Overview of Upper Eyelid Blepharoplasty
Upper blepharoplasty, or surgery on the upper eyelid, is a common facial operation. It can be done for how one looks (cosmetic reasons) or how one functions (functional reasons). This procedure is popular because eyes and eyelids are a key feature of the face. They are seen by others and by you each time you look in a mirror. Plus, they are important in how we communicate with one another, looking from one person’s eyes to another. That’s why many beauty products are designed for eyebrows, upper and lower eyelids, and eyelashes.
Upper blepharoplasty is a surgery that repairs or rebuilds the upper eyelid. This can involve managing the skin of the upper eyelid, the septum which is a thin, firm tissue separating the eye, any droopy eyelid condition called ptosis, and any excess or lacking fat around the eye and upper eyelid areas. The reason for this surgery can be purely cosmetic or necessary for the eyelid’s function – often, it’s both.
The term ‘dermatochalasis’ refers to loose or excess eyelid skin and muscle. It results from changes like the loss of elastic tissues, thinning of the skin, weakening of the tissues in the eyelids, rubbing, and aging. It can also be influenced strongly by genetics.
‘Steatoblepharon’, a Greek word that means “relating to fat,” is the condition when the fat pads in the eyelid become more prominent. It can happen in both the upper and lower eyelids. This might be associated with the weakening of the septum and the muscle and skin of the eyelids. Dermatochalasis and steatoblepharon usually start to show in a person’s 40s, but can sometimes appear earlier.
The term ‘blepharoplasty’ itself comes from two Greek words: blepharon which means “eyelid” and plassein which means “to form”.
Anatomy and Physiology of Upper Eyelid Blepharoplasty
Understanding the anatomy of the upper eyelids is important. The eyelid skin crease is where the levator aponeurosis (a broad, flat tendon that lifts the eyelid) connects to the skin. Above this crease is the eyelid fold which covers the skin crease. The space between the crease and the edge of the eyelid is called the tarsal platform. Ideally, the ratio of the tarsal platform to the distance between the upper lid crease and eyebrow follows the golden ratio (1:1.618). The golden ratio is a mathematical ratio commonly found in nature that is considered aesthetically pleasing. Removing too much fat can disrupt this ratio, which can alter appearance.
Temporal hooding, which is sagging skin on the outer parts of the eyelids, can often occur due to sagging eyebrows and extra skin. It’s important to assess this during surgeries to decide whether direct surgery on the eyelid can address the issue or if the tail of the brow needs to be adjusted. Certain diseases such as thyroid eye disease and Ehlers-Danlos syndrome can cause more pronounced hooding.
The distance from the lower brow to the upper eyelid should be at least 20 mm and often needs to be 25 to 30 mm, depending on age, gender, and eyebrow position. Ensuring a healthy and attractive eyelash curve is also important during eyelid surgery.
At the level of the tarsal plate (a plate of dense connective tissue found within the eyelids), the front part of the eyelid is composed of skin and orbicularis oculi muscle (the muscle that closes the eyelids). The eyelid skin thickness does not change significantly with age but can lose its elasticity. The tarsal plate and tarsal conjunctiva (the mucous membrane that covers the front of the eye and lines the inside of the eyelids) form the back part of the eyelid at this level.
The tarsal plates stretch across the eyelids and become the medial and lateral canthal tendons (ligaments at the inner and outer corners of the eye). The upper tarsal plates are approximately 10 mm in height and about 1 mm in thickness. Behind the orbital septum (a thin, fibrous membrane), we find the preaponeurotic fat (a layer of fat).
The upper eyelid contains two fat pads, which are separated by a loose septum. The color and physical properties of these pads can vary. The levator palpebrae superioris muscle, which lifts the eyelid and is controlled by the oculomotor nerve, becomes an aponeurosis (a type of fibrous tissue) shortly after turning downwards at the Whitnall’s ligament. This aponeurosis connects to the front of the tarsal plates and the skin, forming the eyelid crease.
Muller’s muscle, which is controlled by the sympathetic nervous system, originates from the levator muscle and inserts into the tarsal space. The lacrimal gland, consisting of two lobes, produces tears and is usually not visible unless it moves forward.
The canthal tendons, the medial and lateral, are complex structures that connect the tarsal plates to the eye socket. The lateral canthal tendon, for example, has an anterior and a posterior limb and a further attachment inferiorly. There is some debate about whether this is a truly separate structure or not.
Why do People Need Upper Eyelid Blepharoplasty
Upper blepharoplasty is a type of surgery done to fix certain issues with the upper eyelid. It might be needed for a number of reasons related to how the eye functions. For example, if the upper eyelid has become too loose and saggy, it can interfere with a person’s ability to see properly.
Many people with this problem often have to raise their eyebrows or tilt their chin upwards in order to see better. This might especially cause difficulties while driving or identifying traffic lights. Some medical professionals might perform a visual field test to measure the range of a person’s peripheral vision, though not everyone agrees that this test is necessary or changes how they select treatment options.
Another problem that can lead to needing this surgery is constant use of the forehead muscles due to saggy eyelids or droopy eyelids leading to headaches. Eye irritation could also occur due to the eyelashes sagging or turning inward because of excessively saggy eyelids. In some cases, irritation of the skin can occur when the skin of the upper eyelid rubs against the skin of the lower eyelid, causing an inflammation of the skin (dermatitis).
Additionally, some people may have droopy upper eyelids that become worse when they are looking downward. This is known as down-gaze ptosis. This can interfere with activities such as reading.
Some people may seek upper blepharoplasty for cosmetic reasons rather than for functional ones. They might be looking for a more defined skin crease in the upper eyelids or they might want to reduce the appearance of puffy fat in the upper eyelids. Depending on what changes the person wants, a brow lift (a surgery to reduce wrinkles and sagging on the forehead and above the eyes) might be done at the same time as the upper blepharoplasty.
When a Person Should Avoid Upper Eyelid Blepharoplasty
There are some conditions that can make a blepharoplasty, which is a surgical procedure to fix drooping eyelids, more risky. These include having dry eyes, thyroid disease, eyes that bulge out (proptosis), and blood clotting disorders.
Dry eyes can vary in severity. If you have severe dry eyes, it might be best to avoid this surgery because the exposure of the cornea (the clear layer at the front of the eye) during surgery can make the dryness worse.
If you have a thyroid disorder that causes your eyes to bulge out, this surgery might cause issues with closing your eyes fully (known as lagophthalmos), which can lead to problems with your corneas and vision.
In people with blood clotting disorders, the risk and management of the surgery need to be assessed individually, often with the help of their doctor.
If you’ve had a blepharoplasty before, the doctor will carefully check the available skin for the surgery, how well the muscle around the eye (the orbicularis) is working and whether you have any issues with closing your eyes fully before suggesting the surgery again.
Lastly, blepharoplasty is generally not recommended for people who have a sensitivity to light, also known as photophobia, to avoid any complications post surgery.[8]
Equipment used for Upper Eyelid Blepharoplasty
To perform an upper blepharoplasty, which is a type of eye lift surgery, the surgeon does not need any special equipment. They simply use the typical tools found in a set for plastic surgery and oculoplastic surgery, which focuses specifically on procedures around the eyes.
Who is needed to perform Upper Eyelid Blepharoplasty?
An upper blepharoplasty, also known as an eyelid lift, can be done either while you’re awake but numb (local anesthesia) or while you’re asleep (monitored sedation). This is a safe procedure that can be done in a doctor’s office, a surgical center, or a hospital. The doctor performing this surgery, which is called a surgeon, is highly skilled in this particular operation. The surgeon also knows what to do if any issues come up before or after the surgery.
Preparing for Upper Eyelid Blepharoplasty
Before undergoing a blepharoplasty, which is an eyelid surgery, the doctor needs to understand various aspects of the patient’s health. They will look into past illnesses like diabetes, hypertension, thyroid issues, respiratory problems, skin diseases, kidney diseases, swelling problems, and any bleeding problems. This is done to ensure that the surgery is safe for the patient. The doctor will also check the medicines and supplements the patient takes, given that certain ones can increase the risk of bleeding during the surgery. Other lifestyle habits like smoking and alcohol consumption are taken into account as they can affect the healing process post-surgery.
It’s also important for doctors to understand the patient’s mental health history. If there are indications of certain behaviors or disorders, such as narcissistic personality disorder, body dysmorphic disorder, or a tendency towards dramatic behavior, referrals to a mental health professional may be necessary.
Eye health history is another key factor. The doctor needs to know if the patient has ever had eye surgery, including laser eye surgery, because these procedures can sometimes mean the patient will need more lubrication in the eyes afterwards. The doctor also needs to know about any previous or current issues with dry eyes.
During the examination, the doctor will look at the patient’s upper eyelids as well as the forehead and eyebrows. Sometimes, after eyelid surgery, the position of the eyebrows can drop, and this becomes especially noticeable in men. The size and symmetry of the upper eyelids are measured. Any differences will be noted down. The doctor will also inspect the thickness of the eyelid skin and check for inflammation or skin problems.
Evaluating the blink, closure, elasticity of the lower eyelid and assessment of the tear film on the cornea is essential. The Bell’s phenomenon, which is a reflex that enables us to close our eyes, is also checked as about 15% of people have a neutral or negative response.
Understanding the anatomy of the eyelid is crucial for surgery. The fat pads that cushion the eye can actually change our eye shape. These fat pads can bulge as we age, especially the one located near the tear gland. The doctor will look at the position of these fat pads during the examination.
The position of the patient’s eyebrows and the fat pad of the brow is also assessed, as these factors contribute to a youthful appearance. Sometimes, eyelid surgery requires surgical repositioning, rather than removal of any tissues.
Finally, the doctor will measure several factors like the distance between the corneal reflex (the reflection of light off the cornea) and the margin of the eyelid, the functionality of the eyelid muscle, the dimensions of the pupils, and the movement of the eyes. This comprehensive examination will help the doctor fully assess the patient’s needs for successful eyelid surgery.
How is Upper Eyelid Blepharoplasty performed
First, let’s talk about the process of drawing on your skin. The surgeon will use ink to outline where the eyelid fold should be, whether it’s making a new one or going over the existing one. It’s helpful to note that where the surgeon draws the line might be lower than where the final crease ends up. Making sure both eyes look the same is important, so symmetry will be a priority. The surgeon will make further markings to show how much skin, muscle and fat needs to be removed. This will depend on many different aspects of your unique face and body. It’s best to tread lightly and remove as little tissue as possible, for a more natural look.
The markings shouldn’t extend too far either direction: towards your nose, they won’t go past the corner of your eye, and towards your ear, the markings won’t pass the edge of your eye socket. To ensure a good amount of skin is left, the surgeon will measure the distance between the markings and your eyebrow. It’s crucial to leave enough skin between the edge of the incision and your eyebrow — about 10mm. This, however, may change depending on several factors like past surgeries, strength of the muscle around your eye, and any dryness in your eyes.
When it comes to cutting and removing the tissue, the surgeon will take out more from the outer corner of your eye. This is especially true for those with droopy eyebrows and no plans for a brow lift, but want a smoother look on the sides of their eyes. Just be aware that this approach may impact the nerves running to the muscles around your eyes and might result in an inability to fully close the eye.
Lately, there has been a shift towards focusing on enhancing volume and not just removing tissue, because as we age, we lose fat in our eyebrows and middle of our face. Oftentimes, there tends to be more fat around the inner corners of our eyes because this area doesn’t recede as we age. So the surgeon might take this fat and move it to the areas where more volume is needed.
The operation can be done with either numbing only the area around your eye, or having you asleep for the procedure. The numbing happens with a special drug injected under the skin and it’s important to not inject too deep to avoid affecting the muscle that lifts your eye lid. You might slightly jerk or move suddenly when being injected. So, to prevent this, the surgeon will hold your head steady and will point the needle away from your eye. Injections are usually repeated throughout the surgery to manage the pain.
The surgeon can use a variety of tools to make the incisions: a sharp blade, an electrical tool, a laser, or a needle that uses radiofrequency. When removing the orbicularis muscle — the one that closes your eye — the approach needs to be very precise. Too much removal can lead to problems so the amount depends on your age, how much extra muscle and skin you have, and whether a brow lift is being performed as well.
In some cases, the sheet of connective tissue behind the eyelid — the orbital septum — doesn’t need to be cut. However, removing a part of it results in long-term tightening as the tissue restores over time. In most cases, the surgeon will cut this layer to remove fat properly.
The central fat pad should be dealt with carefully to avoid unsatisfactory results or creating a hollow look. Certain patients might require a procedure where fat is moved from one area to another to give the eyelid a youthful appearance. In some cases, the fat taken from the corner closest to the nose can be moved to the central area if there is a deficiency there. The most important thing to keep in mind is the art of knowing how much to remove, how much to preserve, and how much to move.
Once everything is done and taken care of, the surgeon will stitch the wound using certain materials. You could have individual stitches which dissolve over a period of time or artificial materials which don’t dissolve but give a more secure closure.
Following the operation, you will be prescribed antibiotic eye cream to apply twice daily on the stitches and artificial tears to manage any dryness in your eyes. Most patients don’t need strong painkillers. You can resume blood thinning medication the day after the surgery. Cooling your eyelids for 24 hours after surgery can help with swelling and discomfort. You should also sleep with your head elevated for two nights. You can resume your regular shower routine the next day, even getting your stitches wet.
Possible Complications of Upper Eyelid Blepharoplasty
After undergoing eyelid surgery, it’s normal to experience some swelling and bruising, which may last up to 2 weeks. In case your upper eyelids have been operated on, you might notice some level of dryness. To help with this, most patients will have to apply eye drops throughout the day and some might need to apply a moistening ointment at night.
The feeling in your eyelid might decrease for a few weeks after surgery. This is due to the surgery affecting certain nerves in your upper eyelid. So, you might feel some numbness along the edge of your eyelid for six to eight weeks. This is particularly noticeable for women when they’re applying makeup on the eyelid edge.
Right after the surgery, almost every patient will experience some problem closing their eyes fully, a condition known as lagophthalmos. However, this usually improves within a few days. This is where the surgeon’s experience is really important, since a number of factors can affect your ability to close your eyes. Anesthetics used during the operation can temporarily weaken muscles around the eye, which can affect eyelid closure. To help with this, most surgeons aim for a slight lagophthalmos during surgery. Eye drops and ointments can be helpful for the first days or weeks until the issue resolves.
Even without lagophthalmos, you might experience dry eyes because the surgery can affect the way you blink and close your eyes. If you have any other conditions that contribute to eye dryness, such as acne rosacea or blepharitis, it can become worse after surgery. In some situations, temporary plugs may have to be placed in the tear ducts until the dryness improves.
Some patients might have some eye watering due to dryness. Special ointments at night and gels during the day can effectively help with this issue.
The appearance of bruising is quite normal, but serious bleeding behind the eye, known as a retrobulbar hemorrhage, requires immediate medical attention if it occurs. Signs of this can be severe pain, bulging eyes, nausea, vomiting and vision loss. Any severe pain after eyelid surgery should be considered a possible bleed until the doctor can confirm it’s not.
When the operation is done to try to create an eyelid crease, it usually ends up being a little higher than initially planned. Lowering this crease can be difficult and the results are unpredictable.
After eyelid surgery, it’s not unusual for the heights of the two eyelids to be slightly different. Usually, doctors advise waiting for the swelling to settle to see if additional adjustments are needed.
Surgery can also be performed to address common issues in the upper eyelid such as fine wrinkles, which can be improved with laser treatment. “Hooding” at the outer eye corner can be reduced with a surgical technique that extends the eyelid skin up toward the brow.
When a well-defined crease in the upper eyelid needs to be created, the surgeon may move a particular eye muscle during the surgery. Removal of a small amount of tissue and fat can also help to create a more defined upper eyelid crease. As one gets older, some fat pads in the eye area may become more prominent, leading to a deep fold in the upper eyelid. This “hollowing” can be improved by repositioning fat from behind the eye to under the incision, or by using fat grafts.
There are several ways suggested to make small adjustments to the position of the outer corner of the brow. These include injections of a substance like Botox, or removal of a small amount of muscle to give a slight lift to the brow. It should be noted, however, that an “internal brow lift” isn’t a long-lasting way to change the position or curve of the brow. So, we don’t recommend it.
What Else Should I Know About Upper Eyelid Blepharoplasty?
Upper blepharoplasty is a common type of surgery that can improve both the look and function of your eyelids. However, because your eyelids play a crucial role in protecting your vision, it’s really important for the surgery to be carefully planned and carried out. If you’re considering this surgery, your surgeon should let you know that you always have the option not to go ahead with it. If you decide you do want to proceed, they should give you a thorough understanding of what you can expect during and after the operation. They should also let you know about any potential outcomes that could specifically affect you. It’s all about ensuring you have all the information you need to make the best decision for your health and wellbeing.
