BLEPHAROPLASTY

Background

Upper lid blepharoplasty surgery is most often carried out to rejuvenate the upper eyelids.  It always entails skin removal and sometimes entails muscle removal depending on the patient and their eyelids.

The procedure can be combined with various other forms of surgery to improve the appearance of the eyebrow, such as a browpexy.  Sometimes fat is removed, particularly at the inner corner of the upper eyelid.

This is a commonly performed cosmetic procedure and excellent results can be expected. However, as with all surgery, there are risks as well as benefits and alternatives.

All patients can expect to be bruised for one to two weeks and swollen for two to three weeks.  Incision sites heal well and are usually well hidden within the skin crease.  Sutures, if not dissolvable, are removed five to seven days after surgery.

It is important to understand that there is a risk to the vision, albeit a very small one.  There is a 1 in 5,000 to 1 in 10,000 chance of permanent, irreversible loss of vision due to haemorrhage behind the eye.  This risk can be reduced by sensible pre-operative preparation, good surgical technique and post-operative care.

Another risk factor, in general terms, of this surgery is that too much skin can be removed which can impair adequate eyelid closure.  However, this is readily avoided by sensible surgical technique.

Most patients would expect to have slightly dry eyes (or worsening of pre-existing dry eye) for four to six weeks.

Nearly everyone has a degree of facial asymmetry which will persist after surgery; usually surgery reduces it but does not abolish it with regard to the eyelids.

Browpexy, if needed, is done through the same eyelid crease incision made for an upper blepharoplasty (eyelid lift) or an eyelid ptosis repair (droopy lid repair). Once the skin is open, the surgeon dissects to the brow bone and then anchors the underlying brow soft tissue to the bone, allowing for stabilisation. It doesn’t lift the forehead, only the eyebrows.

Browpexies are not as powerful as an endoscopic forehead and can sometimes prove temporary. They should last five years, sometimes longer. Sometimes patients then decide they want a browlift. This can be done without affecting the blepharoplasty results.

The risks of browpexy surgery, as it is done in conjunction with the blepharoplasty, are the same as the latter, as well as dimpling from the suture or nerve damage.  

If you experience any loss or lowered sensation in or around your forehead, this will normally normalise within 6 months.

Lower blepharoplasty surgery is the removal of fat bags or smoothing out of the area below the eyes. If you have this surgery at the same time you would most likely need this done under general anaesthetic as it is a longer procedure (you’d be in theatre for about 2.5 hours).  There are, therefore, really important ‘starving instructions’ as below.

You MUST NOT eat, drink, suck or chew anything from six hours before the time you are asked to come into the hospital. Please note that this includes sweets and chewing gum.   The time you are asked to come into the hospital will be on the admission letter which the hospital will send you.

Pre operative assessment

If you are having a general anaesthetic, or a local anaesthetic under sedation, the hospital will contact you to arrange a pre-operative assessment (urine sample, blood pressure check etc) which usually takes place a few days prior to surgery.

Pre operative instructions

Assuming you notify Mr McMullan of all medication at your initial consultation, unless told otherwise, continue to take your medication up to and following surgery. It is very important that you let Mr McMullan know of any allergies you may have.

Please avoid ginseng, garlic, ginkgo biloba, vitamin C & E pills for 10 days prior to surgery.

Some people find that taking Arnica pills, available from most pharmacies and wholefood shops, in the ten days prior to surgery helps to reduce the bruising.

Please read the post operative instructions below and ensure that you have everything ready for your return home; ie compresses, clean tea-towels/wash cloth, over the counter painkillers etc

As you will need to avoid bending down for at least a week after surgery, please sort out your items in the kitchen, medicine cabinet etc, so they are within easy reach. You may not do any heavy lifting either so it may be worth asking a friend/partner to do the grocery shopping, dog walking etc.

Please avoid alcohol, ideally for a week preceding surgery.

Please ensure you have organised someone to be with you for the first night in case you need any help. One eye may have a pad placed over it for one night (you can remove this the following day) in which case you will be monocular so may need help with stairs, judging distances etc.

You may wish to wash your hair on the morning of surgery so that you don’t have to wash it too soon after surgery (you are urged to keep your head raised post operatively –see post-op instructions).

Please wear comfortable clothing to the hospital. Please do not wear make-up or moisturise around the eye area on the day of surgery.                                            

Post-operative instructions – VERY IMPORTANT

Social distancing

Please ensure you adhere to social distancing in the fortnight after surgery, really to avoid catching any bug, not just Covid, as you want to be able to heal in good health.

General instructions

After surgery there will be bruising for 1-2 weeks and swelling for 2-3 weeks. It is important that you help the healing process by following these instructions:

Cold Compresses:

On the day of surgery and two days after surgery, you should apply cold compresses to your eyelid/eyelids.  Obviously, if you have a patch in place you cannot use compresses on the patched eye.  In order to make a cold compress first take a clean, wet wash cloth and rest it over the eyelids.  Place either a bag of frozen peas or a ziplock bag filled 2/3rds of the way with ice and 1/3rd of the way with water over the wash cloth.  It is easiest to use cold compresses when seated in a reclined position.  The more you use cold compresses the less you will bruise and swell after surgery and the faster you will recover. 

You should use the compresses a minimum of 20 minutes out of every hour while awake. When sleeping you do not need to use the compresses and getting adequate sleep is important to healing.  It is useful to keep your head elevated when you sleep. 

Warm compresses:

Warm compresses are used to help resolve bruising.  If your face is not bruised after the first 2 days and your eye is not irritated, then you do not need to use warm compresses.  A warm compress can be made by placing a wash cloth under hot tap water.  To prevent scalding your skin always test the compress out on the back of your hand before applying to your face as your surgical area may have decreased sensation.  Warm compresses should be applied to the bruised portion of your face for 15 minutes 3 times daily until the bruises turn yellow.

Important general guidelines:

Ø  Perform no heavy lifting, no bending with your head below your heart, or extreme exertion for at least seven days.  Avoid any activity that causes your face to turn red.

1st 24 hours after surgery:

Ø  Keep your head elevated at all times (additional pillows without kinking your neck while sleeping)

Ø  Place a clean old towel over your pillow, in case the wounds drip any blood.

Ø  Gently place cold compresses as often as possible.  More frequent ice compresses will lessen bruising and swelling.

Ø  Expect swelling to worsen and often it will be worst upon awaking from sleep.

24-72 hours after surgery:

Ø  Continue cold compresses.

Ø  Limited activity only with head elevated

Ø  Shower but avoid scrubbing or rubbing surgical area.  Pat dry wounds and ice after shower

Ointment

Ø  With most surgeries you will be provided with a small tube of antibiotic ointment to place onto the incision line – apply 3 times a day with very clean hands.  If your eyes feel dry or scratchy you may also put the ointment in your eyes but this will of course blur your vision.

After 72 hours:

Ø  Switch to warm or hot compresses, 15 minutes 3 times a day.  These will increase blood flow and carry away fluid and bruising from the surgery.  This will also safely break apart blood clots and wound crusts.  Because your skin sensation will be decreased postoperatively, we advise against warm compresses that are uncomfortable to touch on the back of your hand.  To avoid skin burns, DON’T USE MICROWAVED TOWELS.

Ø  You may resume regular showers unless the wounds are still patched.

Ø  Do not remove or change your dressing unless advised to do so by me.  This will be done for you at your post-operative visit.

Medication

Ø  Resume all your usual prescription pills and eye drops unless instructed otherwise.  Be sure to take blood pressure medicine with a very small sip of

Ø  water even on the day of surgery.

Pain control. 

Ø  Extra strength paracetemol (unless allergic) and cold compresses will be plenty for most patients, and if that is not enough Mr McMullan may give you a prescription for stronger medication for the first few days as needed.  It is normal for you to have some pain after surgery.  The pain should get better on a daily basis and if it is getting worse instead of better this is not normal and you should contact Mr McMullan immediately.

Important information about your wounds:

Ø  Notify us if enlarging redness, purulent (non-clear) discharge, or increased tenderness or pain develops.  Bloody discharge for a few days is normal.  The sutures are placed apart to allow blood to egress in order to decrease swelling and bruising.

Ø  Your wounds will naturally be red for a while.  After the first week start applying sunscreen with at least SPF15 for at least the next 6 months to minimize any darkening of your scars.  Makeup may also be restarted.

Ø  Utilize the provided antibiotic ointment for the first week at least at bedtime.  The ointment may blur the vision if you put it in your eyes or if it accidentally gets in your eyes, but the small tubes provided to you are safe for your eye unless you are notified otherwise.

Ø  Your sutures (stitches), if they are not dissolvable ones, will be removed 5-7 days after surgery.

Ø  Wash you face in cold, boiled water and blot, rather than rub, dry at least until you have your sutures removed.

Vision. 

Ø  Your vision after your surgery will be blurred from your eyelid swelling and application of the antibiotic ointment.  If, however, you experience a sudden loss in vision in conjunction with worsened swelling or pain in your eyeball, then notify Mr McMullan immediately or, failing that, attend Eye Casualty at your nearest hospital.

Six week period after surgery

Ø  If booking a holiday, please avoid foreign travel for at least four weeks, ideally six weeks, after surgery to ensure that you can be seen by McMullan if any issue occurs.

Ø  You may swim after four weeks

Ø  Gentle exercise only, after two weeks

These guidelines promote faster healing but the total healing time varies from person to person. Your bruising and swelling and/or scarring may last less or longer than average.

Risks of surgery

These are as will be discussed with Mr McMullan during the consultation and as above and also as detailed in the blepharoplasty information including ‘EIDO’ leaflets which will be given to you, and which you can find online and a consent form.