Overview of Blepharoplasty
Blepharoplasty is a type of surgery that focuses on improving the appearance or function of the upper or lower eyelids. Depending on the situation, a person might need the surgery on both their upper and lower eyelids, either at the same time or in separate procedures.
Before proposing or performing this surgery, doctors need to have a deep understanding of the anatomy of the eyelids. This knowledge enables them to identify any eyelid abnormalities that can be corrected with surgery, while also helping them avoid any potential complications that might occur as a result of the surgical procedures.
Anatomy and Physiology of Blepharoplasty
The upper and lower eyelids have two main parts: an anterior lamella (front part) and a posterior lamella (back part). The orbital septum, a membrane inside the eye socket, separates these parts. The front part of the eyelid consists of skin, a layer of fat beneath the skin, and the orbicularis oculi muscle (muscle responsible for blinking and closing the eyes). The back part is made up of the tarsal plates (a plate of dense tissue) and the conjunctiva (the thin layer covering the eye).
The tarsal plates give your eyelid its shape and structure. The upper eyelid’s tarsal plate is about 10 mm tall, while the lower eyelid’s is about 4 mm tall.
The eyelids are attached to the eye socket by the medial (inside, closer to your nose) and lateral (outside, closer to your ears) canthal tendons. These tendons keep the tarsal plates in place. The lateral canthal tendon has a top and bottom part; from these parts, attachments extend to Whitnall’s tubercle (a small bump) located 2 mm inside the outer rim of the eye socket. Similarly, the medial canthal tendon also has a top and bottom part, with additional attachments extending to the crests (raised edges) on the tear ducts.
The upper eyelid has two pockets of fat, called preaponeurotic and nasal fat pads. These fat pads give the eyelid its fullness and are separated by the interpad septum (a membrane that divides spaces). The lower eyelid has three areas (nasal, central, and lateral) with distinct fat pads. These fat pads are separated by muscles, specifically the inferior oblique muscle (separates nasal and central areas) and components of Lockwood’s ligament (separates central and lateral compartments).
The tear trough, or the nasojugal groove, is the part of your eyelid that you can see when you have bags under your eyes. It forms due to the attachment of the orbital malar ligament (a supportive tissue) to the skin of the lower eyelid.
The levator apparatus is a structure in the upper lid responsible for raising your eyelid. It is composed of two muscles: the levator palpebrae superioris muscle (the primary muscle that raises your eyelid) and Müller’s muscle. Müller’s muscle is controlled by your nervous system, whereas the levator muscle is controlled by the oculomotor nerve (a nerve that controls eye movements). Combining these muscles to form the levator aponeurosis and attaching it to the tarsal plate helps with raising the eyelid.
Lastly, the lacrimal apparatus includes the parts responsible for producing and draining tears from the eyes. It includes the lacrimal gland, which makes tears that then travel through channels called lacrimal canaliculi and the lacrimal sac, and ultimately drain down the nasolacrimal duct. The lacrimal gland can sometimes cause the upper outside corner of your eyelid to appear fuller; modifying this can make your eyes look better, but it could lead to dry eyes if the tear production is affected.
Why do People Need Blepharoplasty
Dermatochalasis refers to the condition where there’s extra skin on the upper or lower eyelids. People might choose to get an eyelid surgery, or blepharoplasty, if they are uncomfortable with how this excess skin looks. However, having a lot of extra skin can also cause physical problems. For example, if a person has too much skin on their upper eyelids, it might interfere with their field of vision or cause the skin to fold over onto itself. Extra skin on the lower eyelid can cause the lid to turn outwards, a condition known as ectropion.
Another common issue is a fat bulge in the upper and lower eyelids called steatoblepharon. This can be a problem for people who are bothered by its appearance. Significant steatoblepharon or dermatochalasis is often a reason for upper or lower eyelid surgery. The goal of the surgery for the upper lid is to remove some of the skin and fat to give a more youthful appearance and get rid of the excess skin fold. It’s important not to remove too much skin or fat as this could cause the upper lid to appear unnaturally hollowed or lead to complications such as the inability to fully close the eye (lagophthalmos). Similarly, surgery on the lower eyelid aims to remove the excess skin and fat and to lift the sagging lower lid.
Another problem that can be specific to the upper eyelid is ptosis, where the upper eyelid droops over the eye. This often happens due to aging or if the muscle that lifts the upper eyelid becomes detached from the eyelid. This can be measured by finding the distance from the center of the pupil to the upper eyelid when looking straight ahead. Typically, 4 mm is considered normal. If a person’s upper eyelid droops more than usual, covering more of the pupil, it might benefit from a procedure to tighten the muscles that lift the eyelid.
Turning outwards of the lower eyelid, also known as ectropion, is another reason for lower eyelid surgery. Ectropion is often caused by loss of elasticity and increased looseness of the lower lid. This can be checked using a test where the lower lid is pulled away from the eye and then let go. If the lower lid is slow to go back to its normal position or doesn’t go back at all, a procedure to tighten the eyelid might be needed.
When a Person Should Avoid Blepharoplasty
Before a patient undergoes any eyelid procedures, it’s important for the doctor to know about any eye-related medical conditions they might have. This would involve a thorough eye examination, including a check of the retina (the layer at the back of your eye). The doctor would specifically ask about your vision, whether you have dry eyes or if your vision is obstructed in any way.
They also need to consider any general health problems you have that could affect your eyes. This includes thyroid disease, diabetes, high blood pressure, or inflammatory diseases that have been treated with steroids. If a patient has a history of problems with bleeding or blood clots, the doctor needs to know this too.
Additionally, a few tests might be used for patients who are about to have a blepharoplasty (eyelid surgery) to check if there might be any issues with the surgery:
1. Shirmer’s Test: This measures how much tears your eyes produce and can help identify if you might experience dry eyes after the surgery. This is done by placing paper strips inside your lower eyelid for 5 minutes and seeing how much moisture is on the paper afterwards. If the paper measures 15mm or more of moisture, this is considered normal. A measure of less than 5mm indicates that the eyes aren’t producing enough tears.
2. Visual Field Testing: This test is used to check if your vision is being blocked in any areas due to drooping eyelids or excess skin. The test is usually done once when the eyelids are in a normal position, and then again when excess skin is taped above the level of the eyelid. Goldman perimetry and Humphrey visual fields are the types of tests used to look for these vision problems.
3. Jones Test: This test checks for blockages in the tear ducts. In the Jones I test, a dye is injected into the tear sac and left for 5 minutes to see if it flows out the other end. If the dye does come out the other end after 5 minutes, this means the tear ducts are open and working well. If not, the Jones II test is carried out, where the tear ducts are washed out with a syringe and the flow of the dye is checked again. If the dye comes out after this, it suggests there’s a problem affecting the normal operation of the tear duct system. If still no dye flows out, it suggests there’s a physical blockage causing the problem.
Equipment used for Blepharoplasty
To do the procedure, normal eye surgery or plastic surgery equipment should be sufficient. A local anesthetic mixed with a substance called epinephrine will be very helpful.
Not only does this mixture allow the surgery to be done while you’re awake but relaxed (a state called sedation), but the epinephrine also makes your blood vessels tighter. This helps to control bleeding during the procedure, a situation also referred to as ensuring hemostasis.
Who is needed to perform Blepharoplasty?
Blepharoplasty, which is an operation on the eyelids, can be done in a doctor’s office rather than a hospital. Typically, a local anesthetic is used to completely numb the eyelids, but this process can be quite uncomfortable. So, doctors usually also use sedation, which helps to make you feel relaxed and calm.
It’s important to know that if the doctor is using something like an intravenous (IV) sedative, which is a strong medicine given through a tube in your vein, then this should be done under the careful watch of a specially trained anesthesia provider. This professional knows how to handle your breathing and other body functions while under the influences of the anesthetic.
If IV sedatives are used, the operation should be performed either in a hospital or in an operating room that has been recognized by the American Association for Accreditation of Ambulatory Surgery Facilities. This is a group that ensures that the operating rooms meet certain standards for safety and quality.
To give you the safest care and the best results, only doctors with special training in blepharoplasty should perform this operation. They could be board-certified plastic surgeons, oculoplastic surgeons who focus on the area around the eyes, or facial plastic surgeons.
How is Blepharoplasty performed
Upper eyelid surgery (blepharoplasty) involves the removal of a section of skin from the upper eyelid. The surgeon creates a marking for the cut that will be made. It starts from a small distance above the inner and outer corners of the eye and reaches its peak at about 10 mm above the central part of the eyelid. The upper side of the marking is made following the natural upward curve of the eyelid and eye socket. This can change during surgery as the surgeon must ensure that there is enough skin remaining between the cut and the eyebrow to prevent the eye from looking hollow. The marks can be extended up to about 1 cm beyond the outer corner of the eye to remove excess skin on the sides.
The surgery can be carried out using different methods. One of these involves the removal of some of the ring-shaped muscle that controls blinking along with the skin. This is because the muscle contributes to the fullness of the upper eyelid but removing too much can also make the eye appear hollow. This method of surgery may also include the removal of fat situated behind the eye. The surgeon must be careful not to overcorrect during the operation.
In addition to upper eyelid surgery, the surgeon may also correct droopiness of the upper eyelid. This involves modifying the muscles that raise the eyelid and has to be done very carefully to ensure that the eyelid can fully close after surgery. If the correction will not result in an excessive gap when the eye is closed, the surgeon completes the procedure by removing excess muscle and skin, closing the cut.
Lower eyelid surgery, which is a common cosmetic procedure, involves a combination of methods tailored to the patient’s needs. These methods can include the removal of skin, resection of excess fat, smoothening of the transition between the lower lid and the cheek, and tightening the complex of the lower lid. There might be complications if too much skin or fat is removed. In dealing with the boundary between the lower lid and the cheek, fat from other sections of the lid may be spread over this boundary or the lid could be reshaped to give a younger appearance. The tightening of the lower lid is done by a specific procedure that adjusts the position of the lower eyelid. Some surgeons may use temporary measures like sutures or tapes to support the eyelid during the recovery phase.
While the techniques for upper and lower eyelid surgery can vary greatly between surgeons, the basic principles remain the same. These give both specialist surgeons and general practitioners a set of guidelines to follow during eyelid procedures.
Possible Complications of Blepharoplasty
Lagophthalmos is a condition where the upper eyelid doesn’t meet the lower eyelid, often referred to as “lid lag”. This can sometimes happen after an eyelid surgery known as blepharoplasty. With certain types of this surgery, a small amount of lid lag can occur but should go away over time. If you have this issue after surgery, your doctor might suggest using lubrication drops to protect your eye from scratches. It’s important to have close check-ups during this time to make sure the lid lag is getting better.
Ectropion is another potential outcome of eyelid procedures. This is when the lower eyelid turns or rolls outward, possibly due to excessive removing of skin, scarring, or loosening of supportive structures in the eyelid. Initial treatments may involve gentle massage or taping the eyelid upward; however, in many cases, a surgical procedure to tighten the lower eyelid might be necessary. Until this can be performed, eye lubrication can be utilized to lessen any discomfort.
Some patients may experience dry eyes after the surgery. Your doctor might use a special test before the surgery to check if you’re at high risk of dry eyes. If you have dry eyes after the surgery, lubricating eye drops are usually the go-to treatment. In some cases, if these symptoms don’t go away, you may need to see an eye specialist.
Retrobulbar Hemorrhage is a severe complication of blepharoplasty where bleeding occurs at the back of the eye, causing pain, bulging of the eye, and vision problems. This is usually caused by bleeding following the removal of fat from behind the eye during surgery. If you develop these symptoms after surgery, you should consider the possibility of this condition — immediate medical attention is needed, and the treatment often involves a procedure to relieve pressure in the eye.
What Else Should I Know About Blepharoplasty?
Blepharoplasty refers to eyelid surgery, which is a common procedure that can improve the vision and appearance of a patient. Understanding why you might need this surgery can help ensure you’re evaluated properly. Also, knowing about the possible complications can help you get the right follow-up treatment after your operation.