Tampa Eyelid Surgery Specialist

Any type of –plasty within the field of surgery simply means a change in shape or configuration. A “bleph,” refers to eyelid, so this super-fancy word just stands for eyelid reshaping surgery.

Eyelid reshaping surgery may address the extra skin of a puffy lower or upper eyelid. In order to achieve the best aesthetic result, the eyelid procedure may involve removing overgrown (hypertrophied) muscle, and possibly removing the fat around the eyeball (post-septal fat), or repositioning it.

An upper eyelid blepharoplasty may be combined with a transbleph brow elevation or browlift and frowning muscle removal or weakening. A lower eyelid blepharoplasty may be combined with a mid-face lift to address festoons, droopy cheek fat pads, and smile lines.

There are two reasons for wishing to address upper eyelid problems, aesthetic, or functional. From a purely cosmetic standpoint, the brows may be positioned too low, or arch in a less feminine way, there may be upper lid skin excess and folding, leading to the prematurely aged, or chronic fatigue/ “always tired,” appearance. When the folding gets to the point of obstructing the patient’s field of vision, the procedure is done for functional, or reconstructive reasons. Typically, a patient must lose at least 30% of their total visual field owing to droopy brows and/or lid skin for insurance approval. Other medical reasons to have this done, include chronic irritation from skin folding with or without infection, or severe eye fatigue by the afternoon or evening, a night job, especially one requiring the operation of heavy machinery.

The indication for lower lid blepharoplasty is the desire to improve the appearance of the lower lids and/or midface. Patients who have herniated post-septal fat-pads (the fat pockets surrounding the eye), lower lid rhytids (wrinkles), and excess skin (though less typical) would benefit from excision of the herniated fat, and a conservative skin excision with lower lid tightening. The presence of droopy malar fat pads (the fat pads of the cheeks), hollows in the medial periorbita (to the lower inside of the eye), and smile lines, would benefit from added inferior dissection and lifting of the midface (a midface lift).

The fat pads that surround the eye are bound by a thin membrane that keeps them within the bony orbit or the eye socket. With time, the septum (thin membrane) may weaken and allow pseudoherniation of this “post-septal” fat, causing a bulgy lower eyelid. This may also be cause by a genetic predisposition to more fat, more swelling, or a weaker septum. It may also be due to hypertrophy (overgrowth) of the muscles within the eye-socket, which then push the fat out (as happens in Graves’ disease). The descent of the malar fat pad, or the fat-pad that is in the soft tissue of the upper cheek can cause a second bulge to the lower outside of the first. This is due to aging under gravity, and may be exacerbated by weightloss.

Yes, this is best demonstrated by taping the brows and lids into a higher position and demonstrating a clear improvement in the range of the visible optic field from the untaped state.

Typically, a patient must lose at least 30% of their total visual field owing to droopy brows and/or lid skin for insurance approval. Other medical reasons to have this done, include chronic irritation from skin folding with or without infection, or severe eye fatigue by the afternoon or evening, a night job, especially one requiring the operation of heavy machinery.

Because this procedure addresses the bulging fat of the lower lids only, any improvement in excess skin is only mild. To adequately address excess skin, a laser or chemical resurfacing procedure must be added. In addition, nasolabial folds or smile lines and droopy cheek fat, or festoons will need the external approach.

While blepharoplasty surgery may address excessive skin on the upper and/or lower eyelids, it will remove fine wrinkles around the eyes, or anywhere else on the face. To achieve this skin resurfacing, whether laser (CO2 or erbium laser) or chemical (TCA or phenol, or blue peel), must be added to blepharoplasty or any other lift or excision type plastic surgery to help with fine rhytids.

Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright, pinching just enough skin to allow closure of the lids without any remaining skin redundancy. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The previously marked skin is excised. Redundant muscle may be excised as well. The septum (membrane behind which the fat-pads are found) is either entirely opened, or opened at intervals. Fat from both eye-sockets is excised and compared for symmetry. The septum may be closed. At this point if the muscles elevating the eyes are to be repaired, this is performed. The skin and muscle is closed together on both sides.

Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright; the transcutaneous approach may be taken through a number of incisions, but most commonly just under the lower lash line. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The dissection is carried to the septum, which is opened, the fat in question removed or repositioned symmetrically, the lid tightened horizontally, a small triangle of outside skin excised, if at all, and the skin closed.

Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright; the transcutaneous approach may be taken through a number of incisions, but most commonly just under the lower lash line. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The dissection is carried to the septum and further down to as far as the crease on the side of the nasal alae (flaring portion of the nose), this is done in the subperiosteal plane (under the facial bone covering) in patients requiring large correction, and in the superficial plane in patients requiring less correction of the nasal fold or smile lines. The septum is then opened, the fat in question removed or repositioned symmetrically, and the lid tightened horizontally. The previously dissected cheek fat pads are suspended in an elevated position adding bulk to the cheek-bones and improving the smile lines (nasolabial folds). The cheek is suspended securely to the fascial or bony tissues to the outside of the eye, a very conservative extra skin excision is performed, and the incisions closed.

The distinguishing feature of this approach is the lack of a skin incision. Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. A topical anesthetic is applied to the eye, a corneal shield may be applied to protect the cornea. A cut is made in the depth of the conjunctival sac or the fornix. Dr. Gerzenshtein prefers this approach to the approach that uses a more superior incision, for multiple reasons. Through stab incisions in the capsulopalpebral fascia fat is removed under direct vision, checking constantly for symmetry and any bulging still remaining. Typically, no suturing is required, as the puncture sites heal within a day. If mild to moderate skin laxity is present, carbon dioxide laser resurfacing is added to the lower lids.

There are several advantages to transconjunctival blepharoplasty. First, no skin incision is made. This reduces post-operative discomfort. Second, because the skin, and the septum (membrane behind which the fat-pads are found) are not violated it is believed that the risk of ectropion or lid eversion, scleral show (lid drooping and/or retraction), and other serious post-operative problems are avoided. When combined with carbon dioxide laser resurfacing, however, retraction may still occur. This procedure should be reserved for patients with minimal skin excess in the lower lids, minimal malar (cheek) pad descent, mild nasolabial folds (smile lines) but considerable bulging of the lower lid fat pads.

Upper eyelid blepharoplasty typically follows either an open (coronal approach) or an endoscopic approach to brow elevation. The reason to perform the operation in such a sequence is to ensure that an excessive amount of skin is not removed; often lifting the brows will stretch out the upper eyelid skin, correct much of the redundancy and permit correction with much less of an upper eyelid skin excision. Performing the upper eyelid surgery first, risks excising too much skin, and not realizing this until the after brow elevation takes up additional skin. The open browlift is performed as follows. A cut is made either behind or along the forehead hairline. The forehead is undermined to the level of the eyebrows, either on top of the bone (subperiosteal), or on top of the bone covering (subgaleal). Frown muscles (corrugators, procerus, and depressors) are resected (removed). In some cases, sections of the frontalis (the eyebrow raising muscle, and the same one that causes the cross-forehead creases) are also removed. The brows are fixed in a symmetric configuration that is aesthetically pleasing, taking into account patient sex, and preoperative preference. A sliver of skin is removed at the edge of the incision, which serves to tighten skin laxity. The endoscopic brow-lift is typically performed in younger patients, in whom the problems include brow ptosis or drooping, with or without excess upper eyelid skin, as well as crow’s feet, but without significant forehead excess skin. Because minimal skin excision is needed, the browlift is performed through three small incisions behind the hairline. There is a multitude of devices available for fixation of the brows. Dr. Gerzenshtein prefers the Endotine® Forehead fixation device. The two outside (lateral) incisions serve as points of small triangular skin excisions. In addition, the lateral brow-lift may be added to the endoscopic approach to correct any skin excess, especially when the browlift is combined with the lower blepharoplasty, with or without the midface lift procedure. The previously marked upper eyelid skin is excised. Redundant muscle may be excised as well. The septum (membrane behind which the fat-pads are found) is either entirely opened, or opened at intervals. Fat from both eye-sockets is excised and compared for symmetry. The septum may be closed. At this point if the muscles elevating the eyes are to be repaired, this is performed. The skin and muscle is closed together on both sides.

Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright, pinching just enough skin to allow closure of the lids without any remaining skin redundancy. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The previously marked skin is excised. Redundant muscle may be excised as well. The septum (membrane behind which the fat-pads are found) is either entirely opened, or opened at intervals. Fat from both eye-sockets is excised and compared for symmetry. After performing an upper eyelid blepharoplasty, but before closing the skin, the forehead is undermined under the layer (periosteum) covering the skull bones. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. A drill is used to make two symmetric holes to either side of the midline in the calvarium that extend only partially through the skull. This is assured by using a manual drill with a stopper. Two symmetric drill holes are made in the outer portion of the skull. The TransBleph fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. The septum may be closed. At this point if the muscles elevating the eyes are to be repaired, this is performed. The skin and muscle is closed together on both sides. A compressive dressing is then applied to allow the forehead soft tissues to scar in the appropriate position.

The ENDOTINE® Endoscopic Forehead Lift Procedure is essentially the endoscopic browpexy that uses the ENDOTINE® Forehead fixation device to achieve stable fixation of the forehead tissues. Three incisions are made behind the hairline, one in the center, the other two behind the highest portion of the non-hair bearing scalp in the front. Dissection is carried out under endoscopic guidance to achieve release of the forehead skin and underlying soft tissues. Furrow-causing muscles are removed, and cross crease muscles are weakened. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. Extra skin is removed from the two outside incisions, and the incisions are closed.

This procedure is reserved for patients who will be undergoing upper blepharoplasty (or upper eyelid skin, muscle, and/or fat excision) and have very little excess skin in the forehead, have little in the way of cross-forehead creases, but do have significant brow droop (brow ptosis). It may also be used in cases where skin and creases are present, but the patient only wants to address brow position, and through the least invasive approach. Marks are made to outline the amount of skin to be removed from the upper eyelids. The skin is excised, along with muscle, and possibly fat. Excess is gained to the space under the eyebrows, and over the skull bone. Adequate release is assured by elevating the skin and witnessing re-positioning of the eyebrows in a symmetric fashion. Two symmetric drill holes are made in the outer portion of the skull. This is done with a drill bit that is protected from entering too deep into the bone. The fixation devices are deployed. They look like plastic hang-hooks. The skin is re-draped over the hooks in the desired position. A compressive dressing is then applied to allow the forehead soft tissues to scar in the appropriate position.

Depending on the degree of necessary dissection, and patient comfort with local anesthetic only, the procedure may be done under local or regional block with or without sedation, or under general anesthesia or some variation of it. Marks are made with the patient upright; the transcutaneous approach may be taken through a number of incisions, but most commonly just under the lower lash line. The appropriate anesthesia is then administered, and the superficial eyelid tissues infiltrated with local. The dissection is carried to the septum and further down to as far as the crease on the side of the nasal alae (flaring portion of the nose), this is done in the subperiosteal plane (under the facial bone covering). The septum is then opened, the fat in question removed or repositioned symmetrically, and the lid tightened horizontally. Symmetric holes in the cheekbones are made with a handheld drill. A hook-like absorbable device is placed into the holes and the previously dissected cheek fat pads are suspended in an elevated position by hooking them on the previously placed ENDOTINE ® Midface Lift devices, adding bulk to the cheek-bones and improving the smile lines (nasolabial folds). A very conservative extra skin excision is performed, and the incisions closed.

Excessive removal of post-septal or peri-orbital fat that causes lower lid bulging is thought to cause a hollowed out appearance to the eyes in the long-term post-operative period. No good studies to this effect have been carried out, but the thought and the anecdotal evidence does seem to indicate that post-septal fat excision should be conservative, or just enough to get the job done. Aside from removing the fat, a good approach has been to position a tongue of the fat within the lower lid groove, especially towards the nasal side to fill in the circles under the eyes, and smooth the transition between the cheek and lower lid fat.

There is no external incision with transconjunctival approach, so there is no possibility for an external scar. That does not mean that an internal scar cannot for and cause distortion of the lower lid.

A subciliary approach is the most often employed external incision. This incision tends to heal imperceptibly, although as with any cut, there is the possibility of poor healing, and distortion of the lower lid. Even the most prominent of incisions usually become inconspicuous within several months. The usual problem with an external incision is not so much the cicatricial scarring of the skin, but the septal scarring that may cause lower lid distortion.

Typically, there is no right age for blepharoplasty and/or browpexy. Browlifting and blepharoplasty can be classified as reconstructive, restorative, or cosmetic. Reconstructive blepharoplasty/browlifting is typically performed as early as adolescence because it addresses either the total absence of facial musculature, as may be found in certain syndromes, or paralysis of the facial muscles, whether traumatic, or congenital. Restorative blepharoplasty/browlifting is used to set back some of the changes brought about by aging. This is performed to restore natural eyebrow position, in conjunction with removal of excess upper eyelid skin. The creases or “crow’s feet” to the outside of the eyes are also addressed. It is called restorative blepharoplasty/browpexy because the plastic surgeon attempts to replace the skin back to it original position, and remove any excess. Browpexy and blepharoplasty performed to restore a normal field of vision in a patient with acquired brow drooping is also a form of restorative browpexy, performed for functional rather than cosmetic reasons, with the fringe benefit of improvement in appearance. Patients may be candidates for this as early as their thirties. It all has to do with how severe the changes are, and what the patient desires. Typically, the massive weight loss patient will present at an earlier age, while most will present later in life. Minimal changes will likely be corrected with less invasive methods, whereas severe aesthetic disturbances may need a full coronal approach combined with other surgical and non-surgical modalities. Provided the patient is healthy, there is no upper age limit to blepharoplasty, browpexy or browlift surgery.

On waking from anesthesia, you will find yourself in the recovery room with dressings, and ice or gel pack in place. Your vision may be blurry owing to protective ointment applied to your eyes during surgery. You will be able to depart once sufficiently recovered from anesthesia, and lucid. A friend or family member will drive you home and stay with you for the next 2 days to help you with activities of daily living. Initially, you will feel tired and run down. This will be at its worst in the first several days after surgery. The lethargy may be attributed to general anesthesia and will improve substantially over the first week after a blepharoplasty. Discharge from your incisions should be minimal over the 1st 2 days after surgery, though bleeding may occur with excessive activity, and at least some spotting over the dressing is normal. The dressing present after surgery will be removed, along with a special garment, during the first post-operative visit. Drains, if present, will likely be discontinued at the same time. If dilute local solution was used (superwet or tumescent technique) pain and discomfort will be mild initially, and will increase and peak within two days. The pain will then subside over the course of one to two weeks. Use of prescription pain medication will help significantly.

Nausea and vomiting in the postoperative period is not uncommon and has to do with the type of anesthesia used and overall patient sensitivity to the various medications. It generally resolves within 1 to two days after surgery. Increasing fluid intake (provided you have no history of heart or fluid trouble), especially via one of the “ade” (Gatorade, PowerAde, etc.) solutions available for sports use, combined with anti-emetic medication should minimize this problem.

Use of opiate pain medication, combined with inactivity, and dehydration may lead to constipation. Increasing fluid intake will help this as well, especially in combination with walking, and use of a stool softener.

Swelling and bruising peak within three days of surgery and gradually subside over the following week, but may persist for up to four weeks. The two sides rarely bruise to the same degree, and a mild difference in swelling is normal, however, if swelling is notably different you will need to come in for evaluation immediately. Your appearance early on in the course of recovery may be distorted by a significant amount of swelling, giving you a bloated, puffy, pale appearance with blotchy bruising. Do not be disturbed, this will pass, and you will look and feel much better within several weeks.

Apart from swelling and bruising, most patients will experience tightness and numbness over the forehead if a browlift was performed with the blepharoplasty. Most numb places will regain sensation over several months, in the case of the open or coronal browlift approach; this may take up to six months. Expect improvement in all of your symptoms, worsening over the course of recovery is not normal and needs to be addressed via a prompt phone call. If a browlift was performed, hair may be lost around the incision 1 month after the surgery. It will usually return within 4 months after the initial loss. Healing incisions will adopt a pinkish hue that should gradually fade over the next six months to a year.

Some patients react to absorbable (inside) suture, small pustules or whiteheads along the incision may signal this. The suture may be removed in the office if the problem becomes bothersome.

Facial camouflage make-up may be applied two weeks after surgery to conceal bruising, and healing incisions. Telltale signs of blepharoplasty surgery will resolve within 1-2 months. The final result will be obtained once all of the swelling has resolved, typically around six months.

When prescribed, antibiotics are extremely important to take as directed for proper blood levels and effect. Antibiotics may cause gastrointestinal symptoms, loose bowel movements, or yeast infections. Prompt notification is the key. Anti-emetic (nausea), analgesic (pain), a sleeping aid, and a stool softener should also be prescribed, and taken as directed. If you are sensitive to narcotic medication, start off slowly, with ½ or ¼ dose and work up (this class of pain medication may not only make you disoriented, lethargic and nauseated, but also constipated, and can cause you to have a difficult time urinating).

You should never mix Tylenol™ with certain combination narcotics that already contain acetaminophen, as this may cause damage to your liver. If you do not want to take the prescribed pain medication for any reason, simply substitute it with Tylenol™. Any of the prescribed medications may cause an allergic reaction. If you notice swelling, redness, raised wheals over any portion of your skin notify the office. If you have trouble talking, breathing, have tongue and mouth swelling; consider it a medical emergency and cal 911 without delay. Finally, do not drink alcohol while using the prescribed medicines for at least two weeks until after surgery. This is because there are dangerous interactions between alcohol and pain, nausea, and insomnia medication. Alcohol may render the antibiotic useless, worsen fluid exacerbation, and result in a dehisced incision from bumps or falls sustained while inebriated.

It is not a good idea to drive a car or engage in activities that depend on your coordination for 48 hours after your blepharoplasty surgery, or after taking any of the pain, nausea or insomnia medications prescribed. Walking and getting about is highly encouraged for multiple reasons, including a decrease in the incidence of clot formation in the veins of your legs. A companion should be with you for the first 24 hours to monitor and help you get about as necessary. It helps to apply refrigerated conforming gel masks over the face for the first 2 days after surgery to reduce swelling and discomfort. Ice should not be applied directly, and will be changed every 15-20 minutes to maintain cold temperature. If the gel pads are no longer useable, frozen vegetable packs, especially frozen peas, work well. A cold compress (damp from a thoroughly wrung out towel) may be substituted for gel or frozen packs if you find this more tolerable. On the third day after surgery, gel pads or frozen pack applications are stopped. When resting/sleeping, laying on your back with several pillows under your head and back, or placing a pillow or rolled blanket under the head of your mattress, will decrease swelling.

You should not sleep in the supine position supine for at least 2 weeks after facial surgery. When getting up from bed, you can help yourself by using one hand to support your head, and using the other to grasp a stationary object or to push off the bed. Plan to be away from work for one week; assuming your post-operative course is uncomplicated. For the first week, avoid activities that raise your blood pressure such as heavy manual labor, repeated heavy lifting, strenuous exercise, or bending over. Refrain from sexual activity for 1 month after your surgery. After 1 week you may engage in light exercise only, walking for example. Social activities may be resumed within 1 week of surgery, but may necessitate camouflage make-up. No heavy lifting is permitted (10 lbs or more) for 2 weeks after rhytidectomy. No smoking and no nicotine substitute (patches, chewing tobacco, etc.) should be used for at least 6 weeks after surgery, smoking will decrease blood and oxygen flow to healing tissues and can cause loss (death) of skin, fat, and muscle in the operated field, especially along the incisions. It can slow down healing to double of normal time, worsen scar appearance on the outside, lead to a tough, fibrous scar on the inside, and increase the risk of fluid pockets.

Do not manipulate the incisions until the first post-operative appointment (24 hours after surgery). The routine closure will have non-absorbable suture without an external dressing and a coat of antibiotic ointment. On occasion incisions will be closed with absorbable suture and covered via steri-strips. At the initial visit any post-operative dressing will be removed, so please bring a scarf with you for the trip home, as your hair will be disheveled. You may shower or wash over the steri-strips or exposed suture material. Do not bathe, or submerge, for at least 3 weeks after surgery. Be gentle and pat when applying soap, rinsing, and drying. After drying, steri-strip covered incisions do not need any more attention. After drying over incisions with exposed suture, apply a thin layer of triple antibiotic ointment. If present, when the edges of the steri-strips become frayed, trim them. With time, as very little is left behind, they may be removed (usually 2-4 weeks). In some cases additional tape will be used for removing tension from the suture line, or placing tissue in the desired position of healing. If such tape is present, it will be re-applied at the first office visit, and you will be shown how to do this on your own.

As a general rule, keeping the incisions clean and dry will result in the most aesthetically pleasing healed incision with minimal scarring. Do not allow scabs to accumulate, if present you may gently tease it off with peroxide soaked q-tip. While tending to the incision, watch for signs of problems as outlined below. It is not routine to have drains placed at the time of surgery, however, at times, if bleeding is diffuse, and cannot be addressed via surgical maneuvers (clipping, suturing, tying) it may be safer to leave behind a drain in attempting to prevent a hematoma (blood collection). If present, the drains will be removed within one to three days. If non-absorbable sutures were used, they will be removed 7 days after surgery. All incisions behind the hairline/scalp will have clips or suture removed 10-14 days from surgery. Do not expose incisions to the sun and/or tanning UV light for at least 1 year, however, you may begin tanning 4 weeks after surgery while keeping incisions covered. If sun exposure in unavoidable, use a product with SPF of at least 30. On the third day after surgery, discontinue gel pad application.

The routine closure will have non-absorbable suture without an external dressing and a coat of antibiotic ointment. On occasion incisions will be closed with absorbable suture and covered via steri-strips. At the initial visit any post-operative dressing will be removed, so please bring a scarf with you for the trip home, as your hair will be disheveled. You may shower or wash over the steri-strips or exposed suture material. Do not bathe, or submerge, for at least 3 weeks after surgery. Be gentle and pat when applying soap, rinsing, and drying. After drying, steri-strip covered incisions do not need any more attention. After drying over incisions with exposed suture, apply a thin layer of triple antibiotic ointment. If present, when the edges of the steri-strips become frayed, trim them. With time, as very little is left behind, they may be removed (usually 2-4 weeks). In some cases additional tape will be used for removing tension from the suture line, or placing tissue in the desired position of healing. If such tape is present, it will be re-applied at the first office visit, and you will be shown how to do this on your own.

As a general rule, keeping the incisions clean and dry will result in the most aesthetically pleasing healed incision with minimal scarring. Do not allow scabs to accumulate, if present you may gently tease it off with peroxide soaked q-tip. While tending to the incision, watch for signs of problems as outlined below. It is not routine to have drains placed at the time of surgery, however, at times, if bleeding is diffuse, and cannot be addressed via surgical maneuvers (clipping, suturing, tying) it may be safer to leave behind a drain in attempting to prevent a hematoma (blood collection). If present, the drains will be removed within one to three days. If non-absorbable sutures were used, they will be removed 7 days after surgery. All incisions behind the hairline/scalp will have clips or suture removed 10-14 days from surgery. Do not expose incisions to the sun and/or tanning UV light for at least 1 year, however, you may begin tanning 4 weeks after surgery while keeping incisions covered. If sun exposure in unavoidable, use a product with SPF of at least 30. On the third day after surgery, discontinue gel pad application.

The swelling associated with blepharoplasty surgery will vary in terms of duration from patient to patient. Apart from individual tendency to remain edematous after surgery, elevation of the head at all times, especially in sleep and rest, and possibly the use of Arnica may speed up the resolution of swelling. Typically, after a week, much of the swelling is gone, allowing the patient to have a glimpse of the results, with an improvement in excess skin presence and/or drooping. Bruising may persist for a month requiring camouflage make-up. If a more extensive dissection was performed, such as in the case of a midface lift, or a browlift in combination with blepharoplasty, or if upper and lower blepharoplasty was combined, significant swelling may persist for as long as 2-3 weeks. Milder swelling, especially associated with sleeping, and the reclined position may persist for one to two months.

Patients who have a “negative vector,” are prone to complications after lower lid surgery. Although the phrase was coined by a well-meaning, and no doubt intelligent surgeon, the term vector is grossly inappropriate, as would be noted in a review of any high-school physics text. It is intended to signify that the eyeball protrudes further than the part of the cheek-bone that supports it. This, in turn provides no support for the incised lower lid, and carries a significant risk of lower lid droop (ectropion and/or scleral show), with its attendant troubles of dry-eye, or wet-eye, or corneal irritation, or scarring, not to mention a poor cosmetic result. Preoperative dry eye, and absence of the protective Bell’s reflex, ectropion, entropion, scleral show, exophthalmos, whether associated with thyroid disease, or Graves’ all predispose the blepharoplasty patient to significant post-operative complications. Lower lid work carried out in high-risk individuals should include a complete disclosure of the possible problems, solutions, and pre-emptive and intra-operative preventive steps to minimize the risks. This may mean tightening of the lower lid, involving more invasive means combined with primary support of the septum with a substance like alloderm.

Risks associated with blepharoplasty surgery may be grouped into anesthesia risks, and surgical complications. Anesthesia risks are common to any surgery and are discussed elsewhere. Events such as cardiac complications (heart attacks or myocardial infarctions), allergic or anaphylactic reactions, lung-related adverse effects (pulmonary embolism, pneumonia), kidney, liver, or any other organ system problem would all fall under that category. Complications related to the act of surgery may be grouped into risks involved in undergoing any procedure, and risks particular to blepharoplasty or brow lifting. Risks of any procedure include bleeding or hemorrhage, infection, whether skin, soft tissue, abscess, or necrotizing, acute and chronic pain, and acute or chronic skin sensitivity. Delayed healing is more common is persons with vascular disease and smokers. Fluid collections known as seroma may occur in the dissected space, this typically resolves with fluid drainage. Fine results are anticipated but never guaranteed. Dissatisfaction with the cosmetic outcome of any procedure will require procedural correction.

Complications related to specifically to blepharoplasty surgery include asymmetry, which may need surgical correction through re-operation, inadequate correction of the excess skin, over-correction of the lids leading to an inability to close the lids (which may lead to its own problems with the cornea, tearing, dryness, etc. and is usually a result of a combination procedure with upper blepharoplasty – persistent symptoms of this nature may require surgical reconstruction). Alopecia, or hair-loss around the incision is not a frequent complication, but is not rare, and my necessitate hair replacement or re-positioning for correction when blepharoplasty is combined with browlifting. Contour abnormalities, divots, lumps, bumps, wrinkles may result from a blepharoplasty surgery. When presenting weeks after surgery, irregularities may be a result of internal scarring. They typically resolve without issue, but may need correction in some cases. Recurrence of the upper lid skin excess droop is also a common negative outcome in eyelid surgery, in which case additional skin must be excised. “Dog ears” are more of a possibility with the open approach, and may also require secondary correction. Scars are not particular to the blepharoplasty procedure, but their prominence, or asymmetry if present, after this procedure may be hard to mask, and may require revision blepharoplasty surgery or other means of making the inconspicuous. Blindness is caused by pressure due to bleeding into the eye-socket, and is exceedingly unusual. Bleeding around the eye is a true surgical emergency and needs prompt decompression. Damage to the muscles that move the eye (especially the inferior oblique) is also a possibility. This would necessitate prompt repair, and in the case of a delayed diagnosis a reconstruction at a later time. Dryness of the eyes may be exacerbated or unmasked by blepharoplasty surgery. In spite of certain pre-operative tests and a thorough history, it may not be avoided. Ectropion, (an out and down dislodgment of the lower lid from the eyeball), scleral show (drooping lower lid), lid irritation, and at times entropion, may be caused by lower lid blepharoplasty. This may require further surgery for failure to resolve within several months. Difficulty closing the eyelids, owing to scar contracture may necessitate surgery to prevent permanent damage to the corneae. Eyelid hair-loss is typically temporary if it occurs, but if lashes fail to grow back within 4-6 months, surgery may be warranted. Transient swelling at the corners of the eyelids is quite common, and more so when upper and lower lid work is combined. This is usually self-limited, but takes several weeks to months to resolve.

Intermittent application of ice packs, or more economically frozen veggie packs will diminish swelling, as will a compression garment designed specifically for browlift patients. When it comes to reducing bruising two natural substances, bromelain, and arnica can help. Their properties are listed below.

• http://www.anyvitamins.com/bromelain-info.htm
• http://www.botanical.com/botanical/mgmh/a/arnic058.html
• http://www.alpinepharm.com