Aesthetic Surgery
There are many elements to aesthetic eyelid surgery, and very many different treatment options. It is most important is to have a clear idea of what you would like to achieve and to find someone who can discuss the options with you.
As we age our face loses its elasticity and volume, it then stretches and is pulled downward by gravity. Our range of facial expressions repeatedly creases our skin to give us the classic deepening wrinkles of an older face. Many of these lines are welcome as they give “character” to our faces. Many, however, are less welcome, especially if they make us look older than we feel, or crease the brow to suggest that we are concerned when we feel carefree.
While botox and fillers remain very useful, if the skin has stretched too much, or the deeper tissues have been pulled too far downward by gravity, then a surgical aproach is required. An eyelid lift (Blepharoplasty) is the most popular facial surgery in both the UK and USA. The upper lids and lower lids can be lifted and tightened with the scars hidden in the upper eyelid crease or the subciliary line.
A facelift is more dramatic and not particlularly well named, as it is more of a jowl and neck lift than face lift. There are now many techniques described to try to lift the midface, but this area remains the most difficult, and the interface with the lower eyelid is key.
What can go wrong with any eyelid surgery?
1. Infection of the wound. This is minimised with sterile technique and by using antibiotic ointment to the stitches and antibiotic tablets. Wound infection can be minor but can lead to a worse scar.
2. Large bruise or haematoma. This is minimised by taking it easy for 2 weeks after surgery, stopping aspirin and other anticoagulants if safe so to do, and regular use of ice packs. A haematoma may mean you have to go back into theatre to have the blood clot evacuated and then be resutured with the risk of a worse scar.
3. Visible scar. The cuts to the skin should fade to a thin white line. Not every scar heals equally well. A thickened or reddened scar can be improved with silicone scar remodelling gel, but the treatment needs to be continues for months to have a good result.
4. Theoretical risk to vision. Any eyelid surgery carries the risk that an undiagnosed infection or bleed could damage the optic nerve. This is so rare that in comparison a normal car journey is a much greater risk to your vision.
Upper Lid Blepharoplasty
The upper eyelid lift (technically called a blepharoplasty) is a procedure to correct heavy drooping upper lids - features that can make you look older and more tired than you feel. It is one of the safest and most reliable of all the cosmetic surgical procedures, with a very high satisfaction rate.
The best candidates are men and women who are physically healthy, psychologically stable, and realistic in their expectations. Most are 35 or older, but if droopy, baggy eyelids run in your family, you may decide to have eyelid surgery at a younger age.
A few medical conditions make blepharoplasty more risky. They include thyroid problems, dry eye or lack of sufficient tears, high blood pressure or other circulatory disorders, cardiovascular disease, and diabetes.
When eyelid surgery is performed by a qualified oculoplastic surgeon, complications are infrequent and usually minor. Nevertheless, there is always a possibility of complications, and the risks you need to consider are the risk of infection, the risk of a large bruise known as a haematoma, the risk of the scar thickening to become more visible and a theoretical risk to your vision.
I usually perform upper lid lifts under local anesthesia--which numbs the area around your eyes, sometimes with intravenous sedation. You'll be awake during the surgery, but relaxed and insensitive to pain. (However, you may feel some tugging or occasional discomfort.)
After surgery, I lubricate your eyes with ointment and may apply a bandage. Your eyelids may feel tight and sore as the anesthesia wears off, but you can usually control any discomfort with paracetamol. If you feel any severe pain, call me immediately.
Post-operative I recommend you to keep your head elevated for several days, and use ice packs to reduce swelling and bruising. (Bruising varies from person to person: it reaches its peak during the first week, and generally lasts anywhere from two weeks to a month.)
The stitches will be removed a week after surgery. Once they're out, the swelling and discoloration around your eyes will gradually subside, and you'll start to look and feel much better.
Most people feel ready to go out in public (and back to work) in a week to 10 days. By then, depending on your rate of healing, you'll probably be able to wear makeup to hide the bruising that remains. You may be sensitive to sunlight, wind, and other irritants for several weeks, so you should wear sunglasses and sunblock when you go out.
Keep your activities to a minimum for three to five days, and avoid more strenuous activities for about three weeks. It's especially important to avoid activities that raise your blood pressure, including bending, lifting, and rigorous sports. Minimise alcohol, since it causes fluid retention.
Healing is a gradual process, and your scars may remain slightly pink for six months or more after surgery. Eventually, though, they'll fade to a thin, nearly invisible white line. You will always be able to find your scars, but I aim for strangers to be unable to see them at 6 weeks, and your friends unable to see them by 6 months.
Blepharoplasty can enhance your appearance and your self-confidence, but it won't necessarily change your looks to match your ideal, or cause other people to treat you differently.
Lower Lid Blepharoplasty
The lower lid lift, or eyebag removal remains one of the most difficult cosmetic procedures. The reason is that the lower eyelid cannot be considered on its own but must be taken in consideration with the whole midface and indeed face. The lower eyelid rests against the eyeball and needs to be in perfect position to protect the eye and carry the tears with each blink into the tear ducts. Any attempt to remove too much skin from under the eye carries a great risk of the eyelid hanging away from the eye. This is made worse if there is any underlying lid laxity. This leads to a poor cosmetic and functional result, and a very unhappy patient!
In a similar fashion the orbital fat that surrounds the eyeball in its socket can bulge forward as we age, and the temptation is to remove this fat. Removing too much orbital fat however, can lead to a hollow appearing socket, with again a poor cosmetic result and unhappy patient!
The factors that age the lower lid and midface are volume loss as much as any fat prolapse and tissue descent.
The steps required to acheive good results from lower lid blepharoplasty therefore include:
Always replace lost volume with tear trough filler and cheek filler.
Always assess and tighten a lax lower eyelid.
Release the arcus marginalis to reset the tethering that tucks in and accentuates the lower lid bag.
Move rather than remove orbital fat, and be very conservative in removing orbital fat when essential.
Release the deeper tissues over the orbital margin and into the midface, to allow the deeper layers to be lifted by sutures to the orbital rim.
Be conservative in trimming excess skin, measure the excess with the patient opening their mouth wide.
Even with all these factors in place I warn my patients that if we can acheive a 99% result for the upper lid, the best to hope for with a lower lid is 70%.
Mole Removal
Many of us have small lesions on our face. Some are much loved beauty spots, but many are unloved lumps and bumps that can very easily be removed.
The surgery is usually with local anaesthetic, and is much less expensive than you may think. If the lesion is at all suspicious of skin cancer then an excision biopsy is recommended. This is covered by private insurance and also available on the NHS.
There is a small risk of infection, bruise and scarring. The scarring should however be less visible than the lump.
Ptosis
The upper eyelid can itself hang low, a condition known as a ptosis. In the early stages this can make your eyes look sleepy, if the eyelid comes lower then it can cover your pupil and affect your visual field and even your vision. In most cases the cause is simply a stretching of where the levator muscle that lifts your upper lid inserts into the lid. It is important to exclude rare neurological and muscular problems. So long as these are excluded the treatment involves tightening up the levator muscle. There are two broad techniques based essentially on whether an upper lid blepharoplasty is also required.
Anterior Approach Ptosis Repair
Posterior Approach Ptosis Repair
Brow Lift
There are a number of techniques to lift a dropping brow. They include Botox, endoscopic brow lift, direct brow lift, transblepharoplasty brow lift, pretrichial brow lift, and bicoronal brow lift. The number of options reveals the dilemma, the balance between effect, scar, cost, numb head, and recovery.
The simplest technique is simply to switch off the muscles that pull the eyebrows downwards with botox. The resulting tone of the frontalis muscle that lifts the eyebrows upwards results in a subtle but effective brow lift. There is almost no risk, but the effect wears off and the botox needs to be repeated.
The endoscopic brow lift has been very popular, and is elegant, but needs to have botox given as well to stop the brow depressors simply pulling the brow back down again, is expensive, and ultimately doesn't generate much more lift than botox alone.
A trans-blepharoplasty brow lift has appeal, is also elegant as you are already making the incisions for the blepharoplasty, and is like an endoscopic lift in reverse, but again is expensive, the issue of how best to re-suspend the lifted periosteum has not been fully answered, and again the best result is with additional botox.
The direct brow lift is very effective but with an unnacceptable scar in most circumstances.
Moving the scar to the hair line and limiting its extent with a pretrichial brow lift can be effective, especially for hairstyles that involve a fringe. There is a risk of a numb head behind the scar.
The bicoronal incision and lift is very effective, but gives a totally numb wooden feeling head behind the scar, a large scar that can be associated with hair loss, an elevated hair line and is expensive and generally less popular than other techniques.
One answer is prevention. Brow descent is a result of years of pulling the forehead down with your frown muscles. Use of botox will delay this descent.
Reconstructive Surgery
As an NHS ophthalmic and oculoplastic consultant much of my work involves reconstructive surgery of the face and eyes.
I train both UK and international surgeons in the techniques for this surgery.
Please see my website www.oculoplastics.info for tutorials and videos.