Upper Blepharoplasty

Due to the natural weakening of the skin, protruding fat pads, and sagging eyebrows, the upper and lower lids may change with age. Because the volume of the eyelids and the natural brow elevation varied from person to person, age-related eye changes can appear very differently. Some people's eyes become weary as they become older. The skin may drop over the natural crease of the eye, obliterating it. The skin may slide over the eyelashes and into the visual field in some situations. Blepharoplasty can treat the aesthetic and functional effects of loose eyelid skin.

What is Upper Blepharoplasty?

Excision of the extra eyelid skin, with or without orbital fat, for functional or cosmetic reasons is now known as blepharoplasty. Upper eyelid blepharoplasty can be done the old-fashioned way with stainless steel tools, radiosurgery incisional methods, or laser incisional methods. Tissue adhesives have been utilized for skin closure in addition to standard stitching procedures.

During human interaction and communication, the eyes and periorbital area are frequently the focus point. Aging-related changes in the appearance of the eyelids can send the wrong message of tiredness, sadness, and lack of vigor, which can detract from the cosmetic appearance of the face. A pseudoptosis can be caused by dermatochalasis (extra eyelid skin) or steatoblepharon (false herniation of orbital fat) in some situations. The obliteration of superior visual fields causes symptoms in these patients.

The relationships of the features of periorbital anatomy are influenced by sex, race, and age. Individuals of diverse sexes and races have varied structures around their eyes. When it comes to surgical changes of the periorbita, these particular anatomic relationships are significant.

Upper Blepharoplasty Indications

Upper eyelid blepharoplasty is done for a variety of purposes, both practical and cosmetic. The globe is protected by the upper lids, which also distribute tears over the eye's surface and allow tear drainage through the lacrimal system. If any of these functions are affected, or if considerable ptosis of the upper eyelid is obstructing vision, the physician must decide whether surgery is necessary.

According to a literature analysis by Hollander et al, benefits of upper eyelid blepharoplasty include a wider visual field and increased quality of life, as well as improved vision and reduced headaches. In terms of the surgery's effect on eye dryness and eyebrow height, there were contradictory results. Blepharoplasty of the upper lids is a cosmetic operation that improves the look of the eyes. The relationships of eyebrows, sub-brow fat, upper lid dermatochalasis, or upper lid steatoblepharon are all required to be changed for this treatment. The patient frequently describes weary or drooping eyes.

The psychological status of the aesthetic patient is one of the most essential topics that all facial cosmetic surgeons should consider. The patient's motivation and anticipation of the outcome are the two most significant factors to consider before the surgeon decides to conduct a cosmetic blepharoplasty surgery. Having well-stated and well-understood surgical goals are the greatest method to ensure a satisfied patient. Patients who expect secondary benefits from cosmetic surgery, such as improved personal relations or professional standing, are not appropriate candidates. Patients who predict this type of outcome judge the surgery's effectiveness based on their own personal fulfillment rather than the reversal of aging changes.

Upper Blepharoplasty Contraindications

Dry eyes, thyroid disease, proptosis, and coagulation problems are all considered relative contraindications. There are various degrees of dryness in the eyes. When a patient has extremely dry eyes, it's best to advise them to avoid blepharoplasty because even a small increase in corneal exposure can exacerbate their symptoms. Blepharoplasty may cause lagophthalmos with corneal and visual abnormalities in the setting of thyroid orbitopathy with proptosis. Coagulation problems must be treated on an individual basis and with the assistance of a physician. Before considering further blepharoplasty, patients who have had one or more prior blepharoplasty surgeries (which is becoming more prevalent) should be thoroughly checked for adequate skin and orbicularis function, as well as any lagophthalmos. Lastly, there is a subset of patients who are photophobic, and blepharoplasty should be avoided in these cases.

Upper Blepharoplasty Preparation

Before having blepharoplasty, patients may be recommended to adjust a few routines. Pre-operative procedures may include the following:

Stop using nicotine and stop smoking. Smoking and nicotine slow down the healing process and age the skin prematurely. When people stop smoking, their cardiovascular activity improves. This can take up to a month, so the sooner you quit smoking, the better.
Discontinue certain medications. Before surgery, specific drugs and supplements must be discontinued. Aspirin, ibuprofen, and vitamin E are among them. Tell the doctor about all medications and supplements you're taking, including prescription and over-the-counter.
Prepare for recovery preoperatively. This includes scheduling time off work, organizing transportation to surgery, and filling prescriptions following surgery. It's also a good idea to plan ahead of time for meals, ask for help with household and child care, and buy supplies for the recovery time.

Upper Blepharoplasty Procedure

Skin Marking

The maximum limit of skin removal and the skin crease is the most significant feature of blepharoplasty marking. Any stain that will not be entirely eliminated when the patient is prepared can be used for marking. The skin pinch or skin flap method is one of the marking techniques. The skin pinch procedure is performed with the patient seated and his or her eyes closed. The lower incision line is determined by the natural palpebral fold. The extra skin is caught between the forceps' jaws with small forceps. When the eyelid skin is smooth and there is no gap between the lids, upper eyelid fold markings are formed.

Skin flaps are formed by detaching the skin over the entire upper eyelid region from the underneath orbicularis muscle in the skin flap procedure. The lifted eyelid skin is subsequently redraped over the orbicularis, resulting in a skin overlap. Excess skin is identified and removed.

The main difference between functional and cosmetic blepharoplasty skin-marking techniques is that in functional blepharoplasty, the lateral incision reaches beyond the lateral canthal area to accommodate lateral hooding and brow ptosis, whereas, in cosmetic blepharoplasty, the lateral incision should not lengthen beyond the lateral canthal area.

Anesthesia

The upper blepharoplasty is normally done under a local anesthetic. 2-3 ml of 2% lidocaine with epinephrine is given subcutaneously over the defined upper eyelid and lateral canthus with a disposable needle for anesthetic and hemostasis.

Upper Blepharoplasty Incision

One side of the wound is lifted and the skin is removed using a radiofrequency cautery with a fine-angled empire tip after the skin incisions are fashioned. Small incisions over the septum allow immediate access to preaponeurotic fat pads when a strip of pre-septal orbicularis is removed. The color (embryonic source, medial fat pad is neural crest-derived) distinguishes the medial (whitish) and central (yellow) fat pads, which are gently tugged out through the orbital septum's microscopic holes. When removing with a radiofrequency cautery, the fat pads should either be excised using electrocautery or held with a hemostatic clamp. Before assisting its retraction back into the orbit, the residual stump in the hemostatic clamp is cauterized.

Two nonabsorbable sutures are used to reposition the retro-orbicularis oculi fat for regaining eyebrow volume and internal fixation at the target place, i.e., 2-3 mm above the supraorbital border. To establish a conspicuous and desired eyelid crease, interrupted horizontal mattress sutures are threaded through the orbicularis oculi muscle, superior border of the tarsal plate, and levator fibers. The skin is then approximated using nonabsorbable sutures, which can be continuous or interrupted.

In the elderly, upper blepharoplasty is frequently combined with brow ptosis repairs, such as internal browpexy, external browplasty, or corrugator myectomy. A browpexy is a stitch that connects the brow to the frontal bone underneath it. It can be done from the inside of the eyelid (internal browpexy) or via a minor incision above the brow (external browpexy).

There have been several surgical procedures for brow lift surgery documented:

The direct brow lifts. It involves the removal of supraorbital skin and subcutaneous tissue above the brow, followed by the skin and subcutaneous tissue being closed.
Temporal brow lift. The incision is made behind the temporal hairline, and the separation plane is over the fascia temporalis proper toward the lateral orbital rim, coupled with soft tissue fixation.
Transpalpebral browpexy. The lateral brow is anchored to the frontal periosteum, at a more cephalad point, through an upper eyelid crease.
Pretrichial brow lift. It is a procedure that lifts the brow by making an incision immediately in front of the hairline. The incision for a mid-forehead lift is made in the deepest creases of the forehead. Skin and subcutaneous tissue are removed, and the wound is closed without tension.
Coronal brow lift. It is an open-sky procedure in which skin and subcutaneous tissue are removed several cm behind the hairline.
Endoscopic brow lift. Endoscopic brow lift has gained widespread acceptance as a treatment for restoring a young brow, as it requires only three barely visible scalp incisions for subperiosteal dissection and final brow repositioning.

Postoperative Care

An antibiotic ophthalmic ointment is applied to the skin incision immediately after surgery. Following the surgery, ice compresses are applied for 48 hours, 20 minutes each hour while awake. For 5 days, the area is cleaned every day and antibiotic ointment is put on the incision before sleep. After this surgery, some swelling and ecchymosis are common, and the cold compresses help to reduce this and reduce patient distress. Acetaminophen is commonly used, and narcotic pain medications may be provided in some cases. Heavy lifting, rapid bending, and vigorous sports activity are discouraged for two weeks after the treatment. The day after the surgery, you are allowed to shower. After 2-3 weeks, normal activities may be resumed.

Upper Blepharoplasty Follow-up

The patient is examined the next day after upper eyelid blepharoplasty to check edema and ensure that the eye is soft and free of bleeding. The wounds are evaluated, and the patient is instructed on how to care for them. Patients are encouraged to gently go over the incision line with a cotton tip applicator drenched in a dilute hydrogen peroxide solution to keep the wounds clean and dry. Any additional comments or concerns are handled at that time. Patients are then seen 5-7 days after surgery to get the sutures removed.

Upper Blepharoplasty Complications

Cosmetic blepharoplasty is often misinterpreted as a quick, painless, and complication-free treatment. This might be the case with adequate preparation, adequate physician expertise, and acceptable patient selection. Unsatisfactory outcomes and unanticipated complications do, however, occur.

Hemorrhage and infection are two major consequences that occur infrequently. Manage hypertension and stop taking medications that make you more prone to bleeding to avoid eyelid hematoma and vision loss from retrobulbar hemorrhage. The need for cautious and meticulous hemostasis during surgery cannot be overstated. Thankfully, retro-orbital bleeding and vision loss are uncommon consequences. Visual loss after blepharoplasty has been reported to occur in one out of every 45,000 patients. Following lower eyelid blepharoplasty, retro-orbital bleeding is the most prevalent complication.

Bleeding in the retro-orbital space can lead to acute compartment syndrome, which necessitates immediate medical attention. The skin stitches are released, the hematoma is emptied, and the incision is re-explored to determine the source of the bleeding if the active hemorrhage is evident. A lateral canthotomy and cantholysis may be conducted if these treatments do not relieve the compartment syndrome. Exophthalmos and vascular congestion can be treated with intravenous mannitol and steroids to lower intraocular pressure. Orbital decompression may be needed in specific conditions to reduce orbital pressure.

Because of the high vasculature of the upper eyelids, eyelid infections after blepharoplasty are quite uncommon. When they do arise, however, they are treated as soon as possible with the necessary antibiotics. The wound is exposed, evacuated, and cultured with debridement of necrotic tissue before being closed.

After upper eyelid blepharoplasty, excruciating pain is unlikely. To control postoperative pain, a mild painkiller without aspirin is typically sufficient. If unmanageable pain persists after blepharoplasty, an examination is conducted as soon as possible to determine the source of the pain.

Excessive skin removal or incisions made in the wrong spots can lead to complications. The production of a band or webbing may occur if the incision is extended above the medial canthal angle. A noticeable scar or folds may develop if the incision is extended beyond the lateral orbital rim. Excess skin removal from the upper lid can lead to lagophthalmos with exposure keratitis, upper lid ectropion, or downward brow traction, aggravating brow ptosis. This problem can be avoided by carefully measuring the density of skin to be removed before surgery. In the early postoperative period, mild lagophthalmos may develop, which can be addressed with lubricant eye drops and ointment.

Excessive skin resection, a scar of the orbital septum to the skin, excessive levator advancement, or atypical scar contraction can all cause severe lagophthalmos. A second surgery may be needed to remove the septum's adherence to scar tissue or to put a skin graft to restore the upper eyelids' anterior lamellar shortening.

Blepharoptosis is a rare complication that might develop as a result of an unintentional levator injury during the surgery. If the ptosis lasts longer than 6 months, the levator aponeurosis must be observed and repaired.

Accidental injury to the superior oblique muscle during the removal of the medial fat pad can lead to extraocular muscular imbalance (diplopia). The superior oblique tendon can be injured by cautery and tissue excision in the medial supraorbital quadrant.

Excessive fat removal in the upper eyelid causes hollowing of the soft tissue above the eyelid crease or a deep superior sulcus. Another issue that can result in asymmetry or folds in the eyelids, as well as a dissatisfied patient, is residual extra skin or fat. Eyelid crease asymmetry can occur as a result of inadequate preoperative planning or a less-than-pleasant response to the surgeon's attempt to change the crease position. When a patient has previous unilateral ptosis, the asymmetry may become more noticeable after the overlying skin folds are removed.

Upper Blepharoplasty Cost

Some sources provide an average blepharoplasty cost, but this can be misleading because typical expenses do not always cover all of the fees related to surgery. Anesthesia, surgical center bills, medications, and post-operative supplies are all common charges. Along with blepharoplasty, a patient's costs reflect the other operations he or she may have. It's essential to weigh the cost of blepharoplasty against the long-term benefits of the treatment. Some people just need eyelid rejuvenation once and see long-term results.

Surgery on the upper eyelids is a reasonably simple procedure. It takes only 1-2 hours and is performed under local anesthesia. Patients can expect to pay as little as $1,500 for their treatment, with an average cost of around $3,200.

Will the Results of Upper Blepharoplasty Be Permanent?

Patients can usually see the outcomes of their eyelid rejuvenation surgery two weeks following the procedure. The eyes appear to be younger and more vivid when the edema decreases. Although normal aging will continue, it is realistic to expect long-term effects from blepharoplasty. Following blepharoplasty, wearing sunglasses and lightly applying sunscreen around the eyes can help to promote healthier and better aging.

Is Upper Blepharoplasty Safe?

Blepharoplasty was one of the top five cosmetic operations conducted in 2018, per the American Society of Plastic Surgeons. The surgery was the most common among patients aged 55 and up. Even though eyelid operations are not devoid of risk, the majority of patients recover quickly. The most frequent side effects of the procedure are bruising and swelling, which usually go away in two weeks.

Is Upper Blepharoplasty Painful?

Local anesthetic, oral or IV sedation, or general anesthesia are all options for blepharoplasty. The type of anesthesia utilized is determined by the patient's comfort level, overall health, and the presence of additional surgeries like a brow lift, facelift, or rhinoplasty. A local anesthetic and an adequate sedative can provide patient comfort. Some patients, on the other hand, prefer to be unconscious during their operation. During the meeting, doctors help patients choose what will work best for them by going over the details of each choice.

Conclusion

Upper blepharoplasty is an esthetic and functional surgical treatment that is frequently done. However, because the eyelids protect the most crucial of the senses, vision, surgery must be done with caution and forethought. Surgeons should tell patients that they have the choice of not having surgery, but if they do, they should be given comprehensive information on what to predict as well as information about all potential scenarios that relate to the specific patient.