Blepharoplasty The blepharoplasty corrects the redundancy of upper and lower eyelid skin. It also removes the fat deposits which cause heaviness of the upper and lower eyelids. In some cases the bulging is due to accumulation of fluid from allergies. Patients with allergy discoloration and bulging are often not relieved by doing a blepharoplasty, but the removal of loose skin definitely improves their appearance. In some cases of prominent lower eyelid fat pads and little loose skin, a transconjunctival blepharoplasty is indicated. The incision is inside the bottom of the lower eyelid, and avoids the external lateral incision. The fat pads are removed by this inner incision and imperfections in the skin can be eliminated with CO-2 laser or chemical peel. Some patients have such over-hang and heaviness from excess skin and fat that their vision is compromised. Visual field documentation from your Optometrist or Ophthalmologist and a letter to your insurance carrier will usually yield coverage for most of the expense of performing your upper eyelid surgery. Lower eyelid surgery is not considered insurable. Eyelid surgery is often performed in conjunction with a facelift and sometimes with a forehead lift. A forehead lift is a procedure designed to diminish the forehead pleats and uplift the brows, particularly if they "hood" the eyelids. In those patients with hooding of the upper eyelids, a combined approach of forehead lift and upper blepharoplasty is recommended. In some cases the forehead lift alone will improve the appearance of the upper eyelids. However, the forehead lift is a much more detailed and complicated procedure and is usually not insurable. A forehead lift consists of one incision from each temple meeting at the central scalp. The forehead is pulled down and some muscle removed. The scar in the scalp is usually covered with your hair style. An alternative to a forehead lift is a browlift. It consists of removal of an ellipse of skin from above each eyebrow so that closure uplifts the brows and oftentimes the upper lids. This may obviate the need for an upper eyelid blepharoplasty. The scars from this ellipse excision can sometimes be notable and require make-up. Also, the brow lift does not evenly lift the hooded areas over the eye. A forehead lift does this evenly and much more effectively An endoscopic forehead lift uses limited incisions behind the hairline using a special T.V. canula and achieves similar results to an open forehead lift. Performing the endoscopic technique has limitations as compared to the open. Ask Dr. Kennedy regarding same. Patients will occassionally have problems in terms of itching or pulling at these incisions, but this will subside with time. The other side effects of surgery are consistent with any operative procedure. Patients have been known to have bleeding which is easily controlled by removing a suture or two, electrocoagulating the bleeder, and returning the sutures to the eyelid region. Bleeding is best avoided by maintaining elevation and applying cold compresses in the first 24 to 48 hours after surgery. The elimination of Vitamin E and aspirin products for at least two weeks prior to surgery also helps to prevent bleeding. these drugs can increase in bleeding and are best avoided for the procedure. Eyelid bleeding is innocuous but the resulting scar tissue stirred up by the postoperative oozing can cause a pulling down effect on the lower eyelid. This pulling down effect or ectropion is usually temporary and will ususally give up and loosen on its own accord. This is, however, aided by taping the lower eyelid up and laterally, or by injection of cortisone into the scar tissue. Occassionally this scar tissue requires a minor procedure to tuck the lower eyelid into an upward and lateral position to further correct this pulling down effect. Again, this entire phenomenon is a rare occurrence and is invariably temporary. Bleeding can be so excessive around the eyes that pressure can be observed on the eyeball itself with a subsequent compromise of major blood vessels in supplying the retina (the back of the eye). Such a problem in blood supply is avoided by a conservative dissection of fat pads in and around the eyes and by doing the blepharoplasty in an amended form. However, should the patient be agitated or should their blood pressure rise unknowingly after the surgery, the chances of bleeding may increase. For this slight possibility, we ask patients to remain calm and sedated and take their pain medication postoperatively as well as to continue with their routine ice compresses. We also ask our patients to continue to be observed by someone for at least 24 hours after their operation. Should they have any increase in pain around the eyes or any effect in vision, they should contact us immediately. For this same reason we constantly monitor our patients during and after their eyelid surgery and turn over that responsibility to the patient and whomever will be caring for them. This bleeding/pressure problem is rectified by immediate evacuation of the blood around the eye. When the pressure is removed, better blood supply is restored to the eye itself and vision is, likewise, regained. The possibility of blindness is an extremely rare event and can be prevented when taking the above proper measures by patient, surgeon and their loved ones. Again, this is an infrequent occurrence which is noted in the surgical journals but is one which should be mentioned in the course of consideration of this surgery. Poor healing and loss of skin is rarely seen in eyelid surgery but can be seen in patients who smoke. For this reason we request our patients to refrain from smoking for two weeks prior to surgery and one week after surgery. The same instructions apply to chewing Nicoret gum. Another side effect of blepharoplasty is dryness of the eyes. This occassionally occurs in older patients who have a tendency to poor tearing. should this occur, artificial tears are required to keep the eyes adequately lubricated. This problem is referred to as keratoconjunctivitis sicca and in some cases patients will routinely have this problem postoperatively. In other cases, patients will actually have an excess of tears after their surgery. Formation of a little cyst or bleb on the whites of their eyes is secondary to the operative maneuver. This clear cyst formation on the eyes is temporary and will subside with proper use of eye drops and compresses. Occassionally you will see some bleeding underneath the whites of the eyes, but again, this will resolve in a matter of days without need for aggressive treatment. Should these clear cysts become too obvious or cumbersome, small incisions in the cysts themselves allowing for drainage will return the tissue to its normal contour. The eyelid procedure is usually performed under local anesthesia with heavy sedation in the office surgery unit. Patients are asked not to eat or drink anything after midnight before surgery. Patients are also requested to wear light clothing the day of surgery and to have a loved one available to drive them home and care for them in the first 24 to 48 hours. After that, patients can make do for themselves and can even venture out with dark glasses to avoid having their sutures seen. Some sutures are removed between the second and fourth day after the surgery and the others are removed after one week. After that time, patients may wear eyelid make-up. The black and blue from the operative procedure may last seven to fourteen days and some swelling may even persist up to four weeks. Most patients are able to return to their duties and meet the public in two weeks using cosmetics for any residual black and blue. Please feel free to ask questions on any of these points raised in this letter of Dr. Kennedy, or any members of the staff.
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