Understanding Cosmetic Upper Eyelid Blepharoplasty, Part I.
Upper eyelid blepharoplasty is one of the most commonly performed cosmetic surgical procedures in the United States. I had originally planned for this to be a single blog post, but I split it into two parts.
In Part I, I’ll go over upper eyelid anatomy, your pre-operative surgical consultation, the steps of upper eyelid blepharoplasty surgery, and the average post operative recovery. In Part II, I’ll discuss how to evaluate before-and-after photos and criteria to consider when choosing a surgeon.
A brief history of upper eyelid surgery
Although upper eyelid blepharoplasty has recently experienced a surge in media coverage, as many celebrities have undergone the procedure, one of the first descriptions of upper blepharoplasty surgery is from a Roman physician (Aulus Cornelius Celsus) around 2000 years ago. Now that you know a bit about the history of upper eyelid blepharoplasty, let’s learn about some basic eyelid anatomy.
Eyelid anatomy overview
Eyelid anatomy is probably the easiest to conceptualize in layers. Starting from external to internal, the first layer we encounter is skin. The second layer is the orbicularis oculi muscle (the muscle that closes the eye), followed by a layer of connective tissue (known as the orbital septum), followed by upper eyelid fat. Under the fat, lies the levator palpebrae superioris muscle, Müller’s muscle (both the levator and Müller’s muscle open the eye), and conjunctiva, which lines the deep surface of the eyelid where it is in contact with the eyeball.
In upper eyelid blepharoplasty surgery, eyelid skin and sometimes fat are removed from the eyelid. In the upper eyelid, there are actually two distinct fat pads: the medial and central fat pads. With rare exceptions, only a portion of the medial fat pad is removed. The medial fat pad is the fat pad closest to the nose that often bulges with age. Removing this fat pad helps to restore a smooth contour to the inner aspect of the eyelid. I’ll talk more about the steps of upper eyelid blepharoplasty later in this post.
The pre-operative consultation
Now, let’s discuss the pre-operative consultation appointment. The consultation appointment helps us determine whether we are going to be a good match from a patient-doctor perspective. Not all doctors are right for all patients, and vice versa. My goal with any cosmetic surgery is to meet or exceed your expectations so that you are happier after surgery than you were before. At your consultation appointment, we both have to make sure this will be possible.
At the consult appointment, you’ll be greeted by one of our reception staff as you enter the building and check in. Once checked in, you’ll be escorted back to one of our examination rooms, and a technician will check your vision and acquire a few additional details about your medical and surgical history. At this point, I’ll join you in the exam room, and we will discuss your goals of care. I will then take several measurements of your face and eyelids, including a measure of the excess skin in your upper eyelids. We will discuss the procedure options that I feel will best meet your goals of care based on your anatomy. Once, we’ve decided on a procedure or set of procedures, we will discuss the associated risks, benefits, alternatives, and indications for surgery and any questions you might have. I will also go over pre-operative instructions at this time.
Meeting with the surgical coordinator
Once I’ve answered your questions, you’ll meet with my surgical coordinator, Alexis. She will go over pricing for the procedure(s) you’ve selected and will also discuss open dates for surgery. If you would like to schedule surgery, you will be able to do so, but there is no pressure or expectation for you to choose a date for surgery at this time. If you prefer to discuss further with family or need more time to think about surgery, Alexis will provide you with her contact information and a folder with additional information on surgery and your fee estimate.
Day of surgery: what to expect
On the day of surgery, you’ll be greeted again by our reception team, who will then escort you back to our pre-operative area. Here, nurses will start an IV, connect monitoring leads, and help prepare you for surgery. You will be interviewed by one of our outstanding anesthetists. They will explain how they will utilize sedation during the case. Usually, we use propofol. If you have had difficulties or sub-optimal reactions with anesthesia at past surgeries, please let the anesthetist know.
Surgical marking and anesthesia
Prior to entering the operating room, I will use a surgical marking pen to draw the shape of my planned incision on your eyelid. Believe it or not, this is probably the most important part of upper eyelid blepharoplasty surgery. The shape of my incision dictates the amount of skin that is removed and where the surgical scar will eventually heal (hidden in the eyelid skin crease/fold). Once marking is complete, I will ask that you keep your eyelids closed at all times to prevent my marks from smudging. It is important that I am able to follow my markings as closely as possible.
Next, we’ll enter the operating room together. Once inside, the anesthetist will give you sedation medicine through your IV. Once sedated, I will inject numbing medicine (usually lidocaine and bupivacaine) into your eyelids. Although these injections would be uncomfortable if you were awake, you will likely not remember experiencing discomfort because you will already be sedated. We do not insert a breathing tube or use paralyzing agents during upper eyelid blepharoplasty surgery. You will still be breathing on your own during surgery.
Preparing the surgical field
After sedation and injection of local anesthetic, a nurse will clean (prep) your face with a surgical cleaning agent. We usually use Betadine (iodine based), but for those with true topical iodine allergies (very rare), we can use other cleaning agents. After your face has been cleaned/prepped, the scrub technician will place drapes around your face to create a sterile field.
Surgical steps of upper eyelid blepharoplasty
At this point, surgery begins. I usually start with the left upper eyelid. I use a surgical blade (scalpel) to make the incision on your eyelid. I do not use a laser for this step, as I feel that scarring from incisions made with laser is wider and less cosmetically acceptable than scarring resulting from a surgical blade. Once the incision is made, the skin within the incision lines is excised using small surgical scissors and cautery. Cautery is also used to control bleeding. After removing skin, I will dissect down to the level of the upper eyelid fat pads and remove medial fat if necessary. Sometimes, I resuspend the lacrimal gland (i.e., the gland that makes tears) if it has fallen out of position/bulges at the outer portion of the eyelid. Next, I close the edges of the skin incision surgical suture. I use Prolene suture, which is similar to Nylon. Prolene suture is nonabsorbable, and thus it must be removed several days after surgery. I prefer Prolene suture over absorbable sutures because it is less inflammatory and breaks less often.
Once suturing is complete in the left upper eyelid, I move to the right upper eyelid and perform upper eyelid blepharoplasty in a similar fashion.
Recovery after surgery
Bilateral (both sides) upper eyelid blepharoplasty usually takes about 20-25 minutes from the time I make the first incision until the time when I place the last suture. After surgery is complete, we will clean your face and place antibiotic ointment on your incision sites. A nurse will monitor you in our recovery area as the sedation wears off. This usually takes about 30 minutes, and at that time, you will be able to return home with a driver. We request that a friend or family member drive you home.
Post-operative care and precautions
Once home, your recovery and healing begins. I ask that you do not partake in any heavy lifting (more than 8 pounds in each hand), strenuous exercise, bending with your head below your heart, or rubbing your eyes for 2 weeks after surgery. During this time, I ask that you apply antibiotic ointment to your surgical incisions 2-3 times per day. For most patients, Tylenol (acetaminophen) is sufficient for pain control. We ask that you do not take NSAIDS (Advil, Aleve, Ibuprofen, Aspirin, Diclofenac, etc) for 3 days after surgery to minimize the likelihood of extra bleeding. I will see you again 6-8 days after surgery to remove the sutures in your upper eyelids.
Bruising, swelling, and final results
With regard to bruising, most bruising and swelling goes away within the first 2 weeks after surgery. You will likely still have some mild swelling at post operative week 2, but it will subside over the following weeks. We do not recommend that you book any major events (weddings, international vacations, other events with photographers, etc) for the first month after surgery, especially if you want to minimize evidence of your recent surgery.
What’s next in Part II
In Part II of “Understanding Upper Eyelid Blepharoplasty”, I’ll discuss how to evaluate before-and-after photos and factors to consider when choosing a surgeon for your cosmetic upper eyelid blepharoplasty.
