The eyes are the most expressive part of the human face – they are truly the windows to our soul. Very important to our appearance, eyelids are also the earliest region in the face to show signs of aging. Even young people can have a tired appearance if their eyelids look puffy or droopy.
Blepharoplasty is a surgical procedure designed to correct congenital or age-related changes in and around the eyes. Upper eyelid surgery is usually a straightforward procedure which involves removing loose, excess skin, tightening muscles, and removing or re-contouring fat. This will correct a hooded upper eyelid, leading to a less tired appearance. Lower eyelid surgery can be more complicated because, in addition to removing excess tissue, the tear trough (dark circle below the eye) often needs correction.
If you are considering surgery, you can request a consultation with Richard J. Warren, MD. A staff member will contact you to discuss the procedure, Dr. Warren's availability, and additional scheduling information.
Frequently Asked Questions
The procedure is performed at the Vancouver Plastic Surgery Center, under a light anesthetic administered by a certified anesthesiologist.
For the upper lids, an incision is created in the upper lid crease (the highest fold of the upper lid), and extra skin is removed. Through this same incision, muscle can be tightened and excess fat can be removed. A number of other procedures can also be performed through this incision. One example is correcting eyelid ptosis, a condition occasionally seen in childhood when an eyelid becomes droopy. This can also develop in older adults, and can be corrected at the time of upper lid blepharoplasty.
The lower lids are approached either through a skin incision next to the eyelashes (subciliary incision), or through a hidden incision inside the lower eyelid (transconjunctival incision). Excess skin can be removed, the muscle can be tightened, and fat can be removed, added or rearranged to correct hollowness.
The incisions are closed with miniature stitches, and cold packs are applied to the eyes.
For upper lid blepharoplasty, a patient only needs local anesthetic with sedation. An intravenous will be started and the anesthesiologist will give sedation to make you sleep through most of the procedure. You are technically awake and you will be able to open and close your eyes to the surgeon fine tune things.
For lower lid surgery, which is somewhat more invasive and trickier to do, I prefer the patient to have a light general anesthetic. The anesthesiologist will put you to sleep with an intravenous but you will not be awake until the procedure is over.
The end result of upper lid blepharoplasty completely depends on how the surgeon designs the removal of skin and fat. The most common errors made in this area are when too much skin, muscle and fat has been removed, leaving eyes that look wide open and round. The preferred approach is to be conservative in order to make a person look like they used to look, not like someone different. Old photographs can be very helpful in trying to fine-tune how much tissue to remove. The fact is that no two people have the same eyes, and no two people should have exactly the same eye operation. Furthermore, the perception of eyelid beauty is very personal, and although there are some standard principles, every individual has his or her own hopes and desires which the surgeon must take into consideration.
The upper lid/brow complex undergoes complicated changes as we age. Some things are more obvious – like loose upper eyelid skin. Other problems, like the "hollow" eyes seen in older people are less obvious, and may require fat grafting – something I frequently perform using the Coleman technique to transfer fat from the abdomen or elsewhere. The eyebrows also may change in subtle ways, necessitating repositioning or reshaping to fully complement the overall result of an upper lid blepharoplasty.
There are a number of things that can contribute to this appearance. The most common problem is bulging of fat above the dark circle together combined with a deficiency of fat in the dark circle. It's like having a deep valley next to a mountain – the higher the mountain gets (the bulging fat), the deeper the valley looks. The reason there's a deficiency of fat in the valley, is that as we age, there is a general loss of fat volume in the mid-face and what fat remains tends to fall away from the eye. Meanwhile, fat from within the orbit (eye socket) tends to bulge forward. A third reason for the dark circle is simply the color of skin – some people, especially those with olive colored skin can have particularly dark skin right below their eyes; unfortunately, this tends to get worse with age.
Once ignored by surgeons, surgery to improve the tear trough has been steadily improving. Traditionally, surgeons used only one trick – removing fat – to deal with the problem. While somewhat effective, this solves only half the problem, because it removes the mountain, but leaves the valley. In the early 1980's one innovative surgeon from Brazil, Dr. Raul Loeb, came up with the idea of using the orbital fat we usually throw away, and transferring it into the tear trough (valley). I have been doing this for almost 20 years and believe it to be the perfect solution for most tear troughs. There are exceptions, of course, such as people who have no bulging fat, or who have had their lower eyelid fat previously removed. In such cases, we can use fat grafting (fat injection) to solve the problem, although this result is somewhat less predictable. The down side of transferring fat from the orbit into the tear trough is that this surgery is a little more invasive and the recovery is a little longer, generally up to 3 weeks.
After your surgery, if you have had upper and lower lid blepharoplasty, you will be kept in the recovery room for at least another 2 hours before you are discharged home. The time is shorter if you have just had your upper lids corrected. Your vision will be a little blurry because of the ointment we have put in your eyes, but fortunately, there is usually little or no pain. For many, the most startling thing is the gradual development of black eyes and swelling which tends to get worse for 24 to 36 hours before it gets better. Eyelid skin is very thin, and it doesn't take much to make your eyes look black and blue. You will be given specific instructions about how to minimize bruising, how to care for your eyes, what your activity level can be and when you may shower. We will speak to you by phone the following day.
Eyelids heal quickly, so you will be asked to return to the office in 4 days for removal of the stitches. However, you will still experience some bruising and swelling. After upper lid surgery, patients often are ready to debut their new look in 7 to 10 days, whereas with lower lid tear trough surgery, it may take up to 2 or 3 weeks. There are often some minor disturbances in vision for about 6 weeks following lower eyelid surgery. You will be restricted from athletic activity for 3 weeks. We normally see you about 2 months after the surgery and at 6 months for your final visit.
It is impossible to cut through the skin and not leave a scar behind. Fortunately, eyelid skin is the thinnest skin on the human body, and has the reputation for healing the best. The lower lid incision is essentially invisible within a few months, while an upper eyelid incision normally looks like a thin white line after it's completely healed, but will be mostly concealed in the eyelid crease.
Like any surgery, there are potential complications. However, the majority of these are rare. The most common things we see are small white bumps in the incision line (milia) which develop over the first few months and are easily removable. Minor asymmetries are also common. Dry eye syndrome is a possibility; this may resolve on its own or it may require treatment with appropriate eye drops. The most feared complication is damage to a person's vision although this is an extremely rare event.