As we age, our eyelids undergo undesirable changes, making us looking tired and older. Many factors, such as heredity ad sun damage, accelerate these changes. Many younger patients will also complain of puffiness of the eyes which can also result from congenital changes leading to excess fatty tissue. Fat deposits, commonly called “bags”, lower eyelids, can be removed by your cosmetic surgeon in a procedure called blepharoplasty, or “eyelift”.

How is Blepharoplasty Performed?

Blepharoplasty can be performed on the upper or lower eyelids separately or both at the same time. The upper eyelid incision is made in the natural skin fold. The lower eyelid incision may be made directly under the eyelash line on the inside of the lower lid. The excess skin and fatty tissue is removed and the incisions are carefully closed. The external incisi9ns blend in beautifully and are virtually unnoticeable after a short time.
Blepharoplasty is commonly combined with a face or forehead lift as part of an overall facial rejuvenation procedure. It can also be combined with chemical peeling to further enhance the results. Usually, a cosmetic surgeon will recommend the peel as a separate procedure, although it can be combined in certain situations.
This surgical procedure can be performed on an out-patient basis, in the hospital, or in an ambulatory surgical suite under either general or local suite under either general or local suite under either general or local suite under either general or local anesthesia, depending on the surgeon and patient’s preferences. When overhanging of the upper lids interferes with vision, the procedure may be covered by insurance.

HOW WILL I LOOKING IMMEDIATELY AFTER?

Some swelling and bruising can be expected. The swelling will usually begin to subside within several days, while bruising may take several weeks t completely fade. Make-up can be used within a few days of surgery to cover any discoloration. Sutured are usually removed a few day after surgery. This operation is easily tolerated by the patient. There may be mild discomfort after surgery which can be easily controlled by medications prescribed by your doctor.

HOW ARE THE RISKS?

There are risks in any surgical procedure. The degree of improvement varies from patient to patient. Yu should discuss all the benefits and risks with your cosmetic surgeon.

THE COST?

Fees vary from one geographic area to another. Your doctor and staff will discuss all financial arrangements with you prior to surgery.
This brochure is only intended as only introduction to this procedure. It should not be used to determine whether you will have the procedure performed and should not be construed to guarantee the result.

EYELID SURGERY

Pre-Operative Assessment
It has two-fold purpose:
1) Identify those anatomic and structural abnormalities that require correction or improvement for optimal result.
2) It must identify any features, disease states or path physiology that will prediscope the patient to post-operative complications.

Presurgical assessment includes complete medical and surgical history, a list of medication and general review of systems.
It is advisable to perform a review and ocular or systemic abnormalities that affect the results of eyelid surgery.

General Medical Evaluation
All patients require a general Hx and physical exam to screen for associated medical problems prior to surgery where appropriate medical consultation and clearance must be needed.
Anticoagulation therapy must be identified prior to surgey and stopped around the time of orbital surgery when possible and depending on the medications for which it is used .If anticoagulation must be continued, consideration should be given to avoid incision of orbital septum and fat excision, since these maneuvers increase the risks of hemorrhage that could result in visual loss. Patients should also specifically be asked about the use of aspirin, which is now frequently used in the older population; and the aspirin, which is now frequently used in the older population; and the aspirin should be discontinued for 7 days to 10 days after surgery of the and orbits.

Informed Consent
Include warnings of the frequent and the most severe complications. Generally, better informed the patient, the more willing he or she will be to accept a less than ideal.

Patients should be informed of the risks of asymmetry,infection,bleeding ,ectropion ,and the failure to achieve the desired aesthetic results.Established of good rapport with the patient and proper patient selection.Unrealistic expectations or emotional instability should be strong a contraindication to surgery as any anatomic or medical circumstances. Preoperative Hx and physical examination are prerequisites for individualized informed consent.

Operative Technique 
Preoperative preparation
Position and draping

– Patient marked in the upright position, the position at surgery and way, which the patient is draped, can alter the relative position of brow and eyelid tissues.

– The patient is placed in a supine position with the head elevated 20 to 30 degrees. This lowers venous pressure and is usually comfortable for the patient and the surgeon.

Topical Antimicrobials
An ophthalmic ointment should be placed in the eye prior to the prep.To prevent irritation from the prep solution themselves. Half strength(5%) povidone iodine solution has been shown to be effective as an antiseptic and can be instilled into the conjunctival sac directly.

Upper Eyelid Marking

q- The patient is asked to relax the brows and close the eyes gently while the upper eyelid skin is smoothed and flattened over the tarsus with the examiner’s free hand. The location is then marked for the supratarsal portion

q- A gracefully curving line is then drawn parallel to the natural lid crease.The height of this line,which will represent the new supratarsal crease,are verified with calipers to ensure symmetry.

q- The excess eyelid skin is determined by gently grasping the upper lid with the eyes closed and seeing how much redundancy can be removed without causing the lids to open.

q- The forceps has been designed for determining excess upper eyelid skin,with a small horizontal bar at the end that easily grasps the skin without pinching it.

q- The preseptal portion of the upper eyelid incision is drawn as gently curving line connecting the previously marked points.

Marking Lower Lid
The lower eyelid markings in anterior view are placed 1.5 to 2.0 mm below the lash margin. Lately, the line extends in a fairly straight fashion and stops at the midpoint overlying the lateral orbital rim.

Anesthesia
The usual anesthetic for blepharoplasty is a combination of local infiltration anesthesia and intravenous sedation. Xylocaine (1%) with 1/100,000 epinephrine is used for its hemostatic effect. The peak vasoconstrictive effect of injected epinephrine occurs in 7 to 10 mins. Inject xylocaine superficially in the subcutaneous place, not intramuscularly. The needle tip should never point at the globe, but rather tangentially or away from it.

An incision is made along the supratarsal portion of the eyelid marking with tension and counter tension held with delicate finger pressure over a gauze.

Excess skin is excised then excess muscle. The orbital septum is opened demonstrate orbital fat. The septum is opened as widely as necessary to visualize the underlying fat and remove excess central and medical fat pads. The septum is best opened midway between the orbits rim and upper tarsus where the orbital septum is further from the levator than is lower excess fat is delicately teased upward clamped and excised. The string is coagulated gently released and congulatives further after release as needed to assume complete hemostasis.

There are two upper lid fat pads, central and medical.

Closure is done simply with a running subcuticular 5-0 nylon monofilament suture. In addition, several interrupted 6-0 nylon sutures as often used to precisely relign the epithelial edges, especially medially and laterally, the running suture can be steritaped at either end, rather than tied.

LOWER BLEPHAROPLASTY

The incision is begun laterally, overlying bony orbital rim. The correct suborbicularis muscle plane is found with a delicate spreading motion. A curved iris scissor is then used to make the skin incision. The scissor is angled to assure an ample quantity of pretarsal orbicularis muscle is retained. The skin and muscle incisions may also be made separately to step the incision to help preserve the muscle.
The orbital septum is opened as widely as necessary to visualize the underlying fat. Fat is gently teased forward and clamped at a level flush with the inferior orbital rim. It is excised and the stump is coagulated. As the clamp is slowly released, further coagulation is performed as needed to assure complete hemostasis.
Marking the excess lower eyelid skin by asking patient to open mouth and asked to look up. The skin is gently lapped over the lower eyelid margin without tension and the excess is first marked and then excised parallel to the wound. Chin down done wuth 6-0 nylon suture.

Postoperative Care
Dressing are not required following blepharoplasty, we use steri-strip to provide temporary support for the lid laterally during the period of peak swelling vision should be checked for light perception in each eye using flashlight immediately after surgery and every 30 minutes afterwards for the first 2 hours. Iced gauze is the eyes add to patient comfort, may help reduce swelling, any sudden swelling severe pain or visual complaints must be immediately assessed. These maybe signs of retrobulbar hemorrhage, for which immediate intervention maybe vision savings.

Maintenance of good ocular lubrication is essential, especially during the early phases of healing, when edema may contribute to lagophthalmos. The patient should be supplied with artificial tears for daytime use, to maintain a moistened tear surface, and ophthalmic ointment for use at night to avoid desicoation or exposure during this time period.

When edema maybe present, early ectropion may occur but it is usually transient. It can be improved with massage to “milk out” edema, and this Tx can be combined with stretching exercises on am upward vector to maintain upward lid mobility. Taping the lid for additional temporary support may be helpful.

Postoperative Recovery
After surgery, there is some soreness and discomfort. If mild pain is experienced, it is easily controlled by medication. You will be asked to keep your head slightly elevated and apply cold compresses to your eyes to help reduce swelling and bruising. If dressing are applied they are usually removed on the eve of surgery or on the following day.

You will instructed to rinse your eyes with an eyewash and to use eye drops for several days following surgery.

Eyelid skin, being thin tends to swell and discolor rapidly after surgery. However, when sutures are removed within a week of surgery, swelling and black-and-blu discoloration will subside. Residual bruising can be covered by light make-up. Other postoperative effects of short duration may include excessive tearing and sensitivity to bright light.

The elimination of sagging, superfluous skin and fatty tissue around the eyes presents a younger rested appearance. Blepharoplasty generally will improve but not remove fine wrinkling at the outer edge of the eyelids.

Although you may be up and about the day after surgery, your plastic surgeon will advise you on the proper schedule for resuming your normal routine. To permit proper healing, you should avoid over activity and refrain from bending over for two to three weeks. Wearing of dark glasses to protect the eyes from wind and sun irritation is suggested for two to three weeks. The decision on when to turn to works depends on how fast you heal and how you feel