Simon N Madge
MA MRCP FRCOphth
Consultant Ophthalmic & Oculoplastic Surgeon
e-mail:
SECRETARY: Tracy Kelly
Tel: 01432 370874
Fax: 01432 274979
tracykellyatwork@btinternet.com
Correspondence & Consulting Rooms :
Nuffield Health
Hereford Hospital
Venns Lane
Hereford
HR1 1DF
e-mail: drsimonmadge@gmail.com
Blepharoplasty Surgery
This leaflet gives you information that will help you decide whether to have
surgery on your eyelids, as outlined in your consultation with me. You might
want to discuss this decision with a relative or carer. Before you have the
operation, you will be asked to sign a consent form and so it is important that
you understand the leaflet before you decide to have surgery. If you have any
questions, please do not hesitate to ask me.
What is Blepharoplasty Surgery?
This is surgery that removes excess loose folds of skin (and sometimes
muscle and fat) from the upper eyelids and ‘bags’ from the lower eyelids.
Why have Blepharoplasty Surgery?
Upper eyelid blepharoplasty is the most common surgical cosmetic procedure
and is typically performed for people with droopy, overhanging eyelids that
impair vision, cause frequent blinking, eyelid fatigue or which simply look
unsightly. In addition, some find that the application of make-up is hindered
as a result of excess skin.
Surgery can be combined with ptosis surgery if the upper eyelid position itself
is low; this will be pointed out to you at the consultation if you are not already
aware of this. An eyebrow ptosis (low-lying eyebrow) may contribute to your
problem and may need to be addressed during surgery.
Lower eyelid blepharoplasty is typically performed on patients with puffy lower
eyelids, which may look unsightly.
There are many different kinds of eyelid surgery, depending on your specific
type of problem. One person’s operation is naturally different to another’s, so
please do not assume that you will undergo the same procedure as a friend.
Eyelid surgery cannot stop the ageing process. However, it can diminish the
look of loose skin and bagginess in the eyelid region.
Alternative treatments
Blepharoplasty surgery is obviously not compulsory for patients with excess
eyelid tissue and no harm will come to you if you do not go ahead with
surgery. Among the alternatives to surgery are no treatment at all, clever use
of make-up, as well as various proprietary skin treatments. In addition, Botox
and fillers (e.g. Restylane) can also be used to enhance your facial
appearance in general (whole face, not just the eyelid region) and may be
suggested and administered by Mr Madge, if appropriate.
What happens at surgery?
Anaesthesia
Eyelid surgery can be performed under local anaesthesia, local anaesthesia
with sedation by an anaesthetist, or under general anaesthesia (asleep).
With a local anaesthetic you will be awake during the operation and you may
feel sensations (e.g. pressure) in the area being operated upon, but you
should feel nothing sharp or painful. You may be able to see some of what is
happening, but you will be aware of the very bright operating theatre lights. In
some cases, I will ask specifically ask you to open your eyes or look up /
down, but otherwise feel free to keep your eyes closed unless otherwise
directed, which will probably leave you most comfortable.
Upper eyelid blepharoplasty
A curved incision is made through a natural crease of your eyelid above the
eyelashes and a crescent-shaped, appropriately sized piece of skin is
removed. If necessary, underlying fatty tissue is also removed. Sutures are
then placed to close the incision, leaving a scar in a natural eyelid crease
position.
Ptosis surgery or eyebrow surgery can be performed at the same sitting,
typically through the same incision.
Lower eyelid blepharoplasty
There has been a recent shift in our understanding of the ageing process, in
that until recently it was felt that removal of, for example, prolapsed fat from
the eyelid region led to a rejuvenated appearance. While this approach
certainly removes ‘bags’, in many patients it simultaneously removed the soft
tissue that conceals the bony orbital rims, creating a hollowed – skeletonised
– appearance. In addition, excess removal of lower eyelid fat can lead to a
deepening of the normal depression in the upper eyelid below the eyebrow,
enhancing the aged look. In the youthful face, there is a smooth transition
from the cheek to the lower eyelid as a result of soft tissue fullness, with the
bony margin being concealed.
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There have recently been devised many surgical approaches to address this
problem, for example, techniques that preserve and reposition the orbital fat,
so allowing a smooth transition between lower eyelid and cheek but
simultaneously eliminating the troublesome eyelid bags.
An incision is typically made 1-2mm below the eyelashes, but the procedure
may also be performed from inside the eyelid (transconjunctival
blepharoplasty). Excess tissues are either removed or repositioned and the
lower eyelid is typically tightened to prevent lower eyelid sagging after the
procedure. Skin incisions are closed with sutures, which are typically
removed at one week.
Procedure
The procedure may be carried out as a daycase or with an overnight stay,
depending on the individual patient’s requirements.
Aspirin / warfarin / clopidogrel drugs
If you are taking any of these drugs, you will be given instructions about how
to proceed at your consultation. If you start taking any of these medications
between your consultation and surgery, or if this was not discussed at your
consultation, it is vital that you contact my secretary prior to your operation
going ahead. I will then advise you how to proceed. If you take non-steroidal
anti-inflammatory drugs (e.g. ibuprofen, voltarol, etc.), it is preferable to avoid
these prior to surgery, however, these are often necessary for other ailments
and should not be stopped if you would otherwise be in pain.
Preoperative instructions
Please dress casually and comfortably. Avoid wearing jewellery and
thoroughly clean your face prior to coming to hospital. No emollients, makeup or contact lenses please on the day of surgery. Please take your standard
oral medication (except see above re. aspirin / warfarin / clopidogrel /
ibuprofen etc.) on the morning of surgery.
If possible, stop smoking for at least 4 weeks prior to surgery and until
wounds are fully healed and at least 2 weeks thereafter.
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Music
In order to help you relax during surgery, I can arrange for some music to be
played while in theatre. If you would prefer to bring your own choice of CD
with you, please do so.
Following surgery
After surgery, you can experience some swelling / bruising for 1-2 weeks and
occasionally longer. Please bear this in mind when scheduling your surgery.
Typically the swelling is at its worst after about 48 hours, so please do not be
alarmed if bruising worsens the day after surgery; this is normal and in some
cases the discolouration spreads down your face from your cheeks to your
chin. If so, it will soon fade.
You may still have a little oozing or bleeding from the site of surgery over the
first few hours, which should resolve by itself. Following surgery, I prefer to
apply a firm dressing to the surgical site until at least the following morning,
typically secured with elastoplast tape. While some surgeons do not do this, I
believe that the great reduction in swelling / bruising achieved with this
technique is worth the temporary inconvenience that padding causes. Should
you wish not to have your eye padded shut following surgery, please discuss
this with me prior to surgery. In patients undergoing surgery on both left and
right eyelids, I typically pad both eyes closed, one for around an hour after
surgery and the other until the following morning.
If the patch becomes loose, apply more tape. Do not remove the patch. While
the patch is on, do not get it wet. Shower from the neck down or take a bath.
Cool packs applied to the wound are very helpful at reducing the swelling and
bruising. If you wish to, apply a cool pack (cold flannel / frozen peas wrapped
in clean flannel / ice cubes in plastic bag wrapped in flannel) to the area for
10-15 minutes, 6 times per day for the first 2 days.
As the local anaesthetic wears off, you will experience tightness of the
eyelids. Pain after surgery is typically minimal, however, if you experience
significant discomfort please take mild pain relief as required (e.g.
paracetamol). Paracetamol taken regularly works better than when taken
occasionally.
Avoid strenuous exercise, bending or heavy lifting for a few days after surgery
as this can precipitate bleeding. Sleep with 2-3 pillows in order to keep the
head elevated – this will help to reduce swelling / bruising.
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Antibiotic ointment should be applied to the wound three times a day, which
prevents scab formation and may reduce the risk of infection. Wash hands
thoroughly prior to applying ointment. If crusting occurs, you may clean the
wound with warm boiled water using cotton wool or cotton buds to remove
crusts and pat dry. Do not use soap. Then apply a layer of antibiotic ointment.
You may shower and wash your hair, but try and avoid getting soap on the
wounds. Dab them dry afterwards and apply ointment.
Stitches / sutures
Skin stitches typically need to be removed, although in certain cases I will use
dissolvable stitches. If stitches are to be removed, I typically remove these 510 days following surgery at your follow-up appointment.
What are the possible common complications of cosmetic eyelid
surgery?
Complications in the hands of trained, experienced oculoplastic surgeons are
rare and precautions are taken to minimise risks. The list below is designed to
be comprehensive; significant complications following blepharoplasty are
uncommon.
Complications after eyelid surgery include:
 Blurred or double vision, usually for a few hours but occasionally a few
days, following surgery. This may occur as a result of antibiotic ointment
smearing the vision, local anaesthetic used during surgery or swelling
of the normally clear covering of the eye (conjunctiva). Conjunctival
swelling is known as ‘chemosis’, and may take a few weeks to resolve.
If blurring persists or worsens, please inform Mr Madge.
 Watery eyes. This is common for several days following surgery and is
due to temporary irritation of the eye.
 Dry feeling eyes. Such a sensation may persist for 2-3 weeks. Intensive
lubrication with artificial tears may be necessary and the need for
lubricants in the longer term is a possibility.
 Corneal abrasion. This is a mild injury to the surface of the eye (akin to
a child’s fingernail injury on the eye) sustained during surgery and is
uncommon in surgery performed by an oculoplastic surgeon. This can
cause intense pain and dislike of bright lights, but rapidly heals.
 Collection of blood around the eyelids or behind the eyeball, called a
haematoma. A sudden haematoma behind the eyeball can cause
permanent loss of sight if not managed appropriately. An oculoplastic
surgeon is trained to prevent and to manage such a problem. Loss of
sight following upper eyelid blepharoplasty is exceptionally rare;
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following lower eyelid blepharoplasty, the incidence of this rare
complication is thought to be less than 1:10,000.
Damage to the muscles that move the eyeball causing double vision is
a very rare problem and usually resolves with time.
Ptosis, where the upper eyelid does not open properly due to stretching
of the muscle / tendon that normally opens the eye; further surgery may
be required. Oculoplastic surgeons routinely undertake ptosis surgery.
A sunken-looking eye can occur if too much fatty tissue is removed.
Modern techniques aim to avoid this complication – see above.
Scarring. Although good wound healing is expected in this anatomical
region, abnormal scars can occur both within the eyelid and deeper
tissues. There is the low possibility of visible marks on the eyelid or
small skin cysts from sutures, which may be temporary or permanent.
Asymmetry. The human face and eyelid region is normally
asymmetrical. Eyelid surgery can only rarely correct this and this is not
usually the goal of surgery.
Infection. An infection following this type of surgery is rare but it is
important to follow postoperative wound care instructions and to use
antibiotics to help prevent such a problem. Limited infections – typically
due to organisms from the patient’s own body – are rare, but are
usually easily treated with oral (or extremely rarely intravenous)
antibiotics. More devastating infections, such as ‘necrotising fasciitis’,
are exceptionally rare (incidence less than 1:10,000) and could
potentially result in permanent disfigurement or even death. I stress that
such outcomes are exceptionally uncommon and their inclusion in this
leaflet are purely for completeness from a medicolegal perspective.
Chronic pain. This may occur extremely infrequently following
blepharoplasty surgery. Tenderness over the eyebrows that persists for
months may commonly be experienced if eyebrow lifting surgery is
undertaken.
Ectropion and lower eyelid retraction. Displacement of the lower eyelid
away from the eye may occur uncommonly following lower eyelid
blepharoplasty and surgical steps are taken to prevent this
complication. If it occurs, further surgery may be necessary.
Eyelash loss. This may occur in the lower eyelid and its occurrence is
unpredictable. While typically temporary, it may potentially be
permanent.
Lack of satisfaction with the final result. As with any operation, there is a
possibility that you may be disappointed with the final results of surgery
and infrequently subsequent ‘touch-up’ surgery may be necessary.
Allergy. In rare cases, local allergies to tape, suture materials or topical
preparations have been reported. Unexpected systemic reactions
occurring to drugs (e.g. anaesthetics) used during surgery are rare, but
can be serious or even potentially fatal and are a risk in any form of
surgery anywhere on the body.
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