Blepharoplasty FAQs

One of the early changes in facial ageing can be attributed to softening of the contours of the eyelid skin and bulging of fat pockets above and below the eyes. With droopy eyelids or bulging pockets, the face may project an inappropriate look of fatigue and lack of vigor despite adequate rest and good health, frequently friends and relatives may comment on how patient looks tired.

What are some of the symptoms of blepharoplasty. “I can’t put my make up on like I used to without it getting all over the place”
Early symptoms of blepharoplasty may include a variety of features including the loss of the upper eyelid show, hooding and puffiness. This may be apparent with difficulty in putting make up on the upper eyelid and this is one of the most commonest features patients describe.

With the upper eyelid as a result of ageing of the soft tissues there can be an unnecessary amount of upper eyelid skin present, the skin that may hang over the eyelashes can with time cause a loss of peripheral vision. A cosmetic effect of the excess skin is it can reduce the youthful appearance of the eye by decreasing the amount of visible upper eyelid, this is referred to as a reduction in tarsal show or dermatochalasis. With time the fold of skin may cover the upper aspect of the visual field is most commonly affected by this condition and may cause difficulty with activities such as driving or reading. Fat pockets in the lower eyelid may bulge forwards and blepharoplasty is required to improve the puffy lower eyelid appearance and may be used to reduce wrinkling of the skin.

Many plastic surgeons perform blepharoplasty in the same or similar manner for all patients. An analogy for this would be like visiting a hairstylist who who can only cuts everyone’s hair in the same way. To achieve natural looking rejuvenation that does not look like a patient has surgery does require an artistic interpretation by the surgeon and a customised approach for each patient individually.

Dr De Silva asks patients to bring old photographs of their appearance, this can be used as a template for the procedure. Often the best results require a combination of blepharoplasty, fat transfer, skin resurfacing and regenerative medicine.

Blepharoplasty will not correct changes in the skin quality including pigmentation, discolouration or wrinkles. The procedure may be couples with skin resurfacing techniques including peels or laser that will improve the skin quality. The dynamic lines that are seen at the corner of the eyes often termed crows feet, are a consequence of the orbicularis oculi muscle that underlines the skin. These wrinkles are not affected by blepharoplasty and are best treated with anti-wrinkle injections treatments.

The position of the brow is a very important consideration in eyelid surgery. Some patients with low brows may require a brow lift procedure to get the best results. Without this a person’s expression can look like they are frowning. Dr De Silva discusses this in detail with his patients, to get the best results the eyelids and brow have to be considered at the same time

Festoons and malar bags (Swelling in the upper area of the cheek) requires careful planning preoperatively. This swelling can be challenging to treat and requires specialised techniques to release anatomical tendons, and a discussion regarding expectations from improvement.

There are medical conditions that can effect eyelid surgery that should be considered prior to surgery to ensure the best blepharoplasty results and minimise recovery and complications.

Thyroid problems, such as hypothyroidism or Graves’ disease can give more swelling during the recovery period. This should be stable for a period of 6 months ore more before considering surgery.

Lower eyelids that droop significantly and reveal the white beneath the iris (the eye’s coloured portion). This may require tightening of the eyelid (termed canthoplasty) and a combination of fat transfer with graft material to support the lower eyelid/

Eye problems, such as “dry eye,” a detached retina or glaucoma, these do not preclude blepharoplasty, however caution is required with the surgery. Dr De Silva has helped patients with severe dry eyes however this does mean additional measures to ensure that the eyes are well lubricated after surgery.

High blood pressure or other circulatory disorders, this is important to assess and control prior to surgery.

Cardiovascular health should be stable for a period of 6 months or more

Diabetes should have a well controlled sugar level

Use of anticoagulants (blood thinners) needs to be assessed and in many patients requires stopping for a short period around the time of surgery.

Festoons and malar bags (Swelling in the upper area of the cheek) requires careful planning preoperatively. This swelling can be challenging to treat and requires specialised techniques to release anatomical tendons, and a discussion regarding expectations from improvement.

Safety is of key importance when considering an aesthetic procedure. Depending upon medical history and age, there are certain medical and laboratory tests that may need to be ordered prior to blepharoplasty. An ECG/EKG or heart tracing will need to be performed on men 45 and over and women 55 and over as a routine screening. Other blood work may need to be performed depending upon individual health history. Women of childbearing age should undergo a pregnancy test the week prior to the surgery to make sure that they are not pregnant at the same time as undergoing blepharoplasty.

Smoking has a negative impact on surgery by delaying healing and may lead to unsatisfactory results. If you are a smoker you are advised to stop smoking or at least to cut down on cigarettes for at least one week before surgery. Smoking slows down the recovery process and it can also increase the risk of complications.

Vaping has less scientific data around its use around surgery. Removing nicotine from vaping products is preferred as this is a potent vasoconstrictor which also may impact healing and recovery.

It is important to avoid any medications that thin the blood and encourage bleeding before surgery, these include: aspirin, ibuprofen, vitamin E, and any type of herbal supplements. This includes stopping all vitamins and herbal supplements two weeks prior to surgery.

Some herbal medicines can also thin the blood, such as St John’s warts, fish oils, Dr De Silva provides his patients with comprehensive information prior to surgery, to ensure that these herbal medicines are discontinued for a short period. This is important to minimise bruising and swelling during the recovery period and ensure a fast recovery after blepharoplasty.

It is also important that the blepharoplasty patient arrange for a caretaker for the first 24 hours after their surgery. Patients need a responsible caretaker to be with them for the first night. Patients are not allowed to drive themselves or take public transportation alone to home because of the effects of the anaesthesia. The Seattle Eyelid and Blepharoplasty Centre surgery staff will ask for the caretaker’s name and contact information as well as who will be taking the patient home from the recovery room at the Blepharoplasty Surgery Centre.

Blepharoplasty is routinely performed under local anaesthesia and may include the use of sedation (oral or intravenous), also called MAC (Monitored anaesthesia care ) or “twilight anaesthesia”. Compared to general anaesthesia, local anaesthesia with sedation is associated with less bleeding, increased safety and faster recovery.

Upper eyelid blepharoplasty is completed through a fine incision in the upper eyelid skin crease, this makes the scar barely visible even as early as 1 week after the surgery. In lower eyelid blepharoplasty the incisions can be made through the skin or through the conjunctiva (a hidden incision through the inner aspect of the lower eyelid) or both approaches concurrently. The advantage of the transconjunctival incision (through the conjunctiva) is the incision cannot be seen after the surgery which may reduce postoperative swelling, bruising or lower lid retraction. The advantages of the incision through the lower eyelid skin is that it may be required if there is excess skin to prevent excessive wrinkling or rolling of the skin. The technique used is often based on a mixture of clinical signs and surgeon’s preference of technique. The concept of laser blepharoplasty has been the use of a laser to cut-through tissues in place of the traditional steel blade. There is a degree marketing hype that surrounds the use of laser technology in a number of medical fields, and there is a lack of validated medical studies showing advantages of the laser blepharoplasty.

Video on how an upper blepharoplasty is completed?

The eye sits in a bone socket of the skull termed the orbit, the orbital fat cushions the eye from the bone walls of the orbit. The bulges in the upper and lower eyelid are caused by prolapsing of the orbital fat. The volume of fat is very small and is less than 5cc in volume. The only method of removing this fat at present is through blepharoplasty surgery. There is no evidence at present that medical treatments with creams or injections are able to reduce the volume of bulging eyelid fat.

There is initial swelling and bruising that occurs after the procedure takes about 1 to 2 weeks to resolve. With the use of ice packs (bag of peas in a zipper container) every hour while awake for the first three days, there is a reduction in the amount of postoperative swelling. Usually the patient may return to normal non-strenuous activities 1 week after the procedure and by 2 weeks the eyelids are on average 90% improved. The best result is usually seen several weeks to months later.

Blepharoplasty is an operation that can reinvigorate an ageing face by the removal of excess skin and fat bulges. On the other hand, if excess skin or fat is removed from the eyelids, this can result in a hollowed or tight appearance, the whole face will appear aged and unnatural, this can be difficult to correct. Although a hollowed-out appearance of the upper eyelid was fashionable a decade ago, the long term appearance is unsatisfactory and modern day surgery plays emphasis in avoiding such an appearance. The modern day philosophy in eyelid rejuvenation focuses on restoring natural and youthful characteristics by relying less on subtraction and more on restoration of volume, with the goal of looking like yourself, but younger. These techniques are termed fat preservation or fat translocation. Dr De Silva uses these techniques for some patients, however every person’s eyes are unique and for most natural results the surgery must be tailored to the individual.

The anatomy of the eyelid is unique and complex, it includes multiple layers of soft tissues to bone including unique skin, fat pockets, numerous muscles, tendons, a tarsal rigid plate and conjunctival lining that lubricates the surface of the eye. The skin of the eyelid is very thin and represents the thinnest skin in the body, enabling the rapid movement required for blinking. Underlying the skin is the orbicularis oculi muscle, this acts as a circular ring around the eye, closing the eye shut. Beneath the muscle is a fibrous layer termed the septum that separates the eyelid from the contents of the orbit (bone socket that the eyeball sits in). The orbital fat is the cause of fat bulges of the upper and lower eyelid as it prolapses through the fibrous septum so it may be seen at the skin surface. There are multiple variables in the eyelid anatomy that difference from person to person as a consequence of both genetic and environmental factors. Each blepharoplasty is tailored towards the needs of the patient and requires surgical interpretation and modification of technique.

Video on how an upper blepharoplasty is completed?

Most patients experience some bruising particularly of the lower eyelids that is gone within about 2 weeks.
Postoperative swelling peaks the day after surgery and mostly resolves over the next two weeks, a small amount may persist for several months or more.

After your surgical procedure, when you arrive home, we encourage you to relax keeping your head elevated on several pillows, at a 30-40 degree angle. For the next two weeks you should sleep on your back with your head elevated.

For the first 48-hours, you should use ice compresses over your eyes for approximately 15 minutes of every hour. This reduces swelling and aides in your comfort.

You may shower the day after your surgery and care should be taken to avoid the direct spray of water on your face. Baby shampoo is preferred because it is gentle on your eyes.

Avoid straining or any activity that causes a feeling of pressure in the face and eyes. Strenuous physical activity is dependent on the type of surgery and could be from 2-6 weeks. You should not be driving if you are still taking pain medicine or have any blurring of vision.

Eyeglasses can be worn after your surgery if you need them. Contact lenses can be used after a 2-week period. Sun exposure should be avoided as much as possible.

Most people are advised to take 1-2 weeks off work, however in most cases, normal tasks can be resumed within two days. Use of computer and internet can be even the same day. Exercise or any strenuous activity that may lead to an elevation in blood pressure are advised against for a minimum of 3 weeks as they will lead to an increase in swelling and delay in recovery. Many patients ask about using a computer and watching television. Eyelid surgery causes some blurring of the vision for several days as a consequence of eyedrops, ointment and swelling. Watching television or using a computer will not affect the healing process and can usually be resumed after several days. Measures can be taken with regenerative medicine to enhance recovery and reduce swelling and bruising.

Puffy eyelids have a similar ageing and negative appearance on a man as they do on a woman. More men are seeking blepharoplasty on a year-by-year basis.
In the competitive and youth-oriented world of business, both men and women have come to appreciate that in addition to being well-qualified for a particular job, their appearance remains a key component of success. 10-20% of Dr Julian De Silva’s patients are men. There are some well known plastic surgeons that do not complete male blepharoplasty, as this is more challenging than female blepharoplasty. Key is a natural improvement, using techniques that preserve masculinity and not feminisation.

The dark circles that may occur around the eyes may be a combination of ageing changes of the eyes and the resulting changes in eyelid contours in addition to actual pigmentation changes in the skin. Blepharoplasty may improve the appearance of dark circles around the eyes as a result of recontouring, however surgery does not result in a complete cure of dark circles. The treatment of dark circles often involves a multi-disciplined approach using both medical and surgical tools to reduce their appearance. A combination approach is key including the use of blepharoplasty, skin pinch, fat transfer, and regenerative medicine to give the best natural results.

There is interchangeable terminology here and it is worthwhile clarifying that eyelid hollowness is different to cheek hollowness (tear trough).
If the eyelids themselves have become hollowed due to previous blepharoplasty or ageing changes, the treatment often is challenging and high complex. The restoration of volume around the eyelids is fraught with technical challenges owing to the very thin characteristics of the skin, reinflation with volume may be performed by surgical or​_ non-surgical means. Volume restoration following hollowing requires individual evaluation as it will depend on multiple characteristics including severity, location, skin colour, thickness, and previous treatments. There are often a number of different treatments that can be utilised to improve the hollowed appearance. Dr De Silva frequently helps patients with revision blepharoplasty using a combination of fat transfer, implants and fillers to augment and improve patients’ results.

After your surgical procedure, when you arrive home, we encourage you to relax keeping your head elevated on several pillows, at a 30-40 degree angle. For the next two weeks you should sleep on your back with your head elevated.

For the first 48-hours, you should use ice compresses over your eyes for approximately 15 minutes of every hour. This reduces swelling and aides in your comfort.

You may shower the day after your surgery and care should be taken to avoid the direct spray of water on your face. Baby shampoo is preferred because it is gentle on your eyes.

Avoid straining or any activity that causes a feeling of pressure in the face and eyes. Strenuous physical activity is dependent on the type of surgery and could be from 2-6 weeks. You should not be driving if you are still taking pain medicine or have any blurring of vision.

Eyeglasses can be worn after your surgery if you need them. Contact lenses can be used after a 2-week period. Sun exposure should be avoided as much as possible.

This is an important symptom that should be known to the clinician before surgery. Blepharoplasty has a tendency to make the eyes drier and depending on the severity of the dry eyes, the surgical blepharoplasty technique should be modified accordingly. Patients with severe dry eyes would require a markedly conservative blepharoplasty to avoid a potential increase in symptoms of postoperative dry eyes. Dr De Silva uses a modified conservative blepharoplasty technique to help patients with dry eyes. Having worked in the field of ophthalmology at Moorfields Eye Hospital, he has developed techniques to preserve muscle function and blinking for dry eye patients.

Blepharoplasty like all cosmetic surgery is dependent on the technique and skills of the surgery. There are techniques that have been developed over the past 10 years that have placed emphasis on obtaining a natural result that avoids changing the appearance of the patient, and focuses on rejuvenation the eyelids looking them appear 10 or more years younger. The best way to evaluate a surgeons technique is by looking at photographs of their patients.

There is no surgery that can result in perfection, the nature of surgery that it is dependent on 3 principal factors: the patient (a combination of genetic and environmental factors), the surgeon and technique, and the healing process which differs from patient to patient. Generally speaking patients have a high degree of satisfaction after blepharoplasty, however those expecting perfection are likely to be disappointed.

Blepharoplasty is a long lasting surgery and generally lasts 8-10 years. Advanced surgical techniques such as the use of fat transfer and regenerative medicine can deliver longer lasting results. In some patients the results can be life long, however as there is so much individual variation in ageing this cannot be guaranteed. All of us will have further ageing with time and if you have blepharoplasty in your 30s to 40s, you will have further ageing with time that may require a tweak revision blepharoplasty in the future.

Blepharoplasty is conducted by a number of different subspecialties including oculoplastic surgeons, oculofacial plastic surgeons, facial plastic surgeons (ear, nose and throat surgeons), general plastic surgeons, oral and maxillofacial surgeons (dental surgeons) and dermatologists. The spectrum of surgeons will have different interests, technique and experience that will vary considerable. In the United States, it has been estimated that an average cosmetic or plastic surgeon performs less than one blepharoplasty per month, compared to oculoplastic surgeons who complete blepharoplasty for cosmetic and reconstructive indications between 10 to 20 cases per month. An oculoplastic or oculofacial surgeon is plastic surgeon who has specializes in the structures immediately around the eyes including the eyelids and blepharoplasty. A good way to evaluate a surgeon is to include a background check and assessing their postoperative photographs.

Cost is tailored to an individual patient needs based on the type of blepharoplasty whether it is combined with additional procedures. Is upper eyelid surgery, lower eyelid surgery or commonly both required simultaneously. Do additional techniques need to be used to enhance the results, these include volume augmentation, skin resurfacing and specialised eyelid contouring techniques. Also, prices differ depending on whether it is a revision or primary blepharoplasty, as revision blepharoplasty can be challenging technically. For an accurate assessment of price, a consultation is recommended. If you decide to have surgery, the consultation fee will be deducted from your surgical fee. Shopping for price may be counterproductive, a good long lasting result that is free of problems is the preferred outcome. Although cost is an important issue, the quality of your care and outcome is most crucial and low cost surgery is ill-advised as there will be compromises in safety and the quality of the result.

Blepharoplasty is most commonly a cosmetic procedure that is not covered by insurance or NHS. In severe cases where the blepharoplasty is severe and reducing a patients upper field of vision or is secondary to an underlying medical condition then health insurance may cover the cost of upper eyelid surgery.

Any medications that have a potential to thin the blood and increase bleeding should be avoided before surgery. These include avoiding aspirin, ibuprofen (and other anti-inflammatory medications) and vitamin E products for 2 weeks prior to and after surgery. You may take paracetamol or panadol if experiencing pain such as a headache. This is very important as if you take such medications your surgery may have to be postponed to another date as there is an increased risk of bleeding.

Relatively strenuous activity such as swimming, gym or other athletic activity should be avoided for 3 weeks. Sport that results in higher pressure and potential traumatic injury to the eyelids need to be avoided for two months, this includes diving and water skiing. After blepharoplasty contact sports should be avoided for a minimum of two months.

After blepharoplasty you may wear eye shadow or false eyelashes a minimum of ten days after surgery.

Asian blepharoplasty is defined as eyelid surgery that creates or re-defines an upper eyelid crease. On reading about asian blepharoplasty it may appear that there are many different ways in which the surgery can be completed. There are principally only two types of surgery, one is using sutures (that tends to be more temporary and requires repeating) and skin-incision (through the eyelid skin, which is long-lasting). There is also a third type that is a hybrid version of the suture and skin incision method (tends to be short lasting) However there are many different types of suture techniques that have been described, that are all variations on the same theme. Dr De Silva prefers to use the skin incision method as this leads to a natural appearance and long lasting result.

One week after surgery the majority of the swelling and bruising will have resolved. Approximately 80-90% of the swelling resolves over this period. There are steps that you can take to speed up the recovery process including applying cold compresses in the first three days after surgery, sleeping with your head elevation and remaining relatively sedentary avoiding exercise over at least the first week.

You can wash from the day after surgery, the eyelids will be stitched together, however avoid rubbing or scrubbing the eyelids as this will encourage swelling and may lead to mild bleeding. Any crusting on the eyelids can be cleaned with water and cotton buds or eye pad. Avoid using a hand towel or flannel to clean the eyelids as this may not be adequately clean for the healing eyelids.

Healing after surgery includes a process of inflammation, this process attracts cells and other healing agents to the area of surgery that leads to repair of the soft tissues and the healing process. As a consequence of inflammation, the eyelid swells, this can be variable and unique to each person. In general the inflammation and swelling gets worse for three days before improving on the forth day, for some people the time course is shorter. There are steps that you can take to reduce swelling and speed up the recover period, including the use of cold compresses on the eyelids after surgery and sleeping with your head elevated.

Sedation is also known as “twilight anaesthesia” or MAC (Monitored anaesthesia care). Twilight anaesthesia means that your body is sleepy and relaxed, you are still conscious and able to respond to questions and instructions. Unlike general anaesthesia where you are unconscious and the recovery after surgery is longer. Typically you won’t remember the procedure or the short period of time following it, though you will feel a little euphoric. Most of our patients have eyelid surgery under local anaesthesia with or without sedation.The benefits of sedation are that it relieves your anxiety around surgery and the recovery after surgery is faster.

Video showing patient experience with sedation anaesthesia for blepahroplasty

With upper eyelid surgery, the stitches are generally removed one week after surgery. Dr De Silva uses very fine non-absorbable stitches that are removed one week after surgery, these stitches cause minimal irritation and scarring. Dissolvable stitches can also be used which fall out themselves, they can cause more irritation. Fibrin tissue glue can be used in place of the stitches, so there are no stitches that need to be removed.

Stitch removal causes minimal irritation and discomfort, caused by gentle pulling of the stitches in order to remove the stitches. No numbing creams or anaesthesia are required for the removal of stitches.

Eyelid fat that bulges forward in the lower eyelids with facial ageing, is orbital fat that functions to cushion the eyeball, both supporting and protecting the eyeball from the bone skull. This fat differs from body fat and does not change with weight loss. Unlike other facial cosmetic surgeries including neck lift and facelift surgery, losing weight will not have an effect on bags around the eyelids. Exercising and weight loss do have a positive effect on health and well being, as well as a positive effect on healing and improving recovery after surgery.

Immediately after surgery it is very common that the eyes do not close completely as there is swelling, the eyelids are impaired by local anaesthesia and this impairs closure of the eyes. Over the first 6-weeks, it is common that the eyes may be slightly open as they will not be blinking 100% as a consequence of swelling and the surgery. After this the blinking and closure of the eyes will return resulting in normal eyelid closure. If the eyes are not closing your surgeon may advise the use of tear lubricants to avoid symptoms of dryness and exposure. The front surface of the eye is very sensitive and dryness can be uncomfortable.

Surgical technique with upper blepharoplasty is important to avoid too much soft tissue being removed, this can result in difficulty closing the eyelids long-term and can be difficult to correct. Dr De Silva takes great care with measurements of the eyelids prior to surgery to prevent this occurrence.

Generally speaking, difficult closing the eye is common soon after the surgery and with normal healing this returns over a period of weeks, tear lubricant drops may be required during this period.

The eyes are key feature that communication and facial ageing with changes around the eyes can suggest tiredness or lack of sleep.

Common changes around the eyelids are loose skin, heaviness of soft tissues and the appearance of bags. These changes can be effectively rejuvenated with blepharoplasty or eyelift surgery as it is sometimes referred to.

The position of the eyebrows does change in position in some people however lifting the eyebrows can have dramatic effects and in some people change the person’s appearance. Although some people do have low brows often looking at old photographs, these individuals also had low brows in their youth. The brow can drop with time as a result of a group of depressor muscles that pull the brow down with facial expressions, frowning and shading the eyes from bright sunlight. In contrast only a single muscle called the frontalis elevated the brow with facial expression. These muscles are often treated with wrinkle injections to reduce forehead and glabellar lines and wrinkles. Winkle injections can result in drooping of the brow by impairing the frontails muscle that elevates the brow.

A youthful feminine brow is positioned above the level of the orbital rim, which is the upper margin of the bony socket in which the eye resides. An elegant female brow is gently arched laterally, with the “tail” of the brow going higher than the inner aspect near the nose. This is a generalization however and each individual woman can have highly variable positions of the brow including low set brows, depending on their genetics and ethnicity. Care is required in performing brow lifts in these patients as lifting a naturally occurring low brow can change a person’s appearance. In the past brow lift surgery was too common, we now know that many people have low brows in their youth and brow lifting is not necessary. With brow lifting a conservative approach is preferred by Dr De Silva as this gives a more natural looking result.

In a man, the position of the masculine brow is often lower at the boney margin of the orbital rim. Dr De Silva advises caution against lifting the brows in men as it can create a surprised and more feminine appearance. There is individual variation in the position of the brows that guides treatment.

Blepharoplasty is more commonly required to give a natural rejuvenation around the eyes and is required more commonly than brow lifting. Every person is unique and the degree of changes in their appearance must be evaluated individually. In addition other factors may be relevant to both blepharoplasty and brow lifting including dry eye, previous laser refractive surgery, exposure symptoms. Brow lifting should be considered in all cases as it may be difficult to complete after upper blepharoplasty.

The eyelid scars can be well hidden with blepharoplasty, the upper and lower eyelids should be considered separately.

With Upper Blepharoplasty the incision can be hidden in the natural skin crease, which means although there is a scar after surgery. The scar is virtually invisible as it is hidden in this natural skin crease. Care is required with the surgical technique in position the skin crease as a person’s eyes and facial appearance can be changed if attention is taken to the detail of the upper eyelid. Dr De Silva has corrected the position of this scar when the scar has been placed by other surgeons without due care or attention, too high the scar becomes visible and unnatural. Closure of the skin with stitches also can effect the healing of the scar. Non-absorbable stitches that require removal are generally preferred as these cause minimal irritation of the skin surfaces and minimise scarring. After the surgery, like all scars anywhere in the body, the scar can initially be thicker in texture and occasionally have small bumps. With time the fibres remodel and the scar thins over a period of months, massage of the scar may aid this process. In most people after 12-months the scar in the upper eyelid is barely visible.

Some individuals may have a medical condition that causes increased scarring, termed Keloid scarring. If you have a keloid scarring you should inform you surgeon. The skin around the eyes is relatively unique as the thinnest skin in the entire body, this appears to offer protection against keloid scarring in the eyelid area.

In lower eyelid surgery, the Lower Blepharoplasty can be completed through the skin (trans-cutaneous) or the inside lining of the eyelid (trans-conjunctival). Dr De Silva’s preference is the trans-conjunctival blepharoplasty which avoids any scars in the lower eyelid as the surgery is all on the inside of the lower eyelid. The trans-conjunctival technique is a newer technique and some surgeons may not offer this technique. Some surgeons’ prefer the older skin incision technique (trans-cutaneous blepharoplasty), although technically more straightforward, it always leaves a scar in the skin. The scar can be seen immediately below the eyelashes in the lower eyelid. After months the scar does fade, particularly in Caucasians, however can not be made invisible unlike with the trans-conjunctival approach.

Overall, modern surgical techniques can make scarring after blepharoplasty very difficult to be seen.

Video on: How to avoid terrible blepharoplasty/ eyelid scars. How to get the very best scars…

Trans-Conjunctival blepharoplasty is the more modern surgical technique for lower eyelid surgery/ blepharoplasty. The technique avoids a visible incision, as the surgery is performed from the inside of the eyelid. The older surgical technique is termed transcutaneous lower eyelid surgery/ blepharoplasty involves making a surgical incision in the lower eyelid. The older technique results in a scar in the lower eyelid skin and has a risk of lowering the lower eyelid resulting in lower lid retraction or rounding of the lower eyelid. The transconjunctival technique accesses the lower eyelid from the inside of the eyelid, leaving important anatomy (including the skin, orbicularis oculi muscle and orbital septum in tact), the technique is more challenging to perform however avoid a scar and is safer.

There is a degree of artistry in lower blepharoplasty, key to the surgical technique is removing the optimal amount of fat, if too much is removed it results in a hollowed out appearance to the lower eyelid, too little fat results in remaining fat bulge. Dr De Silva is conservative and preserves as much of the orbital fat as feasible with a technique termed fat translocation.

Blepharoplasty Animation – How is Lower Blepharoplasty/ Eyelid Surgery completed?

After eyelid surgery there is a period of recovery with which it is best to leave the contact lenses out to enable healing of the eyelids and avoid unnecessary stretching of they eyelids when the tissues are healing. For upper eyelid surgery it is best to wait 1-week before using your contact lenses. For lower eyelid surgery it is best to wait 2-weeks before using your contact lenses. A further consideration is that with blepharoplasty the tear production may be effected and the eyes may feel more tired for a few weeks after surgery and it may be more comfortable to reduce contact lens wear to 6-8 hours for the first few weeks.

Increased droopiness of the upper eyelids is a common change with increasing age and frequently is a result of ageing of the eyelids and increased laxity in the soft tissues.

Non-surgical treatment options for droopiness of the upper eyelids include lifestyle changes (healthy sleep, reduced stress), the use of wrinkle injections in the forehead area, limited skin tightening with radiofrequency or laser resurfacing. However non-surgical options are usually of only modest effect with a short and limited improvement, and only a surgical correction will improve the appearance after the changes are more readily apparent.

Assessment of the eyelids is important to exclude other factors that may be influencing the position of the upper eyelids including ptosis, dry eyes, thyroid eye disease. Ptosis is a condition where the fine muscle that elevated the eyelid has become weak or detached and this requires a ptosis correction surgery to improve. Dry eyes and patients who have undergone previous laser refractive surgery should have an evaluation to exclude dry eyes before considering upper eyelid surgery.

Upper blepharoplasty, also known as eyelid lift surgery, helps improve the shape of the eyelids by rejuvenating their appearance. Most changes in the upper eyelids and lower eyelids are a consequence of facial ageing, however some changes are related to both genetics and the environment (e.g. sun damage and smoking). Blepharoplasty in the upper eyelid involves trimming of excess skin and shaping of the underling soft tissues including the orbicularis oculi muscle and orbital fat. The non-surgical treatment options are of limited effect in improving droopy upper eyelids, a meticulous assessment and treatment of underlying cause is the most effective treatment.

The surgical technique conventionally uses a scalpel to remove skin and soft tissues and additional instruments to reduce bleeding and swelling. Laser blepharoplasty technique a new technique that uses laser to remove skin and shape soft tissues, it has the benefit of as it cuts it immediately stops bleeding thus offer patients benefit of less bruising and swelling after surgery. Many surgeons do not have access to such a laser and are not able to offer laser blepharoplasty to their patients. Dr De Silva utilises both laser blepharoplasty and conventional scalpel surgery, blepharoplasty is a delicate surgery and should be tailored to the individual dependent on your individual eyelid changes and facial ageing.

Blepharoplasty, helps improve the shape of the eyelids by rejuvenating their appearance. Immediately after blepharoplasty surgery the eyes may feel dry as a consequence of swelling and reduced blinking.

Laser refractive surgery improves the refractive properties of the eyes, and involves making a flap in the front window (termed cornea) in the eye, followed by laser treatment, the surgery often results in some dryness immediately after the surgery and contact lenses are often placed over the eyes to aid recovery in the short-term period.

Although blepharoplasty is surgery on the eyelid only and there is no surgery on the eye itself, both the different techniques can lead to dryness immediately after the procedure. It is recommended that they are not completed on the same day and a minimum of 6 weeks to 3 months interval between the different procedures.

Upper and Lower Blepharoplasty can be completed at the same time or separately.

There are some advantages to completing the surgery at the same time, the recovery is generally 1-2 weeks for both surgeries, hence the recovery time is doubled if the procedures are completed separately. In addition there is saving in cost as returning to surgery for a second time does result in an increased use of resources.

Dr De Silva finds that some of his patients prefer to have both surgeries completed at the same time and others prefer to have a shorter procedure first and having gained confidence in the results have the other eyelids as a second procedure. The decision to have the procedures at the same time or separately is a personal preference and will not affect the final result of the blepharoplasty.

Having a small lump on the eyelid incision after blepharoplasty is relatively common. Often a small lump soon after surgery may be healing scar tissue which will improve with time, if however it continues to enlarge in size and has a shape like a small ball it is likely to be a cyst. In the skin there are small glands that if become trapped can produce a small cyst, they are not serious and have no long-term implications. It is not known why some people are more prone to cysts it is however likely to be partly genetics and skin type. A small cyst may spontaneously resolve, if increasing in size it may be necessary to complete a small procedure to remove the lesion. The procedure to remove a cyst usually takes less than 5-minutes with local anaesthesia.

Why does an Eyelid Lump or Cyst occur after Blepharoplasty? How can an eyelid cyst be treated?

When considering having further eyelid surgery it is key to wait sufficient time until healing is complete from the previous surgery which may taken 6 to 12 months. The timing of revision surgery does depend on the indication for revision blepharoplasty and underlying symptoms. Dr De Silva performs revision upper blepharoplasty and lower blepharoplasty on patient’s who have undergone surgery abroad and by other surgeons, patience is recommended, swelling is often present for months after surgery and early intervention may be less predictable. In specific situations such as eyelid retraction with dryness and symptoms of ocular irritation Dr De Silva advises urgent surgery to avoid injury to the person’s vision.

With upper blepharoplasty, artistry is required with the surgical technique to hide the scars in the natural creases of the upper eyelid. If there is marked laxity in the skin towards the outside of the eye, the natural lines (termed crows feet) can be aesthetically used to hide the incision. Often there are eyelid asymmetries and changes in the position of a person’s skin crease that occur with facial ageing that need to be taken into consideration to give a final natural looking result. The final result of a scar is 12-18 months after surgery and with careful planning and consideration should result in a fine line that is hidden in a person’s natural skin crease. Dr De Silva has revised scars of patients who have undergone surgery elsewhere to improve symmetry and hide the skin incisions in a natural eyelid crease.

Although fat bulging of the upper and lower eyelids is usually seen as one of the characteristics of an ageing face. There are a smaller proportion of patients who have a genetic predisposition to eyelid ageing where fat bulges may be present in late teenage and early twenties. The treatment of lower eyelid bags in young adults with negative vector requires specific techniques to support the lower eyelid after blepharoplasty, this is essential to avoid lower eyelid retraction. Support of the lower eyelid ensures a good shaped to the lower eyelid after surgery, some patients may require additional techniques for the best result including lower eyelid volume augmentation including fillers and cheek implants. Dr De Silva has had patients travel long distances for opinions for lower eyelid bags, who have been refused surgery by local surgeons. Please note lower blepharoplasty is not always indicated if you have very early signs of lower eyelid bags.

Puffy lower eyelids in Young People is a consequence of anatomy and negative vector, taken from a book chapter written by Dr De Silva on Lower Blepharoplasty Technique

Dark circles around the eyes are caused by multiple factors, commonly including a combination of loss of volume (fat loss resulting in a depression and shadow under the eyes), very thin skin (thinnest in the body, with fine blood vessels under the skin) ethnic pigmentation under the skin and skin laxity and wrinkles under the skin.
As a consequence of the dark circles being caused by multiple factors, each of these factors needs to be addressed with treatment. The combination of treatments may include non-surgical treatments including volume augmentation of the tear trough depression. These are non-surgical and does not require general anaesthesia or surgical intervention, with a rapid recovery of less than one week. During the recovery, there maybe mild bruising and some swelling in the lower eyelid.
For some patients there may have additional changes in the lower eyelid including fat bags and/ or malar oedema, skin laxity. These additional changes may require eyelid surgery (blepharoplasty) to correct.
Unfortunately there is no cream that used in isolation is effectively going to improve dark circles on their own, however in some patients a combination of specific eye depigmentation creams may be used with non-surgical or surgical treatments to enhance the results.
As a general principle dark circles can be substantially improved with a customised approach to treatment of the dark circles. There is not a single treatment that offers a silver bullet, and most treatments will be effective in offering an improvement, as opposed to a cure.

The length of a blepharoplasty or eyelid procedure will depend on the complexity of the surgery. On average an upper blepharoplasty will take from 1 to 2 hours, less than 30-45 minutes is a short length of time. There is a great deal of individual variation in eyelids and good surgery requires a meticulous attention to detail including measurements and time. It is important that your surgeon takes adequate time to complete the surgery cautiously and without rushing. Combined upper and lower blepharoplasty takes on average 2 and half hours. The other consideration is type of anaesthesia as local anaesthesia generally requires a slightly longer surgery, as further anaesthesia is added during the surgery which can take additional time.
Dr De Silva allows a minimum of 2-hours for most eyelid procedures and allows additional time to ensure the best possible result. For more complex blepharoplasty including laser resurfacing and combination treatments including fat transfer and canthopexy additional time may be required up to 3-hours. Dr De Silva generally limits blepharoplasty to 4-hours as after this time there can be increased swelling that can effect the appearance of eyelids.

In most people discomfort and pain after rhinoplasty settles 24-48 hours after the surgery. In a minority of patients may find some sensitivity and discomfort for several weeks. In some patient the eyes can be dry for a period of weeks, the eyes can be very sensitive to dryness and feel uncomfortable or even painful, tear lubricants are useful to help reduce these feelings during the recovery period. There can be a wide variation in individual patient’s threshold for pain, most patients report only mild or minimal discomfort.

With the techniques Dr De Silva uses, most patients describe surprisingly little pain, and usually for less than 24-48 hours. Oral analgesia is adequate for a couple of days after surgery, and many of my patients never take any analgesia.

Video Blepharoplasty experience of patient in his 80s: https://youtu.be/_RHRx7pqaoo

 There is no specific age limit for blepharoplasty. Often pages in their 70s and 80s can have much loose skin, puffiness from fat prolapse and dark circles under their eyes. Key to a successful blepharoplasty is your general health and fitness. If you have any underlying medical conditions such as high blood pressure, then it is important that this is checked and controlled with appropriate medication. An assessment of your general medical health and your specific eyelids are important to ensure safety, as a guide for surgical planning and for a good result. Often there may be additional factors to consider with increasing age, these can include dry eyes, eyelid laxity and droopy eyelids (termed ptosis), these may require additional treatments at the same time as blepharoplasty to ensure a successful result. Choice of anaesthesia is also important, local anaesthesia or twilight anaesthesia is less invasive than traditional general anaesthesia (GA) and avoids the risks associated with GA.

Dr De Silva has completed customised blepharoplasty for many patients in the 70s and 80s and does not believe that age itself is an issue for having blepharoplasty. Safety is the no1. factor for every patient and once this is confirmed, then blepharoplasty can be a helpful way of rejuvenating a natural youthful appearance.