Introduction to blepharoplasty

Definition and Overview

Plastic surgery for eyelid lift is referred to as blepharoplasty.  It deals with disorders of the eyelid, tear duct, or surrounding tissue. In the past it was mostly performed for functionality; however, gradually, more and more plastic surgeons are choosing to specialise in cosmetic procedures.¹ 

The eye is an important component of facial aesthetics. A blepharoplasty can be used to create symmetry and play a vital role in facial harmony.¹ Furthermore, it is commonly used to rejuvenate the appearance of the face and reduce the perception of ageing.¹ 

Blepharoplasty is one of the most commonly performed cosmetic procedures, and it can be beneficial for symptoms such as tired-looking eyes, drooping eyelids, excess skin, or circles around the eyes.¹ It can also be used in combination with other procedures, such as a brow or mid-face lift, lasers, or chemical skin resurfacing.¹ 

Historical context and evolution

Karl Ferdinand von Gräfe coined the phrase “blepharoplasty” in 1818. This technique was performed for an eye reconstruction due to deformities caused by cancer.² The etymology of the word is Greek whereby Blepharon means eyelids, and Plastikos means to mold.² Blepharoplasty can be both functional and cosmetic, restoring an overall more youthful appearance, with a brighter look to the eyes.² 

Understanding the eye structure

Anatomy of the eyelids

The eyelids are an important feature of the eye. It has many functions such as:

• Maintaining adequate tear film distribution to prevent the eye surface from drying out
• For tear drainage
• To protect the surface of the eye ³ 
• The eyelids also contain glands that secrete substances that are important in lubricating the surface of the eye ³ 

The eyelid is composed of several parts so that it can effectively perform its functions:

• Skin/subcutaneous tissue: The eyelid skin is unique, since it has no subcutaneous fat, making it the thinnest layer of skin in the body.³ In some sections of the eye, the skin is firmly attached, but in others, it is looser to allow for swelling in case of trauma ³ 
• Orbital septum: A thin, fibrous layer of connective tissue, which separates the eyelid structures in the front, from the inner layers ³ 
• Orbital fat: This is located directly behind the orbital septum. In the upper eyelid, there are two distinct fat pads, whilst in the lower eyelid there are three ³ 
• Tarsus: A main structural component of the eyelid, made of dense connective tissue, and contains eyelash follicles.³ The upper eyelid contains approximately 100 eyelashes in 2 to 3 rows, whilst the lower eyelid contains about 50 ³ 
• Conjunctiva: Lines the inner surface of the eyelids and continues onto the front part of the eye.³ It contains mucus-forming cells and tear ducts that assist in keeping the eye lubricated ³ 

Many different conditions can affect the eyelids. One example of a common problem is when the glands that produce oil in the eyelids become obstructed or infected.³ This can cause pain and inflammation, including redness and swelling.³ Another common condition is known as blepharitis.³ This is when the edges of the eyelid become inflamed and irritated.³

Types of blepharoplasty

Upper eyelid blepharoplasty

There are several variations of an upper lid blepharoplasty:²

• Excision of the skin alone 
• Excision of the skin and partial excision of fat pads
• Correction of a drooping eyelid
• Correction of a tear duct prolapse

Upper lip blepharoplasty can be done under local or general anaesthesia.² Marking is generally done prior to the operation in a sitting position, particularly noting any excess skin, which will be removed.² After the area is cleaned, an incision is made, allowing the surgeon to separate the layers, remove excess fat, correct the tear ducts, and make any other necessary amendments.² Finally, this would be stitched up to close the incision.²

Lower eyelid blepharoplasty

Surgery to correct the lower eyelid rejuvenates and restores a youthful appearance to the eyes.² Basic principles are to reduce excess skin and fat, similar to upper eyelid blepharoplasty.² If there is no excess skin, but the patient has fine wrinkles, the skin can be resurfaced with a laser or chemical peel.² This procedure can be done under local anaesthesia or general anaesthesia.  Some surgeons prefer general anaesthesia since injection into the lower eyelid can distort the soft tissue anatomy.² 

There are three different approaches to lower eyelid blepharoplasty, with different methods.  All incisions are made in the skins and excess fat is removed as required.² The types of lower lid blepharoplasty include: ²

• Trans-conjunctival
• Transcutaneous
• Combined

Trans-conjunctival blepharoplasty is indicated in younger patients with baggy eyes, puffiness and dark circles under the eyes, without skin wrinkles.² It can also be recommended for hyperthyroid patients and can be combined with skin rejuvenation techniques.²

Possible complications and risks

Many of the complications associated with blepharoplasty are due to inadequate preoperative examination and counselling.² This may include:

• A drooping eyelid or eyebrow 
• Prolapse of a tear duct (prolapse is the displacement of a part of the body from its normal position)  ² 
• Vision compromise is the most dreaded complication in blepharoplasty, and it can be caused by abnormal bleeding following surgery.² This should be recognised early so that the eye can be decompressed and steroid medications can be administered, which is usually effective in restoring vision ² 
• Other vision problems may include double vision due to injury of the eye tendons 
• There could also be visible scarring which would be aesthetically displeasing ² 

Reasons for undergoing blepharoplasty

Blepharoplasty is most commonly done to improve the appearance of the patient.² This rejuvenates the appearance of the face during natural ageing processes. It can be exacerbated by factors such as excessive exposure, repetitive facial expression, gravity and smoking as well as genetic factors.² 

The various symptoms with which patients present for blepharoplasty are vague.² Often they complain that:

• Their eyelids feel heavy 
• Their visual field is restricted especially whilst looking upwards
• A feeling of pressure on their lashes ² 
• Sometimes, it is also linked to headaches due to a constant need to lift their eyebrows and an appearance of tiredness without feeling tired ² 

There are many other symptoms that could be a cause of a patient seeking blepharoplasty, but they are mostly cosmetic.

Preparing for blepharoplasty

A physical examination prior to a blepharoplasty should be extensive to minimize the risk of complications and give the patient the best outcome.² It should consist of a complete ophthalmic exam including testing eye focusing, the optic field, optic movement and eyelid closure.² Furthermore, the eyes should be tested to exclude dry eye syndrome.² The specific examination for blepharoplasty should be done in a seated position, as this is the natural state of the eye.² Additionally, the presence of drooping brows, the height of the upper eyelid, the amount of excess fat, and the presence of any skin tumours must be recorded.² 

Recovery and postoperative care

Following the surgery, a dressing is not always applied.² Instead, antibiotic ointment is prescribed, to be applied two to three times a day over the incision.² Furthermore, artificial tear drops would be prescribed for application throughout the day, and a gel would be given for night-time.² Generally, the pain should be minimal, and paracetamol would be sufficient to manage it. However, if a patient experiences severe pain, vision should be monitored to rule out abnormal bleeding or other complications.² There is usually a lot of swelling and bruising, which can be aided by the use of cold packs in the first 48 hours following surgery, and then alternating these with heat packs after this.² Sometimes steroids may be prescribed to help reduce swelling.² Patients should avoid bending and heavy lifting, and contact lenses should not be used for at least two weeks.² At least six weeks are required for the final outcome to be assessed to give sufficient time for swelling to resolve.² 

Summary

Blepharoplasty is an eyelid surgery that is typically used for cosmetic purposes. It can provide a youthful and rejuvenated appearance to the face, as well as correcting any asymmetry. Generally, it is not majorly invasive and at times it can even be performed with only local anaesthesia. The full effects can be observed after about six weeks.