SOME INFORMATION FOR OUR PATIENTS ABOUT BLEPHAROPLASTY
(Cosmetic and Reconstructive Upper and Lower Eyelid Surgery)

INTRODUCTION TO BLEPHAROPLASTY

The eyes and eyelids are one of the most prominent features of the face. When looking at the face we immediately gravitate toward the eyes and very often their appearance may affect our overall impression of the face. In addition to the information contained here, during your consultation and examination, we will review specific factors which pertain to your individual case. (As you review this information, please write questions in the margins that we can address during your consultation.)

If the skin of the eyelids is excessively loose or baggy, their appearance may convey a look of fatigue or puffiness, rather than a bright, energetic look. The skin may in fact become so loose that it droops down almost onto the eyelashes in the upper eyelid, becoming a significant annoyance. A bulging or baggy appearance in the eyelid may result from both loose and excess skin as well as from fat within the eye socket, which is bulging forward.

EYELID DEFORMITIES ARE NOT ALWAYS THE RESULT OF AGING. Bulging or baggy eyelids may also occur in the 20-30 year old age group as the result of hereditary factors characteristic within a family. When bulging or baggy eyelids occur in early adulthood, the tissues have not necessarily become loose and lax with age, but may appear bulging only because of hereditary factors.

Eyelid deformities occurring after age 30 and progressively through life are partially the result of tissues becoming looser with age. In every individual, there is fat present in the eye socket surrounding the eyeball. This fat does not change in size or volume significantly with weight gain or loss. There is, however, a tissue barrier (the ORBITAL SEPTUM) which holds the fat in the eye socket. In both the upper and lower eyelid, this layer (orbital septum) may become looser with age, allowing the fat normally present in the eye socket to bulge forward. Combined with loosening of skin, this bulging may produce "bags" in the upper and/or lower eyelid.

As excess skin and "bags" develop in the upper eyelid, the normal lid fold becomes less apparent. The lid sags downward and covers the normally visible portion of the upper eyelid. In women, obliteration of the upper eyelid crease prevents optimum use of eye shadow and other makeup techniques in the upper eyelid. In men, it produces a heavy, tired appearance.

THE POSITION OF THE BROWS AND FOREHEAD ALSO AFFECT THE APPEARANCE OF THE UPPER EYELIDS. When the forehead and brow are sagging, the upper eyelid also sags. Bags or excess sagging of skin in the upper eyelids may be due to DESCENT OF THE FOREHEAD AND BROWS as well as EXCESS SKIN AND FAT IN THE UPPER EYELIDS THEMSELVES. It is important to recognize the contribution of brow sagging to upper eyelid deformities, because removal of skin and fat from the upper eyelids alone will not correct abnormalities of the brow and forehead. If skin is removed from the upper eyelids without planning for correction of the brow position, the amount of brow lifting that can be done in the future is limited. Usually, POSITION OF THE FOREHEAD AND EYEBROWS SHOULD BE CORRECTED EITHER BEFORE OR AT THE TIME OF UPPER EYELID CORRECTION in order to avoid removal of too much skin in the upper eyelids which could effect eyelid closure.

In the lower eyelids, the same effect of the fat bulging forward produces the
appearance of bags or heaviness. Correction of these types of eyelid deformities involves very precise removal of appropriate amounts of excess skin and fat, and this surgical procedure is termed BLEPHAROPLASTY.

The key in upper and lower lid surgical procedures is being conservative in tissue removal, sparing fat and redistributing fullness instead of removing it. This is an important concept in regaining and maintaining youthful characteristics around the orbit. The paradigm shift from a 2-dimensional to a 3-dimensional approach in facial rejuvenation is especially important in eyelid surgery. A hollow eye is an aged eye, whereas a youthful eye has a delicate fullness that appears unaltered.

Surgical techniques must be individualized and modified to achieve these goals. To not hollow the orbit, to support the lower eyelid with tightening techniques (canthopexy or canthoplasty), and to make one of the main goals of lower eyelid rejuvenation procedures to soften and blend the lower eyelid cheek junction, is important in a natural youthful look in this area.

The blending of the lower eyelid/cheek junction area, also called the tear trough area when significantly prominent, is important in reestablishing youthful characteristics in this area. Attention to aging in the malar (cheek) region has been important in a harmonious approach to rejuvenation of the orbital region. Vertical lifting of the malar region and/or refilling lost volume with cheek implants and fat grafting techniques have improved outcomes in achieving more youthful changes in this area. The concept of abrupt transitions in the face being aging characteristics, and smooth transitions from one facial region to another being youthful ones, is most important in the aesthetics of the lower eyelid/cheek transition region.

Facial rejuvenation surgery may be performed as an isolated procedure, or more frequently done in conjunction with other cosmetic procedures of the face. It may be performed under local or general anesthesia depending upon the extent of the procedure being performed, medical indications or patient preference. In general, I do believe, along with our board certified anesthesia colleagues, that for longer and more complex procedures, general anesthesia is a better and safer choice than local anesthesia alone or local anesthesia with sedation.

The purpose of all types of cosmetic surgery is to improve your appearance as much as possible. This change will hopefully improve your quality of life by improving your self image in a very positive way. By addressing and improving those specific areas which detract from your appearance, leaving the positive aspects of your appearance undisturbed, this type of surgery results in an overall improvement in your appearance. Cosmetic surgical procedures are not magic. They are detailed procedures designed to improve specific aspects of your appearance. They can do no more than that. Whether you are happy with the results of cosmetic surgery will depend largely on how well you communicate to us which specific aspects of your appearance you are unhappy with and how well we communicate to you what a surgical procedure can and cannot do toward alleviating the problem. Plastic surgery does not perform transforming miracles. A combination of art and science, plastic surgery is not an exact science. Some of the factors involved in producing the result (such as your healing characteristics) are not totally within your or our control, and therefore, it is impossible to warrant or guarantee the results of your surgery. How predictable the result of your surgery will be depends on a number of factors such as the condition of your skin, the presence or absence of facial fat beneath the skin, the "age" characteristics of the skin, numbers and types of wrinkles present, and the nature of underlying bony structure of the face, as well as hereditary and hormonal influences.

It is not possible by cosmetic surgical procedures to make someone who is 50 years old appear 30 years old or younger. Although this may seem obvious, through misconception or misinformation, these ideas reach the public. All surgical procedures which involve an incision in any area must leave a scar. While these scars are usually inconspicuous and easily camouflaged by makeup or hairstyle, they are nevertheless permanent and cannot be erased.

After talking with you and examining you, I will make every effort to clearly and precisely give an opinion about whether a specific surgical procedure can significantly improve your areas of concern with a high degree of reliability and a minimal level of risk. All cosmetic surgical procedures involve some trade-offs. I will try to outline these clearly for you and answer any questions you might have. The final decision regarding having the surgery is yours, and I encourage you to consider it carefully and deliberately.

AT YOUR INITIAL CONSULTATION VISIT

When I visit with you in the office, I will review your past medical history, as well as your desires regarding blepharoplasty with periorbital rejuvenation. Age is not a limiting factor in determining who can have a blepharoplasty, as long as your general health is good. We will review extensively the information contained here, as well as more specific information with respect to your needs. After examining your eyes, brow and face, I can much more precisely define recommendations for you.

In this consultation, I would expect you to be frank in discussing your expectations with me. Do not hesitate to ask any questions that you may have. I will be equally frank with you, explaining the factors that could influence the procedure and the results.

I cannot make the decision for you regarding whether to undergo surgery or not. I can only advise you regarding the surgical options and anticipated outcomes I would expect for you based upon your individual anatomy, desires, and realistic expectations. I will define goals in a surgical plan at this initial consultation. Follow up appointments will include time to ask further questions or review the procedure so that you are comfortable with its nature and implications. I will educate you and define the operative scenarios and choices available to you, but you must make the final decision regarding the surgical procedure.

When a decision is made to proceed with surgery, preoperative photographs will be taken. These photographs are essential to the planning, execution, and follow-up of your procedure. They are taken with you in the standing position (the position in which you are most often seen). You are lying down during the procedure and I refer to these photographs frequently, as your tissues appear very differently than when you are standing.

Surgical fees for the procedure will be discussed with you. They depend upon the nature and the extent of the procedure being performed. All fees for cosmetic surgeries are payable in advance and include the cost of surgery as well as all postoperative follow up care. Additional fees are required for the surgical facility and anesthesia care, and will be collected on the day of your preoperative visit at the surgery center.

BEFORE YOUR BLEPHAROPLASTY

Our nurse and office manager will make all arrangements regarding scheduling of your surgery and will give you specific instructions as well as reconfirm these with you by telephone and/or letter. Since both of our schedules must be coordinated with the surgical facility and anesthesia schedules, please allow our personnel a reasonable amount of time to make these arrangements. They will make every attempt to accommodate your requests.

Good general health is mandatory for a problem free and predictable recovery from any surgical procedure. Wellness and good general health result from proper diet, regular exercise and appropriately timed medical evaluations focused on preventative medicine. Good nutrition, vitamin and herbal supplements, as well as adherence to holistic health principles are important concepts in maintaining wellness. Certain supplements, although generally beneficial, may have adverse effects during surgery. Please advise us about all your medications and supplements, so we may advise you regarding their safety in regard to your surgical procedure.

We believe that good nutrition is an important component to excellent surgical outcomes. Multiple studies show that most Americans aren’t getting the recommended daily intake of necessary vitamins and minerals, much less the optimal amount. These suboptimal levels of nutrients have been linked with major diseases from heart disease to cancer.

We use a three phase healing program with supplements to help you recover more quickly and with less downtime. We have you start this a week or so ahead of time to ensure that you are boosting your body’s immune system and removing anything that could interfere with anesthesia or increasing bleeding. Immediately following surgery we give you nutrients that help reduce pain and inflammation and detoxify the anesthesia and other medications. The third phase has additional healing nutrients to support your recovery.

Routine laboratory tests including blood counts and blood chemistries, a pregnancy test when applicable, and an electrocardiogram if you are over 50 years old, will be performed prior to surgery. These tests are performed routinely to screen for any abnormalities, which might complicate your anesthesia or surgery.

Do not take any aspirin or any drug containing aspirin for at least two weeks prior to your surgery. Aspirin may retard platelet function, a blood component that is important to normal blood clotting mechanisms. There are many drugs which contain aspirin. Before taking any drug, check the label carefully to assure that it contains no aspirin.

Do not eat or drink anything 8 hours prior to surgery. Safety in the administration of anesthesia or sedation requires that your stomach be absolutely empty for this interval of time before surgery.

Shower or bathe normally the evening prior to surgery.

You should wear loose fitting, comfortable clothing the day of surgery. A loose fitting shirt with buttons in front is preferable to any type of clothing which must be put on over the head. Please be sure that you have all of your questions answered prior to going into the surgical facility. I prefer that you make an additional appointment in the office if necessary to answer questions regarding your surgery. On the day of surgery, I will visit with you briefly immediately prior to surgery. Any final questions will be answered at that time.

Arrange for someone to drive you home at the appropriate time following your procedure, and arrange for someone to stay with you the night of surgery.

THE DAY OF SURGERY

I usually prescribe sedation or premedication prior to your being brought to the operating room. In order to minimize total necessary doses of drugs, sedation is best administered through an intravenous line rather than given in shot form into your muscle. It is normal to be slightly excited or apprehensive immediately prior to the surgery, and this will be alleviated quickly once your intravenous line is inserted. Our anesthesiologist will speak with you and answer all of your questions regarding your anesthetic.

Prior to moving to the operating room, I will ask you to sit up briefly, so that I can mark your surgical site, to use as guidelines during your surgery. Once in the operating room, you will then be positioned comfortably, and will have no recall of further events during your surgery.

Blepharoplasty is performed utilizing local or general anesthesia and requires from one to two and one-half hours to perform. When local anesthesia is used, you will also be heavily sedated and have no recall whatsoever of events during the procedure, nor any recall of discomfort. The operation consists of small incisions made in the prominent crease in the upper lid and immediately beneath the lashes in the lower lid. Skin is elevated, excess fat is carefully removed, and excess skin is redraped and removed prior to closure of the incision.

Blepharoplasty usually causes minor disability and allows early return to routine living. There is usually little or no pain in the postoperative period. Varying degrees of swelling and discoloration occur in the lid areas and cheeks and usually subside within ten to fourteen days.

At the completion of your operation, you will be transferred to the appropriate recovery area where you will remain until you awaken. I purposely like for you to remain drowsy, since you will be much more comfortable. After an appropriate interval of observation, usually a few hours, you will be allowed to leave with someone to drive you home and stay with you the evening of the surgery.

You will have been given prescriptions for pain medication and antibiotics with instructions for each at your preoperative visit.

AFTER YOUR BLEPHAROPLASTY

Since I want you to remain drowsy and comfortable the evening of your surgery, fill your prescription for pain medication before surgery and take one immediately on arrival at home. Pain medication is best taken with a small amount of food and not on an empty stomach since nausea may occasionally occur. Make yourself comfortable, not necessarily in bed; a couch or comfortable chair is fine. You will continue to be drowsy and will awaken intermittently during the evening. Use the pain medication as directed to remain comfortable. Intermittent cold compresses for the first 48 hours after surgery may help with swelling and discomfort.

Do not try to eat any heavy foods the evening of surgery. Liquids or light foods are preferable. You may resume a normal diet the next morning. Should you experience any nausea the evening of surgery, drink small amounts of liquids only: no food until morning. Antinausea medications are generally not needed; any nausea experienced from the medications used in surgery will usually be gone the next morning. If you have a history of nausea after anesthesia, please inform your anesthesiologist the morning of surgery and you will be given anti-nausea medications during the procedure that will help minimize this occurrence after surgery.

UNLESS YOU ARE ASLEEP, KEEP THE ICED GAUZE SPONGES OR ICE COMPRESSES ON YOUR EYES AS CONTINUOUSLY AS POSSIBLE FOR THE FIRST 48 HOURS. THIS WILL SIGNIFICANTLY REDUCE THE AMOUNT OF SWELLING AND BRUISING WHICH DEVELOPS IN THE LIDS.

Your eyes may not close completely for the first 24 to 48 hours due to swelling in the eyelids. The lids themselves may not contact the eyeball in a normal fashion for the same period of time. Usually this effect is minimal, resolves rapidly, and causes minimal irritation to the eyes. Avoid bright sunlight, wind, or other irritating factors for the first 48 hours following surgery as much as possible. If your eyes begin to feel extremely irritated, or if this irritation persists for greater than 48 hours, notify me and I will prescribe appropriate eye medications.

Discomfort following blepharoplasty should be minimal. A mild irritation of the eyes, and itching along the suture lines are usually the only inconveniences. Use the pain medication prescribed for you sparingly. It should not be necessary after 48 hours.

Bruising in the upper and lower eyelids is normal following blepharoplasty. The degree of bruising will vary according to the individual's tissue and bleeding characteristics, but some bruising is inevitable. Bruising resolves over a period of seven to fourteen days. Slight oozing of blood and fluid along the stitch lines is normal for 24 to 48 hours, and is removed simply as the ice compress is applied and changed. Eye ointment should be applied as needed and directed.

You will be given several eye ointments and/or eye drops, and instructed in their use, before leaving the surgical facility. Use these as directed by your discharge nurse. Refresh® drops to keep your eyes moist during the day and Refresh® gel to keep your eyes protected over night should be used routinely for 6 weeks following eyelid or periorbital surgery.

You may shower or bathe normally immediately following surgery - a small amount of water on the incision causes no harm whatsoever. Do not SOAK the incisions with water or any other applied materials for the first 72 hours.

IF YOU DEVELOP A MARKED INCREASE IN DISCOMFORT, SWELLING, OR BRUISING FOLLOWING SURGERY, NOTIFY MY OFFICE IMMEDIATELY. THESE SYMPTOMS, WHEN CAUSED BY EXCESSIVE BLEEDING BEHIND THE SUTURES LINES WITHIN THE EYE SOCKET, CAUSE A MARKED CHANGE IN THE APPEARANCE OF THE EYELID AS COMPARED TO THE OTHER EYE AND ARE READILY RECOGNIZABLE.

If you have a history of high blood pressure, it should first be controlled: exercise should strictly be limited with light exercise resumed at three weeks and more strenuous exercise at six weeks.

Although most swelling and bruising has resolved in 7-14 days, complete
resolution of swelling occasionally requires three weeks or longer. Bruising moves from the lower eyelid area downward into the cheeks and changes in color normally from purple to purplish yellow as resolution occurs.

As swelling resolves, your eyes will appear larger and distinctly different to you than before your surgery. This is normal, and you will adapt to the final configuration of the eyelids as swelling resolves over a period of weeks. In the first 3-4 days following surgery, the lower eyelid often rolls slightly outward, losing contact with the eyeball due to swelling. As the initial swelling subsides in 48-72 hours, lid position becomes more normal.

As mentioned prior to your operation, blepharoplasty does not completely remove either the "crow’s feet" laugh lines at the sides of the eyes, or completely remove all wrinkling from the upper or lower eyelid. Placing excessive amounts of tension on the lower lid in an attempt to remove wrinkles can cause downward pulling and eversion of the lower lid away from the eyeball and must be avoided.

Resume normal tasks of daily living as rapidly as possible. The pain from the procedure decreases to about half of its intensity each 24 hours following surgery. Postoperative discomfort is most marked only during the first 24 hours and regresses rapidly thereafter. Resumption of normal activities, for example, lifting the arms to comb the hair and lifting objects of normal weight, speeds the recovery process and reduces the pain more rapidly. Immobility tends to cause continued discomfort and increased muscle spasms. The only limitation to activity is if you feel significant pain. Discomfort is normal with motion initially, and there is nothing that can be harmed by normal activity. Most patients are back at work in 5-7 days. Call the office for an appointment to be seen as directed following surgery.

You may resume light exercise at 3 weeks following surgery. This includes low impact activities at 1/3 duration of exercise, repetitions, amount of weight, and pulse rate. Your exercise tolerance should gradually increase to 2/3 intensity at 6 weeks, and be at full intensity by 8 weeks. This includes high impact activities such as running, horseback riding, and high impact aerobics.

Postoperative Healing

Postoperative healing requires some mandatory down time as part of the surgical recovery process. Post surgical healing requires the body to repair the surgical wound (whether in the skin, fat, muscle or bone) with scar tissue. The bruise and tissue fluid in the wound are gradually replaced by stronger scar or fibrous tissue over a period of 6-8 weeks. Until the time that the healing area is strong enough to maintain tissue integrity, the wound is held together by the sutures (stitches) placed at the time of surgery. Too much wound tension (stress) before the strength of the healing tissue is satisfactory, can cause disruption of the incision. I place sutures very precisely to account for these healing characteristics to maximize your postoperative activity, comfort, and safety. However, your inherent healing characteristics significantly dictate these parameters. Stretching, movement, massage, and return to normal activities of daily living in the early postoperative recovery allow for the optimal return to your full normal life style.

After the initial burst of high energy healing and the “bulking up” of scar tissue, the wound enters a maturation phase, and the scar tissue becomes thinner, less red, and stronger. The maturing and stabilization of scar tissue occurs over a period of 6 to12 months. Long-term changes tend to be subtler, slower, and less evident than short-term changes that occur in the first 6 to 8 weeks.

There are no absolute parameters regarding return to postoperative activities and one must adjust for variation in pain tolerance, invasiveness of surgery and healing variations.

In general, you cannot speed up the healing process, only slow it down by too much activity too soon. Overexertion can lengthen the period of time for pain to decrease, swelling and bruising to resolve, and the final surgical results to be evident. Healing occurs for up to one (1) year, sometimes longer. The latter changes tend to be subtle and gradual, and therefore not nearly as dramatic as in the initial 6 to 8 weeks.

Please be patient with your own healing. Any change in your appearance affects your perception of self-image and requires an adjustment period of days to weeks. It is normal to have mild feelings of doubt or a low mood during this period in the first 1 to 3 weeks following surgery. These feelings are then rapidly replaced by positive feelings as healing progresses and you adjust to your improved appearance.

If you should have any other questions or problems, please contact our office at
(303) 443-2277.

LIMITATIONS, RISKS, AND POSSIBLE COMPLICATIONS WITH BLEPHAROPLASTY

With any surgical procedure, a very small percentage of untoward complications can occur. These complications are rare, and I mention them not to alarm you, but only to inform you.

Normally following the surgery, a very small amount of blood-tinged drainage may ooze from the stitch lines for 24-48 hours. Very rarely (in less than one case in one hundred), significant bleeding may occur after the operation. If this occurs, the eye becomes EXTREMELY swollen, bruised, and PAINFUL. You should notify me IMMEDIATELY. Should bleeding occur, I remove the stitches to prevent building of pressure in the eye socket. If this pressure is not released, it could eventually put enough pressure on the optic nerve to the eye to impair vision.

It is possible to have untoward side effects to any drug which is administered during surgery. Severe side effects are extremely rare, but can be life threatening. It is for this reason that I insist on performing your surgery in an optimal setting where all conceivable equipment and medical backup are available should you have an unexpected reaction. Anesthetic or sedation risks are extremely minimal. Many cases have been vastly over publicized by the media, and most have occurred in settings where less than optimal facilities, equipment and personnel are present.

Careful examination prior to the operation always reveals slight asymmetry of the eyelids, and although the operation corrects marked differences, slight residual asymmetry may still be present after surgery.

Tearing, mild irritation, or excessive dryness of the eyes following surgery may occasionally occur and necessitate the use of eyedrops or eye ointment for several weeks.

Removal of too much skin or fat from the eyes can cause dry eye problems, hollowing of the orbit or exposure of the eye. A conservative approach to periorbital rejuvenation is very important to avoid these risks. We must improve the eyelid periorbital aesthetics, but maintain eyelid function and protect the eyeball and vision.

Removal of an excess amount of skin, particularly from the lower eyelid, may cause the lid to lose contact with the eyeball and produce significant irritation. This condition occurs rarely and is treated by massage and observation with improvement usually resulting in three to six weeks. In the first 3 to 4 days following surgery, the lower eyelid often rolls slightly outward, losing contact with the eyeball due to swelling. As the initial swelling subsides in 48-72 hours, lid position becomes more normal.

Following blepharoplasty, your eyes will appear larger and more "open" to you, the result of removal of excessively sagging or bagging tissues. Initially, you may notice slight changes in the shape of the lid openings. This is due to swelling and subsides over the first few weeks.

Any change in your appearance affects your perception of self image, and requires a period of days to weeks to adjust. It is normal to occasionally have mild feelings of doubt or low mood during the adjustment period in the first one to three weeks following surgery. These feelings are then rapidly replaced by positive feelings as healing progresses and you adjust to your improved appearance.

Impairment of vision following blepharoplasty has been reported but is felt to be extremely rare, resulting from severe UNTREATED bleeding or infection.

All of the above-mentioned complications of blepharoplasty are unusual but occur occasionally despite the most vigorous standards of surgical practice. They are mentioned not to alarm, but to adequately inform you.

CONCLUSION

Blepharoplasty is a procedure that improves the appearance of eyelids, which are excessively wrinkled and bulging due to excess skin or fat. Discomfort and postoperative disability are usually minimal; satisfaction is usually extremely high with a significant improvement in overall appearance and "youthfulness" of the eyes.

During our office consultation, I will discuss additional and more detailed information regarding all of the areas mentioned in this information sheet. You will have an opportunity to ask in-depth questions. Please review this sheet carefully and write down any questions you may have.