As you watch Victoria Principal do her infomercial, you ask yourself “Why can’t I have those beautiful eyes?” Well you can, but as with everything else in life there is a price to pay. The majority of patients seek eyelid improvement because of age-related changes in the external eye complex. As we age we lose the elasticity in the skin of the upper eyelid causing overhang which occasionally interferes with vision and most obviously in the lower eyelid where we see drooping, puffing and fat protrusion producing wrinkles and deep shadows which concealer won’t eliminate. Understanding the relationship of the eye to the rest of the face is important and it is the first thing we notice when we meet someone. A normal eyebrow upper eyelid relationship is one where the distance between the eyebrow and upper eyelid crease occupies two thirds the distance from the upper eyebrow to the upper eyelid’s lower margin. If the brow is low to begin with, removal of skin will only make it lower requiring a concomitant brow lift. Eyelid surgery cannot adjust a sagging brow, eliminate crow’s feet or make dark circles beneath the eyes disappear.

Eyelid surgery also known as blepharoplasty involves the excision of small amounts of skin from each eyelid and the removal of small amounts of fat below the upper and lower eyelids. The eyelid is extremely thin and is separated from the surrounding eye muscles by thin areolar tissue. This tissue is the plane in which dissection occurs with the lifting of the lid to gain access to the fat. Transcutaneous blepharoplasty has been the gold standard for years. A fine incision is performed under local anesthesia with a little sedation below the lower eyelashes and another is performed in the upper eyelid crease. These may extend beyond the eyelid producing a fine line upon healing.

There is no general consensus on the approach and in younger patients, some Plastic surgeons prefer a transconjunctival (TCJ) incision inside the eyelids, so no scar is visible. This has the advantage in lower lid surgery of less bleeding and scarring post-operatively. One of the more serious complications known as ectropion is when the scarring of the entire lower lid pulls the margin away from the eye and must be redone. This rare complication is markedly reduced with the TCJ approach. An upper transconjunctival approach is new and still has few indications. What is gaining the attention of surgeons are new methods of draping the fat and tissues as opposed to removing them thus avoiding increased bleeding and skin bruising intraoperatively and postoperatively.

Patients should first be aware that they have normal corrected vision and no problems with tearing or dry eyes as this procedure may exacerbate these conditions. Patients with high blood pressure are at increased risk of bleeding postoperatively and diabetics may require antibiotics to prevent infection. A checkup with an Ophthalmologist will usually tell you if you are good candidate for this surgery.

A referral to a Plastic Surgeon who has performed hundreds if not thousands of these should be your next move. An explanation of where the surgery will be performed and what are the possible complications should be explained to you. But it would be best to see pictures of their work, both the best and worst cases, which are kept filed by all. I would estimate that it will cost between $3,000 and $5,000 for the surgeons services plus a surgical fee for the use of the facility. In the majority of cases this is not covered by insurance unless the Ophthalmologist confirms some interference with vision or serious turning inward of the lid (entropion) or outward turning (ectropion) preoperatively.

For the youthful face, minimal excision of fat along the nose and a small excision of skin in the corners will give you that doe-eyed model look. For the elderly face, more extensive excision of fat and some times of muscle will reduce most of the luggage. Normally a surgeon will tell you that recovery with disappearance of the black and blue skin bruising will be over in two to three weeks, but truthfully you will not forget about your eyelids for two to three months. Healing is a lengthy process. Postoperatively you will be told to sleep on your back with your head elevated and use ice packs for about two days.

An antibiotic ointment will be given to apply to the scars and prevent infection. Then the drama begins. Swelling of the lids will progress for the next few days and the bruising is not to be believed. But slowly it all returns to normal over the next three to eight weeks. In most cases you will be able to see easily and only very rarely will this procedure interfere with vision, which becomes a surgical emergency. The disruption of nerves in the lids may cause some numbness for a while, but normal sensation returns by two months. There is minimal pain associated with the procedure requiring Tylenol only after the first post-op day.

Blepharoplasty is now the third most popular cosmetic surgery among women in the US. So if you see yourself in need of a lift, seek out a qualified Plastic Surgeon. If you go into this procedure with realistic expectations, you will leave with “Eyes Wide-Open.”

Best of Luck in Your New Future,

Cerise Richards, M.D.