Eyelid Surgery

The routine closure will have non-absorbable suture without an external dressing and a coat of antibiotic ointment. On occasion incisions will be closed with absorbable suture and covered via steri-strips. At the initial visit any post-operative dressing will be removed, so please bring a scarf with you for the trip home, as your hair will be disheveled. You may shower or wash over the steri-strips or exposed suture material. Do not bathe, or submerge, for at least 3 weeks after surgery. Be gentle and pat when applying soap, rinsing, and drying. After drying, steri-strip covered incisions do not need any more attention. After drying over incisions with exposed suture, apply a thin layer of triple antibiotic ointment. If present, when the edges of the steri-strips become frayed, trim them. With time, as very little is left behind, they may be removed (usually 2-4 weeks). In some cases additional tape will be used for removing tension from the suture line, or placing tissue in the desired position of healing. If such tape is present, it will be re-applied at the first office visit, and you will be shown how to do this on your own.

As a general rule, keeping the incisions clean and dry will result in the most aesthetically pleasing healed incision with minimal scarring. Do not allow scabs to accumulate, if present you may gently tease it off with peroxide soaked q-tip. While tending to the incision, watch for signs of problems as outlined below. It is not routine to have drains placed at the time of surgery, however, at times, if bleeding is diffuse, and cannot be addressed via surgical maneuvers (clipping, suturing, tying) it may be safer to leave behind a drain in attempting to prevent a hematoma (blood collection). If present, the drains will be removed within one to three days. If non-absorbable sutures were used, they will be removed 7 days after surgery. All incisions behind the hairline/scalp will have clips or suture removed 10-14 days from surgery. Do not expose incisions to the sun and/or tanning UV light for at least 1 year, however, you may begin tanning 4 weeks after surgery while keeping incisions covered. If sun exposure in unavoidable, use a product with SPF of at least 30. On the third day after surgery, discontinue gel pad application.

The swelling associated with blepharoplasty surgery will vary in terms of duration from patient to patient. Apart from individual tendency to remain edematous after surgery, elevation of the head at all times, especially in sleep and rest, and possibly the use of Arnica may speed up the resolution of swelling. Typically, after a week, much of the swelling is gone, allowing the patient to have a glimpse of the results, with an improvement in excess skin presence and/or drooping. Bruising may persist for a month requiring camouflage make-up. If a more extensive dissection was performed, such as in the case of a midface lift, or a browlift in combination with blepharoplasty, or if upper and lower blepharoplasty was combined, significant swelling may persist for as long as 2-3 weeks. Milder swelling, especially associated with sleeping, and the reclined position may persist for one to two months.

Risks associated with blepharoplasty surgery may be grouped into anesthesia risks, and surgical complications. Anesthesia risks are common to any surgery and are discussed elsewhere. Events such as cardiac complications (heart attacks or myocardial infarctions), allergic or anaphylactic reactions, lung-related adverse effects (pulmonary embolism, pneumonia), kidney, liver, or any other organ system problem would all fall under that category. Complications related to the act of surgery may be grouped into risks involved in undergoing any procedure, and risks particular to blepharoplasty or brow lifting. Risks of any procedure include bleeding or hemorrhage, infection, whether skin, soft tissue, abscess, or necrotizing, acute and chronic pain, and acute or chronic skin sensitivity. Delayed healing is more common is persons with vascular disease and smokers. Fluid collections known as seroma may occur in the dissected space, this typically resolves with fluid drainage. Fine results are anticipated but never guaranteed. Dissatisfaction with the cosmetic outcome of any procedure will require procedural correction.

Complications related to specifically to blepharoplasty surgery include asymmetry, which may need surgical correction through re-operation, inadequate correction of the excess skin, over-correction of the lids leading to an inability to close the lids (which may lead to its own problems with the cornea, tearing, dryness, etc. and is usually a result of a combination procedure with upper blepharoplasty – persistent symptoms of this nature may require surgical reconstruction). Alopecia, or hair-loss around the incision is not a frequent complication, but is not rare, and my necessitate hair replacement or re-positioning for correction when blepharoplasty is combined with browlifting. Contour abnormalities, divots, lumps, bumps, wrinkles may result from a blepharoplasty surgery. When presenting weeks after surgery, irregularities may be a result of internal scarring. They typically resolve without issue, but may need correction in some cases. Recurrence of the upper lid skin excess droop is also a common negative outcome in eyelid surgery, in which case additional skin must be excised. “Dog ears” are more of a possibility with the open approach, and may also require secondary correction. Scars are not particular to the blepharoplasty procedure, but their prominence, or asymmetry if present, after this procedure may be hard to mask, and may require revision blepharoplasty surgery or other means of making the inconspicuous. Blindness is caused by pressure due to bleeding into the eye-socket, and is exceedingly unusual. Bleeding around the eye is a true surgical emergency and needs prompt decompression. Damage to the muscles that move the eye (especially the inferior oblique) is also a possibility. This would necessitate prompt repair, and in the case of a delayed diagnosis a reconstruction at a later time. Dryness of the eyes may be exacerbated or unmasked by blepharoplasty surgery. In spite of certain pre-operative tests and a thorough history, it may not be avoided. Ectropion, (an out and down dislodgment of the lower lid from the eyeball), scleral show (drooping lower lid), lid irritation, and at times entropion, may be caused by lower lid blepharoplasty. This may require further surgery for failure to resolve within several months. Difficulty closing the eyelids, owing to scar contracture may necessitate surgery to prevent permanent damage to the corneae. Eyelid hair-loss is typically temporary if it occurs, but if lashes fail to grow back within 4-6 months, surgery may be warranted. Transient swelling at the corners of the eyelids is quite common, and more so when upper and lower lid work is combined. This is usually self-limited, but takes several weeks to months to resolve.

Patients who have a “negative vector,” are prone to complications after lower lid surgery. Although the phrase was coined by a well-meaning, and no doubt intelligent surgeon, the term vector is grossly inappropriate, as would be noted in a review of any high-school physics text. It is intended to signify that the eyeball protrudes further than the part of the cheek-bone that supports it. This, in turn provides no support for the incised lower lid, and carries a significant risk of lower lid droop (ectropion and/or scleral show), with its attendant troubles of dry-eye, or wet-eye, or corneal irritation, or scarring, not to mention a poor cosmetic result. Preoperative dry eye, and absence of the protective Bell’s reflex, ectropion, entropion, scleral show, exophthalmos, whether associated with thyroid disease, or Graves’ all predispose the blepharoplasty patient to significant post-operative complications. Lower lid work carried out in high-risk individuals should include a complete disclosure of the possible problems, solutions, and pre-emptive and intra-operative preventive steps to minimize the risks. This may mean tightening of the lower lid, involving more invasive means combined with primary support of the septum with a substance like alloderm.

Intermittent application of ice packs, or more economically frozen veggie packs will diminish swelling, as will a compression garment designed specifically for browlift patients. When it comes to reducing bruising two natural substances, bromelain, and arnica can help. Their properties are listed below.

• http://www.anyvitamins.com/bromelain-info.htm
• http://www.botanical.com/botanical/mgmh/a/arnic058.html
• http://www.alpinepharm.com

Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright, pinching just enough skin to allow closure of the lids without any remaining skin redundancy. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The previously marked skin is excised. Redundant muscle may be excised as well. The septum (membrane behind which the fat-pads are found) is either entirely opened, or opened at intervals. Fat from both eye-sockets is excised and compared for symmetry. After performing an upper eyelid blepharoplasty, but before closing the skin, the forehead is undermined under the layer (periosteum) covering the skull bones. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. A drill is used to make two symmetric holes to either side of the midline in the calvarium that extend only partially through the skull. This is assured by using a manual drill with a stopper. Two symmetric drill holes are made in the outer portion of the skull. The TransBleph fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. The septum may be closed. At this point if the muscles elevating the eyes are to be repaired, this is performed. The skin and muscle is closed together on both sides. A compressive dressing is then applied to allow the forehead soft tissues to scar in the appropriate position.