As we age, gravity often takes its toll on our bodies. Sometimes this results in loose and excess skin on our face and neck. Unfortunately when this happens around our eyes, it can make us look old and tired. Sometimes drooping eyelids are not only a cosmetic problem, but a health one, as in many cases excess skin can interfere with one´s vision. Eyelid surgery may offer you a solution.
Eyelid surgery is a cosmetic change of upper and lower eyelids. Blepharoplasty solves mostly ptosis (drooping of eyelid), fat prolapses or combination of both defects. The surgeon removes excess skin and so-called fat bags (prolapses). If necessary he/she removes also some parts of increased oblique eye muscle. The patient can undergo the upper and lower eyelid surgery at the same time. If there are only fat bags in the lower eyelids and it is not necessary to remove excessive skin, the operation can be done from the inner-conjunctival side of the lid. This is called the transconjunctival version of the eyelid surgery.
If you have droopy or baggy lids, medical specialists recommend undergoing eyelid surgery as soon as possible. The results are then much better and will last longer. Usually, eyelid surgery is done for clients older than 35 years of age, but in some cases, it can be done earlier, usually because of a genetic predisposition of the client. In the case of younger clients, operation of the lower eyelids is done mostly from the inner–conjunctival side of the eye.
Eyelid surgery can improve your look, but do not expect people to treat you differently. It is therefore important to consider what your expectations are from eyelid surgery. Eyelid surgery can be done together with face-lift or browlift.
Prague has many attractive features for those considering eyelid surgery abroad. Its location in Central Europe is easy to access; its mild climate is conducive to healing and its experienced clinics and eyelid surgeons ensure you’ll receive the best possible care. Eyelid surgery Prague costs are often much more affordable than in the UK or with the NHS. For more information about getting to and around the Czech Republic, please visit our handy cosmetic surgery Prague info guide.
First, the consultation with the eyelid surgeon is very important. It is necessary to speak openly about the reasons for the operation and to decide if it is desirable to operate on all four eyelids or just the upper or just the lower. The surgeon will explain the operational procedure and the process of anesthesia. Do not be afraid to ask questions, especially if you have any doubts or are unsure about something. You can also get more information in our blepharoplasty forum.
Avoid the use of medications such as Acylpiryn, Aspirin, Alnagon or Mironal before the eyelid surgery, as they can increase bleeding during and after the procedure.
Eyelid surgery can be only done if the patient is in a general state of good health. Your surgeon will define the extent of pre-operational examinations needed.
While making pre-operation preparations, be sure to arrange for someone to drive you home after your eyelid surgery and help out for a few days, if needed.
If you decide to undergo the surgery under local anesthesia, a presurgical internal examination is not necessary. You are sent to eye department, where quality and field of vision will be checked, pressure inside the eye will be measured and your eye will be examined microscopically with slit lamp (all these examinations are part of normal examination at ophthalmologist).
Blepharoplasty is not performed if your lacrimal aparat does not function sufficiently. Functional tests of lacrimation serve for evaluation (e.g. Schirmer’s test: A small piece of paper with high absorbable features is inserted on the edge of lower eyelid, distance of its moistening is read after certain time). Further the surgeon evaluates various eye parameters:
Size of palpebral fissure: It is a separation between central edge of upper eyelid and the edge of lower eyelid. The palpebral fissure is narrowed, if the distance is less than 10 mm.
MRD1: It is a separation between middle of pupil in the straight position and middle of upper eyelid.
MRD2: It is the same distance between pupil and lower eyelid. Both these distances should measure more than 4 mm.
Distance between eye fold and centre of pupil.
Exceptionally the surgeon requests CT to eliminate pathologic processes in the back part of eye socket.
On contrary functional tests of eyelid levator are common. The upper eyelid is turned and the patient is asked to look upwards. If the levator is in function the eyelid should turn back. The second test checks the elevation of eyelid by elimination of frontalis muscle out of function.
Eyelid surgery is usually performed under local anesthesia. However, the surgeon or patient may prefer to use general anesthesia. In case of general anesthesia, you will not be allowed to eat, drink and smoke for about six hours before the operation. If local anesthesia is used, the patient can leave for home after the surgery, however general anesthesia requires the patient to stay in hospital.
Blepharoplasty usually takes about one hour. The incision of the upper lids is made in a place to allow the scar to be hidden in the eye´s natural folds. The incision of the lower lid is made approximately 2mm under the eyelashes along the edge of the eye. On the base of prior measurements and layout, excess skin and fat bags are removed during the treatment. Then the cut is closed with precise stitches. After the operation, the eyes may be covered with pads and slight elastic compression. According to your needs, the surgery is done on the upper and lower lids simultaneously or separately and can be combined with other cosmetic surgeries of the face.
Indications to this procedure are:
Ptosis: It is drooping of upper eyelid, which interferes beyond the border of cornea. Ptosis can be congenital or caused during life. Mostly it is caused by underdevelopment of muscle that raises the eyelid or by damage of innervation of this muscle. Often also so-called pseudoptosis occurs, when the eyelid does not droop but is covered with skin fold. Pseudoptosis can be also caused by facial asymmetry and therefore is resembles look of a patient with ptosis.
Solution: At first we check the function of eyelid levator. The surgeon fixes the eyebrow with index finger. It disables function of frontalis muscle that works as adjoining muscle to eyelid elevation. After that he/she checks the movement of eyelids. If the movement is greater than 10 mm and ptosis is up to 3 mm, it means that the levator is in good condition.
Fasanell-Servat surgery (Müllerectomy) – Solution to moderate ptosis up to 2 mm with functional eyelid levator. The surgeon turns over the eyelid and cuts out part of conjunctiva and tiny adjoining muscle (Muller’s muscle) and it is sewed to levator. It shortens and reduces the ptosis.
Aponeurosis of levator palpebrae superioris (levator muscle of upper eyelid) – Solution to ptosis greater than 2 mm when the levator’s function is preserved. The surgeon folds the tendon of levator on the smooth cartilage that thickens upper lid.
Resection of musculus levator palpebrae (eyelid levator) – Solution to moderate ptosis with non-functional eyelid levator. The surgeon can choose either approach through skin (transcutaneous) or approach through interior of eyelid (transconjunctival). In case of transcutaneous approach the incision is lead in natural skin fold, so that the final scar is minimally visible. After that part of the muscle is lifted and the rested parts are sewed.
Frontalis suspension – Solution to non-functional levator and/or heavy ptosis. The surgeon makes two short incisions above the eyelashes of upper lid and two incisions above eyebrows. He/she creates tunnel between holes on lids and forehead and laces through them thin fascia artificial or own to the body (firm and flexible muscle cover). Patient after this surgery opens and closes eyelid with the help of frontalis muscle. He/she learns to control the eyelid with this method during rehabilitation.
Fat prolapses, dermatochalasis, and increased oblique muscle: The incision on the upper eyelids and therefore even final scar is lead so that it is hidden in the skin fold of the lid. This way the surgeon gets into the subcutis. After removal of fat prolapses he/she gets to the muscle. Reduction of muscle fibres is not performed commonly, only in case the muscle is too big. By cutting the muscle the surgeon penetrates into fibrous septum, which separates the orbit (part of the cranial cavity containing eyeball) from its external part. It also avoids the transfer of infection to the interior of orbit. Cutting this septum can remove fat that prolapses behind the eyeball. Greater effect can be achieved if the surgeon presses slightly on the eyeball. At the end of the surgery the muscles are sutured. The fibrous septum does not have to be sewed. During the procedure after previous measurement and draft excessive skin is removed. The surgeon must be careful not to remove too much skin, the lid won’t close then.
Indications for lower eyelid surgery are similar to upper eyelids. They can be performed in two surgical approaches. By the first one the surgeon leads the 2 mm incision below eyelashes (subciliary approach), by the second approach is the incision lead from the conjunctival side of lid with laser (transconjunctival approach). The process is similar to upper eyelid surgery. The aim is the same to remove extra skin and fat. Covers on cornea and pads into eyelid are often used by the transconjunctival approach to eliminate unpleasant feelings during fat extraction under local anesthesia. Advantage of this procedure is mainly invisible scars. Although they cause more often complications that the eyelid lifts from the eyeball (Ectropion).
Blepharoplasty can be completed with a surgery correcting the width of palpebral fissure, the height of corners of the eye or their stabilization (canthopexy, canthoplasty).
Canthopexy: It is a surgery of outer canthus that fixes it. It completes blepharoplasty and can be done through same incisions. The surgeon fixes the ligament of outer corner to the ligament that covers parietal bone (periosteum).
Canthoplasty: It is a surgery similar to canthopexy and these terms are often mixed. By canthoplasty the ligaments of outer corner are loosened. After that the surgeon transfers the ligament and sutures it to periosteum. It changes also the shape of eyeball. Also this surgery presents additional procedure to blepharoplasty. Bandages and light elastic compressions are inserted after the procedure. There are new processes, when the excessive fat is not removed but it is shaped into desired shape. Through this method it was achieved to prevent often darker circles below the eyes after blepharoplasty. Sometimes carboxytherapy is recommended for visible eye circles. You can find out more in the articles: Carboxytherapy and How to solve bags and circles below eyes.
In some cases blepharoplasty is not recommended. It is especially when your eyes have small amount of tears or if you suffer from eye infection. If the skin is too short or if you have lagophthalmos (the inability to close the eyelids completely).
Before you go home, you will receive detailed instructions about necessary care and also receive some painkillers. It is recommended to keep your head higher than the body while sleeping. For at least a week, you should avoid physical activities which raise your blood pressure as this is undesirable following eyelid surgery. The first few days after the surgery, the lids will be swollen and small bruises may occur, especially in the area of lower lids. There are many agents that help to moderate bruises and swellings and they therefore accelerate the recovery process. Wobenzym is recommended that moderates swellings. The best is to take Wobenzym second or third day after the surgery and three times a day. It is only an additional treatment; the state improves even without it. A similar effect has also ointment Auriderm, which is applied on the eyelids two times a day. It is good to start to apply it already 10 days before the surgery. There are many of such agents; it is good to talk about their usage with the surgeon. Eyes may be more sensitive to light, and it is usually recommended that patients wear sunglasses. Most people are able to read and perform their normal activities within a few days.
The stitches will be removed at the latest ten days after eyelid surgery, depending on the how the lids were sutured. Most swelling disappears during the first couple of days after surgery, if you carefully apply the compresses. Most clients return to work seven or ten days following eyelid surgery.
If you consider undergoing the eyelid surgery you should know about various complications that can be associated with this surgery. One of them is oculo-cardial reflex caused by pressure in the eyeball. It is manifested by reduction of blood pressure and pulse. This state can be very severe, although usually it is only small pressure reduction. Sometimes we can see separation of the wounds after taking out the stitches.
Most severe complication is so-called ectropion. It is a state when the eyelid is turned outwards and/or when the conjunctiva is separated from the eye. The patient has permanent tears and the skin around the eyes is constantly moist and irritated. One has the feeling of foreign element in the eye. The eye is then too sensitive and easily infected. Ectropion appears soon after the surgery as a consequence of the swellings, such ectropion is temporary and it improves with absorbing of the swellings. Permanent ectropion is caused by removal of excessively big part of the skin or by complication of deep scars in the area of muscles and ligament.
Therapy: It is not simple. If ectropion is caused by excessive removal of skin, muscle or fat and it is visible even during the surgery, an immediate transplantation of removed skin is then recommended. If such state is visible after the surgery, a skin transplanted from the back of the ear lobe replaces the removed skin. Within conservative therapy also a pressure massage and suspension of the eyelid are recommended. Sometimes even a surgical method canthopexy is used (fixation of outer eyelid).
Another possible and severe complication is feeling of dry eye.
Therapy: It is treated by conservative way with the help of artificial teardrops.
We often encounter with lagophthalmos. It is manifested by inability to close eyes completely, especially during sleep.
Therapy: Treatment is conservative because in most cases the improvement is reached without medical help. It is important that the eye doesn’t dry up too much. That is why artificial teardrops and eye creams during night are used. Sometimes it is good when the eyelids are covered with moistured plaster. Exceptionally a surgical treatment is performed.
Swellings and hematomas cause ptosis after the surgery. It is healed automatically during several days. Sometimes the levators of the eyelid can be damaged or innervated during the surgery. That causes permanent ptosis.
Therapy: Following therapy is surgical with the help of frontalis suspension, which is mentioned in therapy of congenital ptosis.
Very rare complication present visible scars, where the ligaments are reproduced. If you already have such scar on your body, consult it with your surgeon immediately after first session.
We usually encounter with hyperpigmentation (increased darkening) of treated area.
Therapy: If the hyperpigmentation is too visible it can be corrected with laser, although earliest half a year after the procedure.
Among very frequent complications that are not too severe belong milia. Those are tiny white formations localized in the scars. They are formed by damage and closing of the apertura of tiny glands.
Therapy: Easy treatment, when the milium is punctured with thin needle and the content is pushed out. If milia are formed repeatedly they can be cut off.
Asymmetry of palpebral fissure doesn’t have to be caused by the surgery. If the patient before the surgery was without asymmetry it means probably asymmetric removal of fat prolapses.
Therapy: The state is treated with reoperation.
The state is often complicated with infections that have very slight progress.
Blindness after the surgery is very rare. It is caused by bleeding behind the eyeball. Pressure of effusion of blood causes mortification of the retina. Symptoms of such bleeding are insidious; it is a tension inside the eye, pain and firm eyeball.
Therapy: It is very complicated. The main aim is to cease bleeding and revision of eyeball. At the same time suction of extravasation of blood. Blood losses are added with infusions and corticosteroids are taken.
The patient can ask for reimbursement of the procedure if it is performed at the clinic that has closed contract with the insurance company. Unfortunately most of the surgeons don’t have that. Surgery of congenital ptosis of eyelids, skin prolapses and fat bags that limit vision are covered. Patient can undergo this covered procedure also at the eye department.
The scars, which are delicate and discrete, may be slightly pink during the initial weeks. Later, they fade and become almost invisible. Usually the eyelid surgery does not have to be repeated. Although the durability of the surgery is very individual, it depends on life style and quality f the skin. Sometimes after 8 to 10 years new fat prolapses occur and reoperation is necessary. The surgeon uses the same incisions; the procedure is simpler than the first surgery. Before and after photos of previous patient’s eyelid surgery can be seen here.