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Anatomy
Both upper and lower eyelids consist of 3 layers: Skin on the outside, muscle
in the middle, and fatty tissue on the inside. Surgery is tailored to the
specific needs of the individual, and would typically involve modifying some
or all of these layers.
Upper Eyelids:
Often the 'first sign of ageing', upper eyelid surgery is generally
simple to perform, and the results are generally good to excellent.
The major problem in most people presenting for this surgery is
skin excess, which hangs onto the lid margin,
and gives a tired appearance. The surgery is done under local
anaesthetic with sedation, and a strip of skin is removed from
the upper eyelid. This leaves a thin, fine scar in the upper eyelid
crease, which fades over a few months to become barely perceptible.
Often, some fatty tissue is removed at the same time, but little
or no muscle (middle layer) is removed. The incision is closed
with stitches which are removed at 5 days to a week post op. Bruising
and swelling are variable, but usually minor - most important
is to avoid aspirin or medication containing aspirin for about
2 weeks prior to the surgery - see under advice
Lower Eyelids:
These are somewhat more tricky surgically, since most of the cheek
fat is suspended just below the lower eyelids, and hence has a
tendency to pull the lower eyelid down somewhat after surgery.
Patients usually complain about eyelid bags, which bulge under
the eye, and are often hereditary. The main problem in the lower
eyelid is usually fat excess, or apparent fat
excess, occasionally with some skin excess.
The "conventional" way of performing the surgery on lower eyelids
is to cut through the skin, through the muscle, and then remove some fat,
and often a bit of skin and muscle too. More recently, there has been a shift
in thinking in this regard - surgeons (like myself) believe that the middle
layer (muscle) should not be injured or operated in most cases, and hence
we do a transconjunctival approach to the fatty pockets.
In essence, what this means, is that the fatty tissue if removed using a direct
approach with a small incision on the inside of the eyelid (leaving no external
scar). In younger patients (and often in older ones too!) this is all that
is necessary, as the skin on the front of the eye often retracts once the
fat is removed. In patients in whom there appears to be a true skin excess
in the lower eyelids, this can be dealt with either by a concommitant light
acid peel (to tighten the skin and minimise the 'crepey' lines) or
surgically by using a 'skin pinch' - a small amount of excess
skin is removed at the time of surgery (in front of the muscle). Hence - fat
is taken from behind the muscle, and skin may be taken from in front of the
muscle, but the muscle itself is not injured / operated upon.
This is thought to minimise the risk of "scleral show"
- when the lower eyelid pulls down after surgery, and gives a sad appearance.
Because the lower blepharoplasty involves surgery very close to
the eyeball itself, I prefer to do this under a light general
anaesthetic to ensure patient safety. In addition, a special corneal
protector is used to shield the eyeball.
If you have any questions about this, feel free to email
me
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