Eyelid Surgery (Blepharoplasty)

Excess skin or a drooping lid?

Heavy, tired-looking eyelids can have more than one cause, and each is treated differently.

• Excess skin (dermatochalasis): With age, the skin of the upper lid loosens and folds over the crease, sometimes down onto the lashes. The lid margin is in the normal position, with extra skin sitting on top of it. Blepharoplasty removes that surplus.
• Drooping lid (ptosis): Here the edge of the lid itself sits too low and may cover the top of the pupil. The usual cause is that the muscle lifting the lid (the levator) has weakened or stretched away from its attachment. Age, many years of contact lens wear and previous eye surgery can all contribute, and some children are born with it. Removing skin alone leaves the lid sitting too low.
• Drooping brow: When the eyebrow descends, it pushes down on the upper lid and can look very much like excess lid skin.

Many people have two of these at once. Measurements at the examination show how much each one contributes, and that determines what the operation involves.

When do drooping eyelids affect vision?

Once upper-lid skin reaches the lashes, it cuts off the top of your field of vision like a blind half drawn down. Most people compensate without noticing by raising their eyebrows, and the forehead strain can leave them with an aching brow or headache by the end of the day. Common complaints include missing overhead road signs while driving and tiring quickly when reading.

In these cases surgery has a functional aim, which is to clear the field of vision. A visual field test (perimetry) is done twice, once with the lids in their natural position and once with them taped up. The difference between the two results shows how much of the loss is caused by the lids.

If your main concern is appearance, assessment starts with the same measurements. What surgery can and cannot change depends on the structure of your lids and the surrounding tissue, and that is discussed at the examination.

How are upper and lower blepharoplasty done?

Upper eyelid

The incision is marked to fall within the natural lid crease. Surplus skin, a thin strip of muscle where needed and any bulging fat are removed, and the incision is closed with fine stitches.

Lower eyelid

Under-eye bags form when the fat cushioning the eyeball pushes forward. If there is no excess skin, the fat can be removed or repositioned through the inside of the lid, leaving no cut on the skin. If there is surplus skin as well, the incision runs just below the lashes. The tension of the lower lid is checked beforehand, because a lax lower lid can be pulled downwards after surgery and the plan has to allow for that.

Ptosis and other eyelid operations

In ptosis surgery, the lifting muscle is shortened or reattached to its proper position. If the muscle is very weak, the lid can instead be linked to the forehead muscle so that raising the brow lifts the lid.

Other eyelid problems treated under oculoplastic surgery:

• Entropion: The lid margin turns inwards and the lashes rub against the cornea. It causes stinging and watering and, if left, can damage the cornea.
• Ectropion: The lid margin turns outwards. The eye dries out, tears spill onto the cheek and the inner surface of the lid becomes red.
• Cysts and lumps: Cysts such as a chalazion and small lumps on the lid are removed surgically. Any tissue that looks suspicious is sent for laboratory examination.

What is measured before surgery?

The examination measures the distance between the lid margin and the centre of the pupil. The strength of the lifting muscle is assessed by how far the lid travels as you look from down to up. Brow position, any difference between the two sides and the tension of the lower lid are recorded. Tear tests are done because dry eye can get worse for a while after surgery, and a visual field test is arranged if needed. This is also the time to mention every medicine you take, blood thinners in particular.

A droop that came on suddenly, varies through the day or comes with double vision is a different matter. These signs can point to a nerve or muscle condition and are investigated before any surgery is considered. If your eyelid drops suddenly together with double vision or a severe headache, go to an emergency department without delay.

Assoc. Prof. Dr. Elif Ceren Yeşilkaya decides on the scope of surgery from these measurements. Removing skin may be enough; some patients also need the muscle tightened or the lower lids treated.

Looking after your eyelids after surgery

• Swelling builds at first and then starts to subside. Bruising may track down towards the cheek.
• Cold compresses and keeping your head raised help reduce swelling, so sleep propped up on an extra pillow or two in the early days.
• Use the antibiotic and anti-inflammatory drops as prescribed. The lids may not close fully at first, which can cause temporary dryness or watering.
• Stitches are removed at a follow-up visit, and your doctor sets the dates of your check-ups.
• Avoid strenuous exercise and keep the incisions out of the sun until your doctor tells you otherwise.

Risks and when to get help straight away

Beyond the expected bruising and swelling, possible problems include asymmetry between the lids, incomplete lid closure for a while, dryness, a more noticeable scar, the lower lid being pulled down and, rarely, infection. Some people need a second procedure to correct the result.

Bleeding behind the eyeball is very rare but can threaten sight. If in the hours or days after surgery pain keeps getting worse, the eye feels tight and pushed forward, or your vision drops, seek help immediately. Spreading redness, fever or discharge also needs to be seen the same day.

The first consultation takes place at Medicana Zincirlikuyu (Şişli, Istanbul). Lid measurements and tear tests are taken at that visit, and a visual field test is arranged alongside if it is needed.