Miami Eyelid Surgery

Introduction
Blepharoplasty, or cosmetic eyelid surgery, remains one of the most requested aesthetic facial procedures. The surgery was first popularized in the mid 1800's, when it was performed for the removal of excessive upper eyelid skin. In the early 1900's, the surgery for the lower eyelid was developed and quickly became accepted.

As in all aesthetic surgery, each surgeon brings to the consultation and then to the operating room an artistic goal as to how the final result of blepharoplasty should appear. I have certain goals that I attempt to achieve when I perform the blepharoplasty surgery. These are: 1) minimal scars in the upper and lower lids, 2) least possible redundant skin, 3) smoothest transition between cheek bone and lower eyelid, 4) symmetry of the upper and lower eyelid position, 5) symmetry of fat position, 6) durability of the procedure, 7) an overall unoperated appearance, 8) rapid and uneventful post-operative course, 9) the absence of complications.

Figure1

Female patient demonstrates aging upper eyelids with normal brow position.

The aging eyelid
The upper lid begins to show evidence of aging almost before any other facial feature. The excessive skin redundancy becomes visible as it begins to crowd and hide the upper eyelid crease (Figure 1).

In the area near the nose, a small amount of fat often bulges out. When evaluating the upper eyelid, it is important to differentiate between the aging upper eyelid and descent of the eyebrow.

The eyebrow descends with time. As it does, the brow skin crowds the upper eyelid, adding to the fullness in the area. The surgeon must differentiate between a low brow and an aging eyelid, in order to council the patient correctly (Figures 2, 3). Occasionally, patients may need both a blephroplasty and browlift to rejuvenate the eyelid-eyebrow area.

Figure2

Female patient demonstrates aging eyebrows.

Figure3

Post-operative view of the same patient after a browlift by Dr. Bustillo.

The lower eyelid may age in one of two ways. There may be premature eyelid aging, which is hereditary. People with this hereditary condition begin to demonstrate lower eyelid "bags" during the late twenties and early thirties. Most people, however, begin to show signs of eyelid aging in their early forties.

Figure4

Female patient demonstrates aging lower eyelids with "bags."

As the lower eyelid ages, the fat that surrounds the eye begins to accumulate under the eye and develop the "bags" that are visible. The skin also begins to age and develop wrinkles. The eyelid muscle can descend and give the eyelid a droopy look (Figure 4). As the malar fat pad descends, a loss of volume can develop between the facial units of the lower eyelid and the cheek.

The upper eyelid surgery
The purpose of the upper eyelid surgery is to remove the redundant skin that overhangs the crease. The procedure is performed through an incision that is placed at the eyelid crease, so that it is completely hidden. The skin is marked carefully before surgery to ensure that the exact amount of skin is removed. The skin is removed and then a small amount of fat is removed in the medial area (next to the nose). The incision is then closed with a tiny continuous stitch that is placed inside the skin to ensure that the incision heals well and is virtually invisible. The stitch is then removed on post-operative day five.

The lower eyelid surgery
The goal of the lower eyelid surgery is to provide a smooth lower eyelid contour that blends with the cheek. This is done by removing the fat that protrudes underneath the eye, removing some of the excess skin, and then elevating and repositioning the eyelid muscle. This must be done in a manner that will maintain the patient' s natural eyelid shape and avoid any malposition. Malposition is the name given to describe the change in the lower eyelid position that can occur from a poorly performed blepharoplasty.

The lower eyelid blepharoplasty can be performed via two different methods. The skin muscle flap technique is performed through an incision just underneath the eyelashes (Figure 5). The skin and muscle are elevated to reach the fat pockets. The fat pockets are then removed. The amount removed must be just the right amount. If too much is removed, the eye may appear hollow after surgery (Figure 6). If too little is removed, then bulges will still be visible after surgery.

Figure5

Diagram demonstrating the skin muscle flap approach to the lower eyelid.

Figure6

Diagram demonstrating the muscle suspension. This elevates the eyelid muscle and smoothes the lower eyelid-cheek complex.

After the fat is removed, I tighten the eyelid muscle. This allows the contour of the eyelid to blend with the cheek (Figures 7, 8). It also tightens the eyelid to prevent any eyelid malposition. The incision is then closed with tiny continuous stitch. This is my preferred technique for most patients that have lower eyelid aging. The technique allows me to remove the excess fat and tighten the eyelid muscle. The combination of these two rejuvenates the lower eyelid and cheek complex.

Figure7

Female with aging upper and lower eyelids.

Figure8

Post-operative view of the same patient after upper and lower blepharoplasty by Dr. Bustillo. Notice the improved definition of the upper eyelid crease and the smooth lower eyelid-cheek complex.

The second technique is the trans-conjunctival technique. I prefer to use this technique for young patients that need little to no skin removal or patients with very prominent eyes. The trans-conjunctival technique involves an incision inside the eye to access the fat. The fat is then removed and a small pinch of skin may be removed, if necessary, from underneath the eyelashes.

Are you a candidate for blepharoplasty?
The majority of patients that undergo the blepharoplasty operation do so in their early forties and on. Occasionally, patients with hereditary eyelid aging will undergo the surgery at an earlier age.

The decision about having the blepharoplasty operation is a very important and personal one. You should consult with your surgeon and your family. For most people that undergo the procedure, the results are life changing. Patients describe an increase in confidence and boost in self-esteem. They feel rejuvenated and feel more comfortable in social settings and in pictures.

The ideal patient must have the proper expectation before undergoing surgery. It is important that the patient have a good understanding of what can be achieved. Clear communication between the patient and the surgeon is very important.

Surgeons are human and therefore are not perfect. While most blepharoplasty patients enjoy the benefits of improved eyelids, it is important to remember that surgery, like all other human actions, is not perfect. A skilled surgeon can achieve near perfection. However, one must remember that the skin and soft tissues the surgeon works with can have inherent laxity and weakness.

Consultation
The consultation begins with a discussion about the specific issues and concerns that the patient may have. It is important to discuss whether the eyelid aging has been present since early adulthood or has occurred slowly over time. Any ocular diseases, including symptoms of dry eye, must be discussed.

A thorough physical examination is performed. The upper eyelid is examined for skin redundancy. The brow position is also examined. A brow that has descended may mimic upper eyelid redundancy. This is important, as performing an upper blepharoplasty on a normal upper eyelid with a low brow, can essentially pull the brow even lower. Patients with a low brow should be counseled about a browlift (Figure 9, 10).

Figure9

Female with aging brow, upper eyelids, and lower eyelids.

Figure10

Post-operative view of the same patient after a browlift and upper and lower blepharoplasty.

The lower eyelid is then examined. The amount of fat herniation is examined as well as the strength of the lower eyelid. Weak lower eyelids may require an additional lid tightening procedure. The position of the eye in relationship to the bony rim is then examined to help determine the technique that should be used for the surgery.

The patient and I then have a discussion about the result that I believe can be achieved with surgery. The patient should understand exactly what the blepharoplasty procedure will achieve for them so that an informed decision can be made. The procedure is explained in detail and all questions are answered.

Preparation
All patients are required to obtain pre-operative labs and a medical clearance from their primary care physician prior to surgery. All aspirin, anti-inflammatory products (naproxen, ibuprofen), and vitamins such as A, ginkgo biloba, and St. John's wart should be discontinued ten days before surgery because they may interfere with blood clotting and cause bruising. Alcohol should also be avoided for five days before surgery to avoid swelling. Patients are required to start high dose vitamin C two weeks before and two weeks after to help with the healing and to reduce bruising.

Anesthesia
The blepharoplasty surgery is performed on an outpatient basis in AAASF-certified surgical facility. Because I believe that patients recover best outside of a medical environment, they are allowed to allowed to return home or to their hotel room the same day after they recover. All surgeries that require anesthesia are staffed by board certified anesthesiologists, which are part of the Baptist Hospital Anesthesiology Department.

The blepharoplasty procedure can be performed under different anesthesia modalities, depending on the patient the adjunctive procedures being performed. If the patient is having the blepharoplasty operation alone, it may be done with either local anesthesia or IV sedation anesthesia. However, if the blepharoplasty surgery is being performed in combination with a facelift, either IV sedation or general anesthesia is used. Certain patients may require general anesthesia for safety reasons. The upper blepharoplasty surgery takes forty-five minutes to perform and the lower blepharoplasty surgery takes about one hour to perform.

Risks
The blepharoplasty operation, like all surgery, does have risks aside from those of anesthesia. A hematoma is a collection of blood that can accumulate under the skin. Although rare, it can occur after a blepharoplasty. The risk of hematoma is about 1%. The treatment usually entails draining it in the office. Most patients that have a hematoma after surgery recover well without any complications. Infections after blepharoplasty surgery are also rare. Patients are given antibiotics prior to surgery and after surgery to help prevent infections.

Recovery
The patient is discharged home the same day after surgery. The first night should be spent relaxed. Activity should be kept to a minimum. A liquid diet is best for the first eighteen hours after anesthesia. The head should be kept elevated using two pillows to help reduce swelling. The patient should place small zip lock bags with frozen peas on the eyes 10 minutes, for every hour spent awake for the first 48 hours.

Pain should be minimal. Tylenol is usually enough to control any minor discomfort. Additional pain medication will be provided, in the event that it is needed. Any significant pain should be reported to Dr. Bustillo immediately, as this may signal bleeding under the skin. Some mild bruising may be visible around the eyes.

The patient returns to the office on the fifth post-operative day. At that time, the small stitch is removed. Patients can usually shower and wash their eyes after the visit. They can also wear make up if they wish.

Most patients return to work and daily activities about to weeks after surgery. Seventy percent of the swelling resolves in the first three weeks. It is recommended that physical activity, such as running or lifting be resumed three weeks after the surgery. The remainder of the swelling can take up to two to three months to completely resolve. This remaining swelling is imperceptible.

The final results of the surgery may not be completely evident until several months after the surgery. The results of a blepharoplasty operation usually turn back the clock approximately ten years. Most patients who undergo the blepharoplasty operation are extremely happy with the results.

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