Surgical Services
Blepharoplasty
Eyelid surgery or Blepharoplasty is a procedure to remove excess skin, muscle or fat from the upper and lower eyelids. Eyelid surgery can correct drooping upper lids and puffy bags below your eyes - features that make you look older and more tired than you feel, and may interfere with your vision. However, it will not remove crow's feet or other wrinkles, eliminate dark circles under your eyes, or lift sagging eyebrows. Whilst it can add an upper eyelid crease to Asian eyes, it will not erase evidence of your ethnic or racial heritage. Blepharoplasty can be done alone, or in conjunction with other facial surgery procedures such as a facelift or brow lift.
The Problem
Whilst the eyes themselves are expressionless, the eyelids are very important indicators of our emotions. When heavy and baggy they portray a tired look; if hooded with loose skin, an aged look; if elongated and almond shaped with a smooth contour, a fresh youthful look.
The eyes are the first facial feature people observe and unfortunately they are also one of the first to show the signs of ageing. Ageing is an irreversible, relentless process of tissue degeneration resulting in loss of elasticity and stretching of skin. The rate of this ageing process varies from individual to individual and depends on the person's genetically determined constitutional clock. It is hastened by the effects of sun exposure, smoking and the stresses of daily life. Hooding of the upper eyelids is the combined effect of descent of the eyebrows into the lid area (blepharoptosis) and an increase in the upper eyelid skin due to loss of elasticity and stretching of the skin (blepharochalasis).
Squinting into the sun with or without sunglass protection will, over the years, lead to fine lines which go on to form wrinkles and then furrows in the forehead and about the eyes. Loose skin in the upper eyelid will rest on the upper eyelashes giving a heavy tired look. It also makes it difficult to wear eye make-up. Fat pads in the inner aspect of the upper eyelid tend to bulge forward aggravating the aged look.
Lower eyelid skin as it ages becomes loose, tends to wrinkle and eventually develops folds under the influence of gravity. The lower eyelid muscle weakens and underlying fat pads bulge forward producing bags.
Skin pigmentation occurs from the degenerating effects of the sun on the skin. It can also be a normal racial characteristic. This pigmentation can produce shadowing of the lower eyelid and contribute to the ageing non-youthful look.
What Causes Eyelid Puffiness?
Puffiness or swelling about the eyelids is produced by any one or more of three possible factors:
- Weakened eyelid muscles (the orbicularis muscles) allow the orbital fat to billow forward under the influence of gravity. This produces puffiness of the eyelids which is constantly present, but can be made to disappear by standing in front of a mirror and contracting your eyelid muscles such as in squinting. The problem can be surgically corrected by tightening the muscle sling with resuspension in the outer aspect of the lower eyelid (a procedure known as canthoplasty).
- Excessive fatty deposits about the eyeball produce bulges or bagginess. These fatty deposits are compartmentalised and when present in excess, the fat pushes the overlying thin eyelid muscle and skin forward producing the baggy contour defect. Removing the excessive fat or strengthening the retaining membranes (skin and muscle) corrects this problem.
- Excessive fluid accumulation about the eyes. This occurs commonly as a result of allergy and is usually worse on getting up in the mornings and improves as the day goes on - with the redistribution of body fluids on rising from the recumbent to the erect posture. Fluid accumulation is not corrected by surgery and if present may lead to a more protracted post surgery recovery. Some morning swelling can be expected in all patients for some variable time after eyelid surgery.
What Is Done?
Evaluation prior to surgery includes your medical history, especially in relation to underlying allergies, visual problems, current medications, and known history of scarring. Advise Dr Olbourne of your need to wear glasses and the date of your most recent eye examination.
Eyelid examination allows assessment of skin quality and looseness, muscle activity and any excess orbital fat and its distribution. It is best not to wear make up for this assessment. It also includes an assessment of the contribution any eyebrow ptosis is making to your eyelid problem and the possible need for eyebrow repositioning to achieve an optimal result.
Photographs are taken before and after surgery to plan the procedure and record your results.
The surgery can be performed in hospital or at Dr Olbourne's Day Surgery Centre (The Carswell Clinic). You have the alternative of general anaesthesia in which you are profoundly asleep and ventilated by a machine or the more modern alternative of intravenous sedation and local anaesthesia from which recovery is much more rapid. The anaesthetist will talk to you prior to the operation to help you decide what is best. Advancement in anaesthesia over recent years has meant more comfort for patients - i.e. pain-free surgery, with minimal post operative sedation and almost no nausea, leading to a quick recovery and "feeling normal". The anaesthetists in our team are highly skilled and experienced in modern techniques and devoted to keeping you comfortable.
Prior to the operation your eyelids will be marked out so that the incisions follow natural lines or creases and ultimately become "invisible", and to allow the determination of the correct amount of skin to be removed. During the procedure the excess skin is removed, muscle is tightened, and redundant orbital fat is excised or replaced in the orbit.
There are several tools that have been designed for use with eyelid surgery. These include fine knife blades, very fine tungsten tip diathermy points and lasers. Despite what is written in magazines, all achieve excellent results in experienced hands and recovery times are identical. Dr Olbourne will happily discuss these alternative surgical options with you.
The surgical incisions are sutured meticulously leaving hairline scars that usually fade quickly, but probably never completely disappear. The upper eyelid scar lies in a natural creaseline formed by the attachment of your eyelid muscle to the skin at the upper level of the tarsal plate (that structure that stiffens and supports the upper eyelid). This is usually 8mm to 12mm above the eyelash line, but may be higher as a normal variant, or non-existent as in Asians. This fold can be created by a procedure termed supratarsal fixation and can Europeanise the Asian eyelids. If eyelids are droopy (ptosis) this can also be corrected by shortening the muscle (known as the "levator muscles") that raises your upper eyelid.
Upper Eyelid Reduction
The lower eyelid scar lies immediately below the eyelashes and may extend out onto the crow's feet line for about 1 cm.
Lower Eyelid Reduction
If lower eyelid fat bulging is the only problem, there may be no need for skin or muscle adjustment. It is then possible to perform this procedure without any external lower eyelid scar. An incision is made on the inner aspect of the lower eyelid and the excess fat removed. This is called a transconjunctival blepharoplasty. This has application in very selected cases and will be discussed with you by Dr Olbourne if it is an option for you.
The specific procedure to be performed on the eyelids varies from person to person and will be discussed with you pre-operatively by Dr Olbourne and his staff.
Prior to surgery you may need to obtain medications to prevent or minimise bruising and swelling. Make sure you obtain these instructions from Dr Olbourne's staff. Immediately after your operation you will be nursed with your head up. Your vision will be blurred by the presence of a lubricant in your eyes which is inserted at the end of surgery. Ice packs may be used to limit the swelling and bruising. It is not the practice of Dr Olbourne to bandage the eyes after surgery.
A running nylon suture is used to close the incisions in the eyelids and is removed with minimal discomfort after two or three days. Drops and lubricants will be provided to you on discharge with instructions for their use.
The eyelids have a protective and lubricating role for your eyes. After surgery, whilst the eyelids are swollen, this function is compromised and so for a few weeks it will be necessary for you to lubricate your eyes regularly with the ointment or drops. The nursing staff will instruct you about this.
Is It Painful And How Will I Feel?
We all fear pain and have very different thresholds at which we perceive pain. Your eyelids may feel tight and sore as the anaesthesia wears off, but any associated pain is usually mild and should easily be relieved by mild analgesics such as Panadeine or Digesic. Your anaesthetist will ensure that you have prescriptions for postoperative pain relief before leaving the clinic or hospital.
Eyelid surgery will enhance your appearance but it won't necessarily change your looks to match your ideal or cause other people to treat you differently. Cosmetic surgery performed in patients with realistic expectations can do wonders for self esteem and for self confidence.
How Will I Look?
Bruising and swelling obviously varies from person to person. It is maximal in the first three days and usually settles over seven to fourteen days. Dr Olbourne will show you photographs of the healing process to give you some idea of what to expect.
Healing is a gradual process and your scars may remain slightly pink for six months or more. Scars vary greatly from person to person, but all go through an initial red itchy stage to a pink nodular and ultimately to a leathery stage at about six to eight weeks, before fading to a thin, nearly invisible white line. This line may be visible in patients with dark upper eyelid skin, but in most patients with white skin it will not be seen. The ultimate quality of any scars is dependent on the thickness of the skin. The eyelids have the thinnest skin in the body and therefore the scars will mature more quickly and be less obvious than anywhere else.
The positive results of your eyelid surgery will last for years. Your eyes will look fresh and with a smoother improved eyelid contour, ladies will be better able to highlight their eyes with makeup. Everyone should look more alert and youthful.
Will Everyone Know I Have My Eyelids Done?
It is usual to feel apprehensive about undergoing a surgical procedure to improve appearance. The usual dilemma is that on the one hand you want to recapture youth and look better, but on the other hand you do not want people to think that you have had surgery to achieve it, fearing that you will be perceived as vain. The real situation is that in our society we all care about how we look. This is reflected in our hair styles, clothes etc. It is interesting to note that one of the fastest growing industries is the cosmetic industry, where in the United States over 2 billion dollars a year is spent on makeup. The vast majority of people are not so discerning and surprisingly they will not notice even quite marked changes to facial appearance. The usual comments you can expect are that "you look well" or "have you been on a holiday?"
Timing Of Surgery And Duration Of Improvement
There is no particular age that is best for eyelid surgery. We all age differently according to a variety of factors: individual genetic makeup, and environmental influences such as sun exposure, skin care and smoking. In general a more youthful look is maintained when eyelid surgery is performed on a younger patient whereas in the older patient a more dramatic change is noted. Deep furrows and wrinkles that have become permanent, need to be accepted, as they cannot be totally eradicated by surgery directed solely to the eyelids.
The best candidates for eyelid surgery are men and women who are physically healthy, psychologically stable and realistic about their expectations. Most are in their mid-thirties or older, but if droopy, baggy eyelids run in your family you may decide to have eyelid surgery at a younger age.
Cosmetic surgery will not stop the biological clock, but will reset it. Although there are many factors determining the overall individual result, on average you can expect from six to ten years of improvement.
Unfortunately, the ageing process is progressive and after a period of years you will again develop ageing facial features including a recurrence of inelastic skin around the eyelids and perhaps weakened eyelid muscles. Usually further improvement can be obtained by a redo of your eyelid surgery which often needs to be less extensive than the original procedure, or alternatively a forehead repositioning or browlift may be indicated.
A misconception often heard is that one may age faster once you have had eyelid surgery. This is not true and although ageing continues post surgery, it is not at an increased rate.
What Cannot Be Achieved By Eyelid Surgery?
Eyelid surgery will not stop the rate at which the skin ages, but certain lifestyles can hasten the ageing process such as excessive sun exposure, smoking and poor skin care. Attention to these areas can prolong the improvement achieved by surgery.
Whilst eyelid contours are markedly improved, all wrinkles are not removed. This applies especially in the crow's feet area which is not addressed by a blepharoplasty. The crow's feet are actually part of the cheek or temple. To improve this problem a brow lift or temporal lift must be considered.
Drooping of the brow produces low flattened eyebrows with a scowling look. This adds to heaviness in the upper eyelids and produces furrowing in the nasal bridge line. This problem is not improved by eyelid surgery, but is better corrected by a foreheadplasty or brow lift.
Skin pigmentation is common in the lower eyelids and is occasionally seen in the upper lids as well. It is most commonly a hereditary ethnic characteristic, but may also be sun induced. Eyelid surgery will not remove this, but rather may make it slightly more obvious by stretching wrinkled loose skin to an improved contour. A skin care program incorporating a light skin peel, either at the time of eyelid surgery or at a later date, may help this problem. Makeup will, of course, camouflage it. The scars from a blepharoplasty will not be as "invisible" in this type of skin.
Facial asymmetry is normal. We all have a strong and a weak side of our facial skeleton and hence left and right eyelids are never identical, nor is the position of the eyebrows. This is of course present prior to surgery, but occasionally patients notice it more after surgery as they study their improvements closely. This asymmetry is normal and in fact enhances beauty. It is never the result of surgery.
Ancillary Procedures Which May Be Performed With Eyelid Surgery
Although blepharoplasty is one of the most common cosmetic surgery procedures performed, it is frequently combined with other procedures, either at the same time or at a later stage, to achieve an enhanced result:
Brow Lift
To correct the brow, bridge of nose and forehead furrows and to reposition eyebrows which have become lower and flatter with ageing. A new endoscopic procedure leaves minimal scarring in the hairline and has a rapid recovery time. This option will be discussed with you where Dr Olbourne feels it appropriate.
Face and Neck Lift
To produce fresh facial features with improved cheek, jawline and neck contouring.
Lip Ancillary Procedures
To rejuvenate the lip to the youthful look. A variety of implants and injections are available to enhance this area.
ss="textMainBold">Rhinoplasty
To reshape and refine the nasal features.
Skin Care Programs
To improve skin quality. These are considered worthwhile to maintain the tone and appearance of the facial skin.
If you would like to know more details about how any of the above may help you, please ask Dr Olbourne or his staff.
What Are The Dangers?
Before you make a decision to undergo plastic surgery, it is important that you be informed of the potential risks, complications and side effects of the surgery you are contemplating. While all care is taken to minimise or to totally avoid these complications and side effects, it is recognised that complications may occur despite the best medical care. For this reason, and in order that you may be truly informed prior to making your decision about surgery, it is important that you carefully read and understand the risk factors.
The side effects which accompany eyelid surgery may occur on a relatively common basis. The complications of this surgery, although rare and unexpected, may occur despite any surgeon's best efforts. When reading and carefully considering this list, please understand that many thousands of successful cosmetic procedures are performed and the occasional occurrence of these side effects may be a part of what is considered a successful cosmetic operation. Likewise, although limited statistically, the complications listed herein do occur, despite optimal care and patient co-operation. You must understand that all these complications have occurred to some patient sometimes and may, ultimately, be part of your own clinical experience. With care and patience many of them can be repaired or mitigated - but these problems do occur and you must consider them.
A few medical conditions make blepharoplasty more risky. They include thyroid problems such as hypothyroidism and Grave's Disease, dry eye or lack of sufficient tears, high blood pressure or other circulatory disorders. A past history of detached retina or glaucoma are also reasons for caution - if you have any of the above, please bring it to the attention of Dr Olbourne prior to surgery so that if necessary a further ophthalmology opinion can be obtained.
Possible Side Effects
Swelling - usually is worst in the first 72 hours and then gradually settles over one to two weeks. Some residual swelling may be present for up to six weeks and may be asymmetric depending on many factors such as your favourite side of sleeping. Rarely swelling may persist longer term and is usually intermittent and associated with underlying allergies. This should be noted prior to surgery.
Bruising - this is maximal in the first 72 hours and then usually resolves over the ensuing 7-10 days. If troublesome, it can be camouflaged with makeup which can be applied within 7 days during which time dark glasses will assist.
Pigmentation - this is usually present prior to surgery, but may be more noticeable following surgery when the skin contour is improved by the elimination of wrinkles. It may be improved by a skin care program, but sometimes it is hereditary and the only effective treatment is cosmetic camouflage with makeup.
Dry Eyes and/or Tearing of Eyes, Burning and Itching - these symptoms commonly occur following eyelid surgery due to the changes in eyelid function, tear quality and tear gland function. They usually settle within a few weeks. Tearing may be related to obstruction of the lacrimal duct-the canal responsible for draining tears from the inner aspect of the eyelid into the nose. Occasionally this will need to be probed to clear it.
Temporary Visual Changes-sensitivity to light, blurring of vision and occasionally mild double vision (diplopia) occur within the first few weeks of surgery. There may also be corneal irritation. These symptoms usually settle rapidly. Occasionally it is necessary to change your prescription for glasses or contact lenses. This change is part of the evolution of your optical function and is never caused by the surgery which is only directed to your eyelids.
Inclusion Cysts-not uncommon following eyelid surgery, small whitehead cysts are noted in the incision lines and these are easily corrected by removal with a fine needle in the office. They are of no consequence and are noticed because of the excessively fine eyelid skin.
Scarring-will occur whenever skin is incised. During healing it will pass through red, itchy, lumpy, white and leathery stage before settling to a final state as a fine white line. Incision lines occasionally may be visible and tend to thicken, requiring steroid injections and rarely additional revision surgery. Although visible incision lines may result, fortunately the facial skin has excellent blood supply which allows for rapid healing. Occasionally scarring may distort the shape of the eyelids and lead to drooping of the lower eyelid, resulting in watering. This is called ectropion and usually settles as the scars mature. Ectropion is minimised by incorporating a lateral canthopery into the blepharoplasty procedure and massaging the lower eyelids postoperatively in the prescribed manner. Occasionally a further surgical procedure may be required to correct this.
Inability To Close Eyes-occasionally it will be difficult to totally close your eyes whilst asleep and hence the importance of inserting lubricating ointments into the eye. When this occurs, it does so in the immediate post-operative phase and usually settles when the swelling subsides.
Possible Complications
Infection-this is exceedingly uncommon, but can occur following eyelid surgery. Antibiotic ointments will usually be used in the first few weeks post surgery.
Blood Clots (Haematoma)-rarely blood clots may develop behind the eyeball or under the skin. These usually require evacuation.
Loss of Eyelashes-this is an extremely rare complication following eyelid surgery.
Ptosis-this refers to drooping of the upper eyelid due to malfunction of the upper eyelid muscle. This is uncommon and can be corrected by a further surgical procedure.
Loss Of Eyelid Skin-this is very rare and usually heals without the need for any further surgical intervention. Very occasionally a small skin graft may be required to replace the damaged area.
Alteration Of Vision-usually temporary but very rare cases of blindness have been reported in the medical literature. Dr Olbourne will discuss the mechanism of this complication with you and the procedures he uses to prevent its occurrence.
Pain temporary or permanent is extremely rare.
Routine
Prior to Surgery
Two weeks prior to your operation you should avoid Asprin or aspirin-containing medicine (Aspro, Disprin, Alka-Seltzer or any medicine containing acetylsalicylic acid) as this can produce bleeding or bruising. Panadol is safe. Also suspend the use of herbal remedies such as St Johns Wort and Gingko Bilboa.
Avoid Vitamin E two weeks prior to surgery as this may also increase a bleeding tendency. Vitamin B and C are safe to use.
Stop smoking to avoid the chance of post operative coughing which increases risks of bleeding and bruising. Smoking also decreases blood supply to the healing tissues, increasing the risks of delayed and poor healing.
Do not drink alcohol for at least two days prior to surgery as alcohol also increases the chances of bleeding and bruising.
In the week prior to surgery, if you develop any sign of infection such as cold, flu or pimples on your face-please notify our office so that we can treat this effectively. If you have a history of facial Herpes please let us know, as Acyclovir started before your surgery should prevent an outbreak.
On the night before or the day of surgery, shampoo your hair as usual and cleanse your face thoroughly to remove all traces of makeup. Do not apply any moisturisers, makeup or hair products after cleansing.
You should bring to hospital your normal toiletries and any regular normal medication that you use. Loose night clothes are recommended. Also bring a pair of sunglasses to wear home. If your surgery is scheduled for the Carswell Clinic, no special requirements are necessary.
Admission Times
The time of admission to hospital or the office surgery will be allocated by the clinic staff. It is important that you have nothing to eat or drink (i.e. nil by mouth) for at least six hours prior to surgery.
After Surgery
If your operation is performed in hospital the nursing staff will assist you by bathing the eyes with a saline wash and the application of ice packs to help reduce swelling. During the day, artificial tears will lubricate and soothe the eyes. A lubricating ointment should be inserted into the eyes every time you go to sleep.
If you choose to have your surgery at the Carswell Clinic, then the nurse will explain the "care of the eyes" to you and whoever may be assisting you at home. You may not drive yourself or be unescorted home, as you will be under the influence of medication. Also for the same reason, you should not conduct business, sign any papers, or take any alcohol on the day of your operation. You will have recovered completely by the morning after surgery.
By 48 hours after surgery, the swelling usually reaches its maximum. The ice pack application may be discontinued unless you find it comforting. An extra pillow is recommended whilst sleeping, and keeping the head elevated as much as possible during the day is advisable. Where possible elevate the head of your bed on a couple of house bricks or telephone books.
Sunglasses will reduce the daylight glare and sun brightness, helping to reduce eye irritability or tear formation.
In the first week following surgery it is advisable to restrict your normal activities where possible. Avoid smoking, alcohol and stress as these factors hinder the healing process. Detailed work such as sewing or other handcrafts, excessive reading, writing or computer work should be avoided as your eyes can become very tired.
Panadol or Panadeine are the desired analgesics for pain relief. No Asprin or aspirin-containing drugs should be taken as these can increase your bruising and may cause bleeding into the tissues. Codeine found in Panadeine or Panadeine Forte can cause constipation. Therefore lots of fluids and a high fibre diet should be taken. A suitable laxative is Nulax if needed.
If you are still in hospital on the second day, the nursing staff will remove your eyelid sutures. Alternatively you will be given an appointment to have your sutures removed at the Carswell Clinic.
There may be minor bruising for up to a week and a cover makeup may be necessary to resume work or social activities. Our clinic staff will happily advise on these products. Eye makeup may be applied at one week, but gentle removal and cleansing is essential. A saline wash is a very soothing finish to your nightly skin care regime for the first few weeks.
Often the weeks following surgery can be difficult as the patient comes to terms with the changes achieved by surgery. It is a transition period when some people have been known to experience guilt and feelings of low self esteem. This is a good time to seek the advice of a beauty therapist and learn the art of enhancing the eyes with eye makeup (colour, shade and light) which you may never have been able to apply before. This can really boost your confidence and maintain a positive state of mind. If you would like an appointment with a trained paramedical beauty therapist, please ask our staff and we will organise a consultation.
Regular appointments are made for you to visit Dr Olbourne for a routine check up. Photographs are often taken to compare with your pre-op photos. At about six weeks you will have accepted the positive results of your eyelid reduction and will be enjoying the "new you".
 CALL DR OLBOURNE IF YOU EXPERIENCE THE FOLLOWING:
- Excessive pain or bleeding
- Abnormal swelling
- Fever during the first 24 hours or especially during the first 7 days
How Much Will The Procedure Cost?
The costs of this surgery relate to:
- surgeon and assistant surgeon
- anaesthetist
- hospital
- ancillary charge (pharmacy, etc)
Dr Olbourne can tell you his fee and give you some indication of the costs of the other people involved in your care.
You must appreciate that the ultimate cost to you will depend on where you choose to go for your procedure and what rebates you will receive from your medical fund and Medicare. This in turn depends on who you may be insured with and what level of insurance you have chosen. Please advise Dr Olbourne if your insurance has a front end deductible cost or "excess". With all the relevant information the doctor's office should be able to give you a very close approximation of what your final costs might be.
Private insurance including Medicare may pay the cost of part of the operation, but not the cosmetic part. If so, they would also contribute to the anaesthetic and hospital costs.
It is always preferable to arrange all your finance prior to surgery to avoid unnecessary stress afterwards which will detract from your enjoyment of having achieved your goal.
Further Information
For further information on this or any other cosmetic procedure, feel free to contact our office. Our staff are dedicated to assisting you and will do all they can to make your surgical experience as comfortable as possible.
You can also assist us by advising us of any aspect of your experience that has not been adequately covered in this brochure. We are always seeking to improve the information we give to patients. Your input will help us achieve that goal.
Contact: Dr. Norman A. Olbourne
MB BS (Hon), BSc(Med), MHL, FACLM,
FRCS, FRCSEd, FRACS
Sydney Institute of Plastic Surgery
7 Help Street
Chatswood NSW 2067
PO Box 5010
Chatswood West NSW 1515
Phone: (02) 9411 - 3177
Fax: (02) 9411 - 3380
Email: info@sydneyplasticsurgery.org
Web: www.sydneyplasticsurgery.org
Conclusion
Your eyes and eyelids are the most important features of facial expression. A blepharoplasty can have a dramatic effect on your eyelids, restoring a brighter, more rested appearance to your face. After blepharoplasty, your eyes can express the energy and self confidence you are truly feeling. I hope these notes have helped you. If you have any further queries please call our office.
One last thing - beware of well-meaning friends, newspaper and magazine articles, which are generally not a good source of information.
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