Diseases and Surgical Procedures

Blepharoplasty - Upper Eyelid

Primary goal: Removal of excess skin and fat to improve the appearance
Secondary goals: Enhancement of eyelid crease, lift of drooping eyelashes, increase in peripheral vision

Anesthesia

Most commonly performed under local anesthesia with oral sedation in an office operating room or with intravenous sedation as an out-patient at a hospital or surgicenter.

Operation

Excess skin is outlined with a marking pen. The initial incision is made along the existing eyelid crease across the length of the entire lid and extending slightly upward and outward into the lateral canthus. The second incision is made a variable distance above the first, depending on the amount of skin to be removed. If the orbicularis muscle is thickened or stretched, a small strip may be excised.

The orbital septum is opened along most of its length, thus exposing the fat pockets overlying the levator aponeurosis (tendon of the eyelid opening muscle). The first or "middle" pocket is removed using a process of dissection, clamping, excision, and cauterization. The second or "nasal" pocket requires deeper dissection. Removal is accomplished is a similar fashion.

The skin edges are closed using either dissolving or permanent sutures. The latter seem to give a more predictable and finer scar.

"Laser-assisted blepharoplasty", in which the actions of the traditional scalpel and scissors are undertaken with the use of a laser, has received widespread attention in recent years. While some advocates have claimed quicker operating time due to decreased bleeding, objective studies have not demonstrated less bruising or a more rapid recovery. Skin scars after healing from laser-assisted blepharoplasty are slightly more irregular and may take longer to strengthen than those made with a scalpel. While electrocautery, heat cautery, heated scalpels, and radiofrequency energy have also been used as cutting tools, none have demonstrated convincing advantages over standard scalpel and scissors.

At the discretion of the surgeon and patient, a modification known as "deep fixation" may be used to deepen the eyelid crease, achieve a more stable platform of skin on which to apply cosmetics, and prevent later scar "migration" out and above the hidden area of the normal crease. During wound closure, the cut skin edges are lightly attached to the underlying levator aponeurosis (tendon) using either permanent or dissolving sutures.

Advantages: Because the eyes are the focal point on the face, upper eyelid blepharoplasty may achieve anything from a subtle to dramatic improvement in a person's appearance. For this and such reasons as its relatively modest cost and quick recovery, many people choose blepharoplasty over full face lift.

Limitations

If performed aggressively in the presence of a weakened or drooping eyebrow, further descent of the brow may occur. "Crow's feet" are minimally improved. If true ptosis (a droopiness of the eyelid due to a defective levator muscle or aponeurosis), blepharoplasty alone will not remedy the problem.

"Functional blepharoplasty" or blepharoplasty undertaken with the primary purpose of increasing the field of vision narrowed by overhanging skin, entails the removal of eyelid skin only. While vision may be improved, the results compared to a full blepharoplasty and may, in fact, be disappointing to a patient who was hoping to coax his or her insurance company into paying for a cosmetic operation.