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Cosmetic Eyelid Surgery (Blepharoplasty)

What exactly is a blepharoplasty?
In simple terms, a blepharoplasty is an operation that removes excess tissue from the eyelids. Usually with the upper eyelids, surgery involves removal of excess skin with contouring of the eyelid crease. The lower eyelids often require the removal of puffy bags. It can be done for functional or cosmetic reasons. A functional blepharoplasty corrects overhanging eyelid tissue that is interfering with vision (Figure 1). Usually the peripheral vision is most affected. Patients with functional difficulties will often state that holding their eyelids up greatly improves vision. Lower eyelid surgery for removal of “bags” is always considered cosmetic (Figure 2).
Cosmetic blepharoplasty is performed for an improved appearance. These patients are not having any difficulty with their vision. Aging and maturation of the face results in gravitational descent. This causes the eyelids to sag and droop. I believe that heredity affects this process. I have had the opportunity to operate on three generations of the same family. Patients who elect to undergo cosmetic eyelid surgery want a refreshed and more youthful look. They want to reverse the aging process. This chapter will mostly be dedicated to a discussion of cosmetic eyelid surgery (Figure 3).

Why consider cosmetic eyelid surgery?
I believe that “your eyes” are the first thing people notice when they look at you. Your eyes reveal a lot about the way you feel. Sagging eyelids and puffy bags can make you look tired and older than you really are. Most patients feel their youthful and vibrant looking eyes have faded. They have tried many eye creams and cosmetics without results. Job situations may also prompt one to consider cosmetic eyelid surgery.
Remember that cosmetic eyelid surgery is a very personal decision.

What needs to be discussed before cosmetic eyelid surgery?
The best candidates for cosmetic eyelid surgery are men and women who are relatively healthy. There really is no age limit for these procedures. I feel that the preoperative consultation is most important. This is where I spend as much time as necessary to fully understand each patient’s complaints and desires. The most important thing that I emphasize during this visit is that patients have realistic goals and expectations. This will eliminate disappointment. Unhappy patients usually have unrealistic goals that were not understood preoperatively. I have decided against operating on many patients because I felt that their goals were not realistic. I could not achieve these goals with surgery.
The decision to operate on both upper and lower eyelids is reviewed during this consultation.
I can show you many pre and post-operative photos of patients that I have operated on. These are used only for illustration purposes and do not imply any guarantee. I also have many patients who would be happy to speak to you about their experience regarding the surgery and recovery

process. Preoperative photographs are available for planning and discussion with the patient, intraoperative guidance, and postoperative comparison.

A complete history is imperative prior to any surgery. This includes:
1.Age
2.Medical history
3.Past surgeries
4.Ocular history
5.Family history
6.Social history
7.Medications
8.Allergies
9.Any bleeding tendencies
In addition, comprehensive eye and eyelid exams are performed. Since transient incomplete eyelid closure (lagophthalmos) is possible after surgery, tear production and stability must be evaluated preoperatively. With dry eye patients, I advise a more conservative approach to surgery. Lubricating drops and ointments may be needed in patients with dry eyes.

Remember that blepharoplasty cannot get rid of wrinkles or crow’s feet. Laser resurfacing, botox and fillers are used to address these problems. These procedures can, however, be performed at the same time as blepharoplasty. They will be discussed in more detail in Chapter 9.

What can I expect during and after surgery?
The surgery is performed in my state of the art ambulatory surgical center (ASC). This facility allows your surgery to be performed in the safest outpatient setting possible. Safety is always our utmost concern.
The actual surgical procedure can take anywhere from one to two hours depending on the number of eyelids being operated on. During the procedure, sedation is administered by my full time board certified anesthesiologist. This puts you in a comfortable, almost twilight state. You feel no pain during the surgery. After surgery, you are usually in the recovery area for approximately 30 minutes.
Postoperative pain is usually minimal in my experience. Ice packs are immediately started for pain and swelling control. Swelling and black and blue (eccymosis) are maximum at about 48 hours and begin to diminish after this. Swelling and eccymosis usually fades during the first 1-2 weeks. I always tell patients that a certain amount of swelling can last 6 weeks to 6 months. The majority of patients, however, swelling is gone in the first few weeks. Most people return to their normal routine after the first week. The stitches are removed in 7-10 days. I have seen persistent swelling in patients with thyroid disease. This is carefully reviewed preoperatively in all patients with known thyroid disease contemplating cosmetic eyelid surgery.
Table 1 reviews my postoperative instructions.

What are risks and complications associated with cosmetic eyelid surgery?
Like any surgical procedure, risks and complications are possible. Table 2 illustrates the form I review with every patient as part of my informed consent. In summary, some of the potential complications of blepharoplasty include: eyelid crease scar, cysts, undercorrection, inability to close the eye, asymmetry, high eyelid crease, sunken eye, droopy eyelid, infection, decrease or loss of vision, hemorrhage (bleeding), numbness of eyelids, retraction or frank ectropion (pulling down of the lower eyelid), and double vision (diplopia).

Who should perform your surgery?
There are many physicians trained in cosmetic surgery. As I’ve stated elsewhere in this book, I am specifically trained as an eyelid cosmetic surgeon. Experience is very important. I have been doing cosmetic eyelid surgery since 1984. I have performed over 5,000 eyelid surgeries in my career. I have developed my own personal philosophy regarding cosmetic eyelid surgery and the “youthful eyelid” that I would be happy to share with you. This comes from performing and studying thousands of my results and the results of others. Most importantly, you need to develop a trusting relationship with your surgeon who listens to your concerns and is easy to talk to.

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