the lower lid, any laxity should also be addressed, particularly where skin is removed in an effort to prevent post operative eyelid malposition.
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.
Upper lids would benefit from blepharoplasty combined with ptosis repairs
Is lid surgery covered by medical insurance?
Most insurance policies exclude 'cosmetic surgery' as a rule but will accept the costs if there is a functional reason for the surgery (i.e. improving the field of vision) or if the problem is caused by a medical condition such as thyroid eye disease. Surgery for eyelid malpositions such as ptosis or ectropion is not considered cosmetic and is covered by medical insurance.
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.
Can lid surgery be performed with laser?
In some patients wanting lower lid blepharoplasty, laser resurfacing may be the preferred technique. In upper lid blepharoplasty, skin is excised and the laser does not have significant advantages over other methods used to cut tissue or diathermy vessels.
Can it affect my eyes?
There have been reported cases of loss of vision with lower lid blepharoplasty although this is very rare and is estimated at only one per forty thousand cases. This exceedingly rare complication should be avoidable with careful surgery and appropriate post-operative care. More commonly there is some transient blurring after surgery from a mild alteration to the blink and tear film.
How long is the recovery period after surgery?
The surgery can be performed under local or general anaesthesia (more commonly local) and post-operatively the eyelids will take one to two weeks to settle. Bruising and swelling is minimised by firm patching initially and the regular use of ice pads for 48 to 72 hours after the surgery.
Auckland Eye - New Zealand Centre of Excellence for Eye Care