Blepharoplasty: what does an 'eye-lid lift' entail?

Blepharoplasty is a common plastic surgery procedure, undertaken for both medical and aesthetic reasons. Also known as an eyelid tuck, either the upper or lower eyelid, or both combined, are operated on in this procedure. Mr Jonathan Britto, a leading plastic surgeon who treats patients in London, Chelmsford, and Colchester, discusses what's behind the medical and aesthetic purposes of blepharoplasty, how blepharoplasty is performed, and the costs involved, and the pros and cons of this popular surgery.  

Why might someone choose to have a blepharoplasty? When is it considered medically necessary?

Blepharoplasty is performed for both medical and aesthetic reasons. It is an eyelid tuck and can be performed on the upper eyelid (upper blepharoplasty), the lower eyelid (lower blepharoplasty), or both simultaneously.  It is a day-case surgery without the need for an overnight hospital stay or a general anaesthetic.

For medical reasons, one might consider an upper blepharoplasty to unload excess skin and muscle in the upper eyelid. This can improve the visual field and reduce fatigue in the upper eyelid. A sagging lower eyelid that exposes the lower part of the surface of the eye is a good indication for a medical lower lid blepharoplasty to resuspend the lower lid, support the tear film and hydrate the surface of the eye.

Aesthetically, an upper lid blepharoplasty improves the definition of the upper eyelid, keeping it feminine in ladies and masculine in men. Men and women have four lines of aesthetic balance in the upper eyelid:

• the upper eyelash line
• the crease of the upper eyelid 
• the orbit or the skeletal margin
• and the eyebrow.

Upper lid blepharoplasty finds the balance between these aesthetic lines to optimise the volume and definition of the upper lid.

A lower lid blepharoplasty, on the other hand, shortens the vertical height of the lower eyelid and balances the volume of the lid so that it reflects light, rather than creating shadows, to balance the eyelid and the cheek. 

What considerations determine whether someone is a good candidate, or not, for a blepharoplasty?

Individual suitability very much depends on whether the consideration is for upper or lower lid blepharoplasty or both. A good candidate for upper eyelid blepharoplasty is someone who has a normal brow position and excess skin and muscle in the upper eyelid which causes a loss of definition with folds over the upper eyelid shelf.  In specialised situations, loss of upper lid definition can be recovered even when there is no skin/muscle excess, a modification known as ‘skin crease reformation’.

There are many reasons why a lower eyelid blepharoplasty would be performed, but the most common is the presentation of loculated eye bags pushing forward into the lower eyelid. These result from the herniation of fat from below the eyeball into the eyelid, excess muscle, or skin, or in some cases a combination of all three. A lower blepharoplasty shortens vertical eyelid height to a youthful ratio, and rebalances the volume of the eyelid and cheek, converting a ‘ski-slope of shadows’ to ‘a reflection of light’.

How is blepharoplasty surgery performed? Are patients awake during the procedure?

Blepharoplasty surgery is performed in my practice under ‘twilight’ or conscious sedation. The patient is calm and comfortable but can open and close their eyes so that there is better control over the result during the surgery. This keeps post-operative bruising to a minimum and speeds up the recovery time.

For an upper eyelid, an incision is made into the deepest part of the crease in the upper eyelid. Through this cut, the excess skin, muscle, and/ or fat is removed, the upper lid skin crease is ‘set’ for the upper lid ‘shelf show’ and the incision is closed with very fine dissolving sutures. 

For a lower eyelid blepharoplasty, if the problem is solely excess fat volume pushing forward from under the eye, the surgery can be transconjunctival, meaning through the internal side of the lower lid, resulting in no visible scar. If there is an additional concern with excess skin, or excess and lax muscle, the surgery is performed anteriorly leaving a fine scar just under the eyelash line extending into the crow's feet. 

Will blepharoplasty remove ‘crow’s feet’?

Crow’s feet are the radiating wrinkles at the corners of the eyes which are present even after we stop smiling! Although attractive when we smile (dynamic lines), the lines are frustrating when in repose (static). The predominant way to remove crow's feet is to treat the area with a muscle-weakening injection such as Botox. Although surgery is not a primary treatment for crow's feet, it can be a partial treatment as part of blepharoplasty surgery, incorporating myectomy where some of the orbicularis muscle is removed to weaken the wrinkles.
 

How is the cost of a blepharoplasty calculated?

Three factors determine the price of the blepharoplasty; the facility fee, the anaesthetic fee, and the procedure fee which includes the follow-up for up to a year afterward. In my practice, we have a set of costs for blepharoplasty, which is a range or family of eyelid procedures that can be relatively straightforward or rather complex. Complexity brings greater costs as it requires a higher level of skill.  All the procedures are done under twilight anaesthesia, which costs about the same as a general anaesthetic. 

How soon are results visible and are they permanent?

The results are almost immediately visible. In the upper eyelid, the first thing that patients will notice is how comfortable it feels to open the eye without excess weight. As the scar softens, the eye ‘feels more open’ and ‘lets in more light’. In the lower eyelid, there is a degree of swelling and bruising, that lasts about two weeks. The contour of the eyelid and cheek are immediately more harmonious, and the shadows are banished in favour of the reflection of light from the lid and cheek. The stitches used are self-dissolving in the upper lid and lower lid. A return to work and normal life comes two or three weeks later and nobody needs to know you've had any surgery. The swelling subsides and the visible result emerges between six and twelve weeks. 

Mr Jonathan Britto MB MD FRCS(Plast) is a leading consultant craniofacial and oculoplastic surgeon based in London and Essex. If you are interested in booking a consultation with him, you can do so by visiting his Top Doctors profile today