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Blepharoplasty/ Eyelid surgery

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Whilst the eyes themselves are expressionless, the eyelids are very important indicators
of our emotions. When heavy and baggy they portray a tired look; if hooded with loose
skin, an aged look; if elongated and almond shaped with a smooth contour, a fresh
youthful look.

The Problem

Whilst the eyes themselves are expressionless, the eyelids are very important indicators
of our emotions. When heavy and baggy they portray a tired look; if hooded with loose skin,
an aged look; if elongated and almond shaped with a smooth contour, a fresh youthful look.

The eyes are the first facial feature people observe and unfortunately they are also one of
the first to show the signs of ageing. Ageing is an irreversible, relentless process of tissue degeneration resulting in loss of elasticity and stretching of skin. The rate of this ageing
process varies from individual to individual and depends on the person's genetically
determined constitutional clock. It is hastened by the effects of sun exposure, smoking
and the stresses of daily life. Hooding of the upper eyelids is the combined effect of
descent of the eyebrows into the lid area (blepharoptosis) and an increase in the upper
eyelid skin due to loss of elasticity and stretching of the skin (blepharochalasis).

Squinting into the sun with or without sunglass protection will, over the years, lead to fine
lines which go on to form wrinkles and then furrows in the forehead and about the eyes.
Loose skin in the upper eyelid will rest on the upper eyelashes giving a heavy tired look.
It also makes it difficult to wear eye make-up. Fat pads in the inner aspect of the upper
eyelid tend to bulge forward aggravating the aged look.

Lower eyelid skin as it ages becomes loose, tends to wrinkle and eventually develops folds under the influence of gravity. The lower eyelid muscle weakens and underlying fat pads
bulge forward producing bags.

Skin pigmentation occurs from the degenerating effects of the sun on the skin. It can also
be a normal racial characteristic. This pigmentation can produce shadowing of the lower
eyelid and contribute to the ageing non-youthful look.

What Causes Eyelid Puffiness?

Puffiness or swelling about the eyelids is produced by any one or more of
three possible factors:

1. Weakened eyelid muscles (the orbicularis muscles) allow the orbital fat to billow
forward under the influence of gravity. This produces puffiness of the eyelids which is constantly present, but can be made to disappear by standing in front of a mirror and contracting your eyelid muscles such as in squinting. The problem can be surgically corrected by tightening the muscle sling with resuspension in the outer aspect of the lower eyelid (a procedure known as canthoplasty).

2. Excessive fatty deposits about the eyeball produce bulges or bagginess. These fatty deposits are compartmentalised and when present in excess, the fat pushes the overlying
thin eyelid muscle and skin forward producing the baggy contour defect. Removing the excessive fat or strengthening the retaining walls (skin and muscle) corrects this problem.

3. Excessive fluid accumulation about the eyes. This occurs commonly as a result of allergy and is usually worse on getting up in the mornings and improves as the day goes on - with the redistribution of body fluids on rising from the recumbent to the erect posture. Fluid accumulation is not corrected by surgery and if present may lead to a more protracted post surgery recovery. Some morning swelling can be expected in all patients for some variable time after eyelid surgery.

What Is Done?

Evaluation prior to surgery includes your medical history, especially in relation to
underlying allergies, visual problems, current medications, and known history of scarring. Advise Your surgeon of your need to wear glasses and the date of your most recent eye examination.

Eyelid examination allows assessment of skin quality and looseness, muscle activity and
any excess orbital fat and its distribution. It is best not to wear make up for this assessment.
It also includes an assessment of the contribution any eyebrow ptosis is making to your
eyelid problem and the possible need for eyebrow repositioning to achieve an optimal result.

Photographs are taken before and after surgery to plan the procedure and record your
results.

The surgery can be performed in hospital or at a Day Surgery Centre. You have the
alternative of general anaesthesia in which you are profoundly asleep and ventilated by a machine or the more modern alternative of intravenous sedation and local anaesthesia
from which recovery is much more rapid. The anaesthetist will talk to you prior to the
operation to help you decide what is best. Advancement in anaesthesia over recent years
has meant more comfort for patients - i.e. pain-free surgery, with minimal post operative sedation and almost no nausea, leading to a quick recovery and "feeling normal". The anaesthetists in our team are highly skilled and experienced in modern techniques and
devoted to keeping you comfortable.

Prior to the operation your eyelids will be marked out so that the incisions follow natural
lines or creases and ultimately become “invisible”, and to allow the determination of the
correct amount of skin to be removed. During the procedure the excess skin is removed, muscle is tightened, and redundant orbital fat is excised.

There are several tools that have been designed for use with eyelid surgery. These include
fine knife blades, very fine tungsten tip diathermy points and lasers. Despite what is written
in magazines, all achieve excellent results in experienced hands and recovery times are identical. Your surgeon will happily discuss these alternative surgical options with you.

The surgical incisions are sutured meticulously leaving hairline scars that fade quickly, but probably never completely disappear. The upper eyelid scar lies in a natural creaseline formed by the attachment of your eyelid muscle to the skin at the upper level of the tarsal plate (that structure that stiffens and support s the upper eyelid). This is usually 8mm to 12mm above the eyelash line, but may be higher as a normal variant, or non-existent as in Asians. This fold can be created by a procedure termed supratarsal fixation and can Europeanise the Asian eyelids. If eyelids are droopy (ptosis) this can also be corrected by shortening the muscle (known as the “levator muscles”) that raises your upper eyelid.

Upper Eyelid Reduction

Hanging loose skin develops with ageing .

Lower incision placed in crease line - 8-12mm above the lash line.

Excess skin removed.

Fat pad reduced if bulging present.

Suture of upper eyelid wound after supratarsal fixation performed.

The lower eyelid scar lies immediately below the eyelashes and may extend out onto the
crow's feet line for about 1 cm.

Lower Eyelid Reduction

Incision line marked under lash line and out from corner of eye.

Skin and muscle elevated.

Fat pads reduced where necessary.

Excess skin and muscle removed level with initial incision line after muscle tightening or canthopexy where needed.

If lower eyelid fat only is to be removed without the need for skin or muscle adjustment, it is possible to perform this procedure without any external lower eyelid scar. An incision is made on the inner aspect of the lower eyelid and the excess fat removed. This is called a transconjunctival blepharoplasty . This has application in very selected cases and will be discussed with you by your surgeon if it is an option for you.

Transconjunctival incision inside lower eyelid leaves no external scar - only protruding fat
can be corrected in this way.

The specific procedure to be performed on the eyelids varies from person to person and
will be discussed with you pre-operatively by your surgeon and his staff.

Prior to surgery you may need to obtain artificial tears, lubricating ointments, steroid
injections and medications to prevent or minimise bruising and swelling. Make sure you
obtain these instructions from your surgeon's staff. Immediately after your operation you will be nursed with your head up. Your vision will be blurred by the presence of a lubricant in your eyes which is inserted at the end of surgery. Ice packs may be used to limit the swelling and bruising. It is not the practice of your surgeon to bandage the eyes after surgery.

Sometimes dissolving sutures or glue will be used on the upper eyelid to save them having to be removed. However more commonly a running nylon suture is used and is removed with minimal discomfort after two or three days.

The eyelids have a protective and lubricating role for your eyes. After surgery, whilst the eyelids are swollen, this function is compromised and so for a few weeks it will be necessary for you to lubricate your eyes regularly with ointment or drops. The nursing staff will instruct you about this.

Is It Painful And How Will I Feel ?

W e all fear pain and have very different thresholds at which we perceive pain. Your
eyelids may feel tight and sore as the anaesthesia wears off, but any associated pain is
usually mild and should easily be relieved by mild analgesics such as Panadeine. Your anaesthetist will ensure that you have prescriptions for postoperative pain relief before
leaving the clinic or hospital.

Eyelid surgery will enhance your appearance but it won't necessarily change your looks
to match your ideal or cause other people to treat you differently. Cosmetic surgery
performed in patients with realistic expectations can do wonders for self esteem and for self confidence.

How Will I Look?

Bruising and swelling obviously varies from person to person. It is maximal in the first
three days and usually settles over seven to fourteen days. your surgeon will show you photographs of the healing process to give you some idea of what to expect.

Healing is a gradual process and your scars may remain slightly pink for six months or
more. Scars vary greatly from person to person, but all go through an initial red itchy
stage to a pink nodular and ultimately to a leathery stage at about six to eight weeks,
before fading to a thin, nearly invisible white line. This line may be visible in patients with
dark upper eyelid skin, but in most patients with white skin it will not be seen. The ultimate quality of any scars is dependent on the thickness of the skin. The eyelids have the thinnest skin in the body and therefore the scars will mature more quickly and be less obvious than anywhere else.

The positive results of your eyelid surgery will last for years. Your eyes will look fresh and
with a smoother improved eyelid contour, ladies will be better able to highlight their eyes
with makeup. Everyone should look more alert and youthful.

Will Everyone Know I Have My Eyelids Done?

I t is usual to feel apprehensive about undergoing a surgical procedure to improve
appearance. The usual dilemma is that on the one hand you want to recapture youth and look better, but on the other hand you do not want people to think that you have had
surgery to achieve it, fearing that you will be perceived as vain. The real situation is that
in our society we all care about how we look. This is reflected in our hair styles, clothes etc.
It is interesting to note that one of the fastest growing industries is the cosmetic industry,
where in the United States over 2 billion dollars a year is spent on makeup. The vast majority of people are not so discerning and surprisingly they will not notice even quite marked
changes to facial appearance. The usual comments you can expect are that "you look
well" or "have you been on a holiday?"

Timing Of Surgery And Duration Of Improvement

T here is no particular age that is best for eyelid surgery. We all age differently according
to a variety of factors: individual genetic makeup, and environmental influences such as
sun exposure, skin care and smoking. In general a more youthful look is maintained when eyelid surgery is performed on a younger patient whereas in the older patient a more
dramatic change is noted. Deep furrows and wrinkles that have become permanent, need
to be accepted, as they cannot be totally eradicated by surgery directed solely to the eyelids.

The best candidates for eyelid surgery are men and women who are physically healthy, psychologically stable and realistic about their expectations. Most are in their mid-thirties or older, but if droopy, baggy eyelids run in your family you may decide to have eyelid surgery
at a younger age.

Cosmetic surgery will not stop the biological clock, but will reset it. Although there are many factors determining the overall individual result, on average you can expect from six to ten years of improvement.

Unfortunately, the ageing process is progressive and after a period of years you will again develop ageing facial features including a recurrence of inelastic skin around the eyelids and perhaps weakened eyelid muscles. Usually further improvement can be obtained by a redo of your eyelid surgery which often needs to be less extensive than the original procedure, or alternatively a forehead repositioning or browlift may be indicated.

A misconception often heard is that one may age faster once you have had eyelid surgery.
This is not true and although ageing continues post surgery, it is not at an increased rate.

What Cannot Be Achieved By Eyelid Surgery?

Eyelid surgery will not stop the rate at which the skin ages, but certain lifestyles can
hasten the ageing process such as excessive sun exposure, smoking and poor skin care. Attention to these areas can prolong the improvement achieved by surgery.

Whilst eyelid contours are markedly improved, all wrinkles are not removed. This applies especially in the crow's feet area which is not addressed by a blepharoplasty. The crow's feet are actually part of the cheek or temple. To improve this problem a brow lift or temporal lift must be considered.

Drooping of the brow produces low flattened eyebrows with a scowling look. This adds to heaviness in the upper eyelids and produces furrowing in the nasal bridge line. This problem is not improved by eyelid surgery, but is better corrected by a foreheadplasty or brow lift.

Skin pigmentation is common in the lower eyelids and is occasionally seen in the upper lids
as well. It is most commonly a hereditary ethnic characteristic, but may also be sun induced. Eyelid surgery will not remove this, but rather may make it slightly more obvious by
stretching wrinkled loose skin to an improved contour. A skin care program incorporating a
light skin peel, either at the time of eyelid surgery or at a later date, may help this problem. Makeup will, of course, camouflage it. The scars from a blepharoplasty will not be as
“invisible” in this type of skin.

Facial asymmetry is normal. We all have a strong and a weak side of our facial skeleton and hence left and right eyelids are never identical, nor is the position of the eyebrows. This is of course present prior to surgery, but occasionally patients notice it more after surgery as they study their improvements closely. This asymmetry is normal and in fact enhances beauty. It
is never the result of surgery.

Ancillary Procedures Which May Be Performed With Eyelid Surgery

Although blepharoplasty is one of the most common cosmetic surgery procedures performed, it is frequently combined with other procedures, either at the same time or
at a later stage, to achieve an enhanced result:

Brow Lift

To correct the brow, bridge of nose and forehead furrows and to reposition eyebrows which have become lower and flatter with ageing. A new endoscopic procedure leaves minimal scarring in the hairline and has a rapid recovery time. This option will be discussed with you where your surgeon feels it appropriate.

Face and Neck Lift

To produce fresh facial features with improved cheek, jawline and neck contouring.

Lip Ancillary Procedures

To rejuvenate the lip to the youthful look. A variety of implants and injections are available
to enhance this area.

Rhinoplasty

To reshape and refine the nasal features.

Skin Care Programs

To improve skin quality. These are considered worthwhile to maintain the tone and
appearance of the facial skin.

If you would like to know more details about how any of the above may help you, please ask your surgeon or his staff.

Risks and complications

Before you make a decision to undergo plastic surgery, it is important that you be
informed of the potential risks, complications and side effects of the surgery you are contemplating. While all care is taken to minimise or to totally avoid these complications
and side effects, it is recognised that complications may occur despite the best medical care. For this reason, and in order that you may be truly informed prior to making your decision about surgery, it is important that you carefully read and understand the risk factors.

The side effects which accompany eyelid surgery may occur on a relatively common basis.
The complications of this surgery, although rare and unexpected, may occur despite any surgeon's best efforts. When reading and carefully considering this list, please understand
that many thousands of successful cosmetic procedures are performed and the occasional occurrence of these side effects may be a part of what is considered a successful cosmetic operation. Likewise, although limited statistically, the complications listed herein do
occasionally occur, despite optimal care and patient co-operation.

A few medical conditions make blepharoplasty more risky. They include thyroid problems
such as hypothyroidism and Grave's Disease, dry eye or lack of sufficient tears, high blood pressure or other circulatory disorders. A past history of detached retina or glaucoma are
also reasons for caution - if you have any of the above, please bring it to the attention of
your surgeon prior to surgery so that if necessary a further ophthalmology opinion can be obtained.

Possible Side Effects

Swelling - usually is worst in the first 72 hours and then gradually settles over one to two weeks. Some residual swelling may be present for up to six weeks and may be asymmetric depending on many factors such as your favourite side of sleeping. Rarely swelling may
persist longer term and is usually intermittent and associated with underlying allergies. This should be noted prior to surgery.

Bruising - this is maximal in the first 72 hours and then usually resolves over the ensuing
7-10 days. If troublesome, it can be camouflaged with makeup which can be applied within 7 days during which time dark glasses will assist.

Pigmentation - this is usually present prior to surgery, but may be more noticeable following surgery when the skin contour is improved by the elimination of wrinkles. It may be improved by a skin care program, but sometimes it is hereditary and the only effective treatment is cosmetic camouflage with makeup.

Dry Eyes and/or Tearing of Eyes, Burning and Itching - these symptoms commonly occur following eyelid surgery due to the changes in eyelid function. They usually settle
within a few weeks. Tearing may be related to obstruction of the lacrimal duct-the canal responsible for draining tears from the inner aspect of the eyelid into the nose. Occasionally this will need to be probed to clear it.

Temporary Visual Changes - sensitivity to light, blurring of vision and occasionally mild double vision (diplopia) occur within the first few weeks of surgery. There may also be
corneal irritation. These symptoms usually settle rapidly. Occasionally it is necessary to
change your prescription for glasses or contact lenses. This change is part of the evolution
of your optical function and is never caused by the surgery which is only directed to your eyelids.

Inclusion Cysts -not uncommon following eyelid surgery, small whitehead cysts are noted
in the incision lines and these are easily corrected by removal with a fine needle in the office. They are of no consequence and are noticed because of the excessively fine eyelid skin.

Scarring -will occur whenever skin is incised. During healing it will pass through red, itchy, lumpy, white and leathery stage before settling to a final state as a fine white line. Incision
lines occasionally may be visible and tend to thicken, requiring steroid injections and rarely additional revision surgery. Although visible incision lines may result, fortunately the facial
skin has excellent blood supply which allows for rapid healing. Occasionally scarring may
distort the shape of the eyelids and lead to drooping of the lower eyelid, resulting in watering. This is called ectropion and usually settles as the scars mature. Ectropion is minimised by incorporating a lateral canthopery into the blepharoplasty procedure and massaging the lower eyelids postoperatively in the prescribed manner. Occasionally a further surgical procedure may be required to correct this.

Inability To Close Eyes -occasionally it will be difficult to totally close your eyes whilst
asleep and hence the importance of inserting lubricating ointments into the eye. When this occurs, it does so in the immediate post-operative phase and usually settles when the
swelling subsides.

Possible Complications

Infection -this is exceedingly uncommon, but can occur following eyelid surgery. Antibiotic ointments will usually be used in the first few weeks post surgery.

Blood Clots (Haematoma) -rarely blood clots may develop behind the eyeball or under
the skin. These usually require evacuation.

Loss of Eyelashes -this is an extremely rare complication following eyelid surgery.

Ptosis -this refers to drooping of the upper eyelid due to malfunction of the upper eyelid muscle. This is uncommon and can be corrected by a further surgical procedure.

Loss Of Eyelid Skin -this is very rare and usually heals without the need for any further surgical intervention. Very occasionally a small skin graft may be required to replace the damaged area.

Alteration Of Vision -usually temporary but very rare cases of blindness have been
reported in the medical literature. your surgeon will discuss the mechanism of this
complication with you and the procedures he uses to prevent its occurrence.

Pain temporary or permanent is extremely rare.

Pre-operation

Two weeks prior to your operation you should avoid Asprin or aspirin-containing medicine (Aspro, Disprin, Alka-Seltzer or any medicine containing acetylsalicylic acid) as this can produce bleeding or bruising. Panadol is safe.

Avoid Vitamin E two weeks prior to surgery as this may also increase a bleeding tendency.
Vitamin B and C are safe to use.

Stop smoking to avoid the chance of post operative coughing which increases risks of
bleeding and bruising. Smoking also decreases blood supply to the healing tissues, increasing the risks of delayed and poor healing.

Do not drink alcohol for at least two days prior to surgery as alcohol also increases the
chances of bleeding and bruising.

Two days before surgery start taking the ARNICA and any Vitamin C which we have
prescribed for you. These have been shown to effectively minimise bruising and swelling.
Avoid tea, coffee and peppermint as these products neutralise the beneficial effects of
ARNICA.

In the week prior to surgery, if you develop any sign of infection such as cold, flu or pimples
on your face-please notify our office so that we can treat this effectively. If you have a
history of facial Herpes please let us know, as Acyclovir started before your surgery should prevent an outbreak.

Ensure you fill any prescriptions for ointment artificial tears, analgesics and steroids which we have sent you. Remember to bring all five vials of solumedrol if prescribed.

On the night before or the day of surgery, shampoo your hair as usual and cleanse your face thoroughly to remove all traces of makeup. Do not apply any moisturisers, makeup or hair products after cleansing.

You should bring to hospital your normal toiletries and any regular normal medication that
you use. Loose night clothes are recommended. Also bring a pair of sunglasses to wear home.

After Surgery

If your operation is performed in hospital the nursing staff will assist you by bathing the eyes with a saline wash and the application of ice packs to help reduce swelling. Three
times daily, an antibiotic ointment will be applied sparingly to the incisions, and at night it
will be inserted inside the lower eyelid. During the day, artificial tears will lubricate and soothe the eyes.

If you choose to have your surgery at a clinic, "care of the eyes" will be explained to you
and whoever may be assisting you at home. You may not drive yourself or be unescorted home, as you will be under the influence of medication. Also for the same reason, you should not conduct business, sign any papers, or take any alcohol on the day of your operation. You will have recovered completely by the morning after surgery.

By 48 hours after surgery, the swelling usually reaches its maximum. The ice pack application may be discontinued unless you find it comforting. An extra pillow is recommended whilst sleeping, and keeping the head elevated as much as possible during the day is advisable.
Where possible elevate the head of your bed on a couple of house bricks or telephone books.

Sunglasses will reduce the daylight glare and sun brightness, helping to reduce eye irritability or tear formation.

In the first week following surgery it is advisable to restrict your normal activities where possible. Avoid smoking, alcohol and stress as these factors hinder the healing process. Detailed work such as sewing or other handcrafts, excessive reading, writing or computer
work should be avoided as your eyes can become very tired.

Panadol or Panadeine are the desired analgesics for pain relief. No Asprin or
aspirin-containing drugs should be taken as these can increase your bruising and may
cause bleeding into the tissues. Codeine found in Panadeine or Panadeine Forte can cause constipation. Therefore lots of fluids and a high fibre diet should be taken. A suitable laxative
is Nulax if needed.

If you are still in hospital on the third or fourth day, the nursing staff will remove your eyelid sutures. Alternatively you will be given an appointment to have your sutures removed.

There may be minor bruising for up to a week and a cover makeup may be necessary to resume work or social activities. Eye makeup may be applied at one week, but gentle removal and cleansing is essential. A saline wash is a very soothing finish to your nightly skin care regime for the first few weeks.

The wounds around the eyes sometimes take on a lumpy appearance around 10-14 days,
so a massage with vitamin E cream twice daily will help. Remember to wash and massage
in a direction up and outwards from the nose to avoid affecting the suture lines.

Often the weeks following surgery can be difficult as the patient comes to terms with the changes achieved by surgery. It is a transition period when some people have been known
to experience guilt and feelings of low self esteem. This is a good time to seek the advice of
a beauty therapist and learn the art of enhancing the eyes with eye makeup (colour, shade
and light) which you may never have been able to apply before. This can really boost your confidence and maintain a positive state of mind. If you would like an appointment with a trained paramedical beauty therapist, please ask our staff and we will organise a consultation.

After six weeks, an appointment is made for you to visit your surgeon for a check up. A photograph is often taken to compare with your pre-op photos. At this stage you will have accepted the positive results of your eyelid reduction and will be enjoying the "new you".

CALL your surgeon IF YOU EXPERIENCE THE FOLLOWING:

  • Excessive pain or bleeding
  • Abnormal swelling
  • Fever during the first 24 hours or especially during the first 7 days

How Much Will The Procedure Cost?

The costs of this surgery relate to:

a) surgeon and assistant surgeon

b) anaesthetist

c) hospital

d) ancillary charge (pharmacy, etc)

your surgeon can tell you his fee and give you some indication of the costs of the other
people involved in your care.

You must appreciate that the ultimate cost to you will depend on where you choose to go for your procedure and what rebates you will receive from your medical fund and Medicare. This
in turn depends on who you may be insured with and what level of insurance you have
chosen. Please advise your surgeon if your insurance has a front end deductible cost or "excess". With all the relevant information the doctor's office should be able to give you a
very close approximation of what your final costs might be.

It is always preferable to arrange all your finance prior to surgery to avoid unnecessary
stress afterwards which will detract from your enjoyment of having achieved your goal.

Conclusion

Your eyes and eyelids are the most important features of facial expression. A blepharoplasty can have a dramatic effect on your eyelids, restoring a brighter, more rested appearance to your face. After blepharoplasty, your eyes can express the energy and self confidence you are truly feeling. I hope these notes have helped you. If you have any further queries please call our office.

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