The effects of aging, gravity, lifestyle and sun exposure have an effect on the soft tissues of the face and this is often seen in the region around the eye. In the lower eyelids a dark circle or bag under the lower eyelid is the first sign of contour change. Additionally the mid-face soft tissue may droop or shrink in volume exposing the facial skeleton and accentuating adverse contours in the periorbital region.
THE RELATIONSHIP BETWEEN THE LOWER EYELID AND THE MID-FACE
Any experienced plastic surgeon will recognise that the lower eyelid and mid-face regions are inexorably intertwined. One cannot be considered without assessing the other and, in Mr McDiarmid’s opinion, one of the main indicators for elevation or augmentation of the mid-face region is amelioration of the lower eyelid and elevation of the lid-cheek junction.
THE EFFECT OF AGEING
The orbital fat begins to bulge forwards through a previously tight layer called the orbital septum which becomes slacker with time. In younger patients with milder degrees of bulging, simply removing the excessive fat from within the eyelid may be all that is required and leaves no external scar (the so-called transconjunctival blepharoplasty). The option of additional tightening of the external skin is also possible using either a chemical peel or laser resurfacing. In older patients the skin around the eyelids can also be excessive and require trimming and redraping, necessitating lower eyelid blepharoplasty. When the cheek is very flat (so-called negative-vector cheek), or the sclera of the eye is clearly visible between the lower part of the iris and the upper margin of the lower eyelid, the lower lid may require tightening with procedures known as canthopexy or canthoplasty (or tarsal strip procedure). For patients with underprojection of the mid-face augmentation this can be beneficial and, in patients whose mid-facial tissues have drooped, a mid-face lift or a high lamellar SMAS lift (which incorporates elevation of the mid-facial tissues) can enhance the effect of blepharoplasty. In severe cases a mid-face lift or malar augmentation may also be advisable in order to provide support for the lower eyelid. Most eyelids with significant bags benefit from canthopexy and its regular use minimises the risk of lower eyelid malposition or ectropion to almost zero. Mr McDiarmid favours the transcanthal variant of canthopexy which creates a very effective retightening of the lower eyelid soft tissues.
In the upper eyelid region it is important that excess skin should not be confused with brow ptosis or drooping of the brow (see browlift section). Brow ptosis characteristically causes the outer parts of the upper eyelid to start hooding over the lid. Patients can check for brow ptosis by feeling the bony orbital rim (brow rim) and comparing the position of the eyebrow to this. If the eyebrow lies at or below the position of the brow rim then this is a sign that lifting the brow may be necessary. In patients who have had an upper lid blepharoplasty previously and have recurrent hooding of the upper eyelid, a carefully performed browlift may be all that is necessary to open the eyes again, and reduce the appearance of tiredness.
WHAT DOES THE SURGERY INVOLVE?
Lower Eyelid Blepharoplasty is performed through a small incision under the lower eyelid lash line (subciliary incision). The fat pockets are reached by making a delicate incision through the orbicularis muscle at the junctions of its pretarsal and preseptal parts. Fat can then be judiciously redraped (only very occasionally removed) and mixed with the cheek fat to efface the tear trough. The tear trough is the gap between the herniated orbital fat and midface SOOF fat (suborbicularis oculi fat). Fat removal is avoided in order to improve the contour of this area without causing hollowing. More frequently almost no fat removal is performed and the fat is simply redraped over the orbital rim and attached to the fat of the midface area (the SOOF). This enables a dramatic improvement in the interface between the lower eyelid and the mid-face and can occasionally efface any evidence of it completely. This is also known as arcus marginalis reset or SOOF lift. Canthopexy (or occasionally canthoplasty) is usually performed and the skin is then redraped, trimmed and carefully sutured (stitched) back together.
Excessive skin in the upper eyelid or blepharochalasis is a more common phenomenon causing the appearance of more widespread hooding and should be treated by upper eyelid blepharoplasty.
Upper lid blepharoplasty involves making an incision in the upper eyelid crease and removing excessive skin, often with a fine strip of the underlying orbicularis oculi muscle and occasionally with a little fat from the medial (inner) upper eyelid fat pocket. The skin is then redraped and sutured carefully to hide the resultant scar. It is possible to perform blepharoplasty surgery under local anaesthesia, although a general anaesthetic is preferable for patients undergoing surgery to all four eyelids, or patients requiring canthoplasty/canthopexy. Most surgery can be performed on a day case basis but patients should not drive to hospital as they will not be able to drive home. In patients who have had canthopexy/canthoplasty the use of ocular lubricants for a few weeks following the operation may be necessary until the natural lubricating mechanisms return to normal. It is also advisable to refrain from using contact lenses for several weeks after surgery.
WHAT ARE THE SCARS LIKE?
The area around the eye heals more forgivingly than almost anywhere else in the body and it is unusual for the scars to be noticeable after surgery. The scar in the upper eyelid runs laterally in the crease, six or seven milimetres above and parallel to the eyelash line from the inner aspect of the orbit, to the lateral orbital rim. Curving the scar upwards slightly here avoids a downwardly slanted crow’s foot later on and gives a happier appearance. In the lower eyelid the scars run along just below the lower lash line and then continue laterally for a few millimeters into the crows feet area.
HOW PAINFUL IS IT?
Additional local anaesthesia is used in all cases, whether or not the patient goes to sleep for the procedure, so this takes the edge off the initial post-operative pain. The amount of discomfort after the local anaesthetic has worn off is usually quite easily tolerable and patients are offered a short course of pain killers on discharge from hospital.
WHAT HAPPENS AFTER SURGERY?
Eyepads with an underlying layer of vaseline are placed over the eyes and antibiotic cream placed into the eyes in the operating theatre. A combination of the tightening of the orbital soft tissues and the creams and dressings applied can cause temporary blurring of vision. Patients undergoing surgery under general anaesthetic should be aware that they will wake up with a bandage over their eyes. Dressings are usually removed prior to discharge and sutures are removed five to seven days after surgery. The majority of bruising should resolve by day ten and Arnica Montana tablets (taken from 48 hrs pre-operatively until the sutures are removed) can help to reduce the amount of bruising and swelling. After sutures have been removed it is necessary to begin massaging the lower eyelid in an upward and outward direction to soften the scars and maximise the lifting effect of the surgery. Contact lenses should be avoided for at least the first two weeks after surgery.
WHAT COULD GO WRONG?
All forms of blepharoplasty and blepharocanthoplasty are very safe when performed carefully with judicious removal of the necessary soft tissues. Lower eyelid blepharoplasty can sometimes make it impossible to wear contact lenses for several weeks following the surgery. Also the eyes can become transiently more sensitive in winds and on cold days causing excessive tear leakage. If the skin is over tightened then the lower eyelid may not sit against the globe of the eye after surgery and the sensitive lower conjunctival fornix can be exposed. This is called lower eyelid malposition and is far better prevented (by canthopexy/ canthoplasty) than treated. More severe cases of lower eyelid malposition can create a condition known as ectropion which may require further surgical intervention to correct it.
Upper eyelid blepharoplasty is a very safe procedure and it is extremely rare for patients to suffer complications. Extremely rarely, following very extensive orbital fat removal, bleeding can occur within the orbit and although blindness has been reported as a complication following this procedure (as a direct consequence of a blood clot compressing the optic nerve) there are only a handful of cases in the world of literature describing it.