Upper eyelid surgery

This article covers how excess skin on the upper lid is assessed, how the operation is planned, the recovery process and the risks. A problem affecting the visual field and a request about appearance are described separately. Drooping of the lid margin and drooping of the brow are covered to show the limits of the scope.

What is upper eyelid surgery?

Upper eyelid surgery, also called upper blepharoplasty, is an operation to remove excess skin from the upper lid.¹ Laxity of the eyelid skin that creates a fold of excess is called dermatochalasis. This excess can change the appearance of the lid crease and can hang over the lashes.²

Restriction of the visual field by excess skin has been studied in detail; the most common cause is mechanical obstruction of the field of view by the redundant skin.² Addressing skin that obstructs the view is a functional aim. Wanting to change the appearance of the lid without the visual field being affected is an aesthetic aim.¹ The two can be addressed in the same operation, but they are defined separately at the examination.

A low lid margin and skin hanging over the lashes are not the same thing. A brow that has come down can also create bunching over the lid; brow ptosis frequently accompanies dermatochalasis.² The skin, the lid margin and the brow are therefore examined separately.

Who is it suitable for?

An assessment can be made in people troubled by excess skin on the upper lid who understand the expected change and the limits of the operation.³ General health, illnesses that can affect wound healing and eye health are part of that decision.³ The same procedure is not recommended to everyone on the basis of age alone or of how a photograph looks.

Where the complaint concerns the visual field, whether the skin genuinely obstructs the view, and whether the complaint relates to another eye problem, are investigated.² Dry eye, a drooping lid margin and a drooping brow can produce the same complaint; telling them apart changes the plan.⁴

For someone attending with an aesthetic aim, the change they want is defined clearly.⁵ Where the aim concerns the upper lid skin alone, a procedure to lift the brow or raise the lid margin is not added to the plan as a matter of course.³ The expected benefit is weighed together with the scar and the possibility of needing further correction.⁶ Not having surgery is also one of the options.

What does the examination assess?

Skin and the lid crease: The position of the excess skin, the height of the lid crease, bunching over the lashes and the differences between the two sides are examined.⁴ Asymmetry present at the outset is recorded; not every difference noticed later is assumed to have been created by the surgery.⁴

Lid margin and movement: The position of the lid when open, the function of the levator muscle that raises the lid, and whether the eyes close fully when closed gently are assessed.⁷ The measurements recorded include the palpebral aperture, the distance between the lid margin and the light reflex, and the height of the crease.⁴

Brow and forehead: The resting position of the brow, its shape, and the habit of raising the brow using the forehead muscle are examined. The brow level and contour are established before the amount of skin to be removed is determined.²

The ocular surface: Stinging, burning, watering, dryness, contact lens use and previous eye treatments should be reported. In people who have had refractive surgery such as laser correction of a focusing error, a separate assessment for postoperative dry eye is made and tear measurement may be requested.⁷

Visual field: Where there is a functional complaint, a visual field test can be used in assessing the obstruction caused by the excess skin.⁸ That examination is not the same as the assessment of visual acuity, which measures the eye's ability to make out letters.⁹

Health and procedure history: Previous eyelid, brow and facial surgery; eye disease, high blood pressure, thyroid disease, a tendency to bleed, allergies, medicines and supplements are reported.⁴ The examination explains which complaint will be addressed by this operation and which needs assessing separately.⁵

How is the operation planned?

Is excess skin or brow drooping the main issue?

Once the brow position has been assessed and its contribution to the bunching over the lid has been separated out, the excess skin remaining on the upper lid is examined.² A temporal lift is assessed separately for the outer part of the brow, and a forehead lift for wider brow and forehead aims. These procedures are not the same operation as removing eyelid skin.³

Brow drooping can be addressed in the same session as upper eyelid surgery.⁷ Where a decision is made to combine procedures, the aim and the limits of each are explained separately.

Is drooping of the lid margin (ptosis) the same operation?

Ptosis is the lid margin sitting in a low position and relates to the structures that open the lid.³ Removing excess skin does not correct those structures; ptosis needs a separate assessment and surgical plan.³

Ptosis and excess skin can occur together and can be addressed in the same session where needed.⁷ That does not mean the procedures substitute for one another. Ptosis repair is not the subject of this article; the aim, the risks and the follow-up of a procedure for ptosis are determined separately.

How much skin is removed, and what sets the limit?

The skin to be removed is marked together with the lid crease and the brow position. The criterion that sets the limit is preserving the ability of the lid to close comfortably.⁷ One review advises leaving at least 20 mm of skin between the lower border of the brow and the lid margin, so as to avoid a deficiency of the anterior lamella.⁷ Removing more skin than needed can lead to difficulty closing the eye and to exposure of the ocular surface.⁷

The differences present at the outset between the two lids are part of the plan. Removing the same amount of skin from each side does not by itself produce symmetry.⁴

Is a procedure on the fat or the muscle needed?

Alongside techniques in which skin alone is removed, upper blepharoplasty includes techniques in which fat is reduced or repositioned and in which a procedure on the muscle is added.⁹ The presence of excess skin does not mean that fat and muscle will be removed in everyone.

Removing too much of the orbicularis oculi muscle, which closes the eye, can impair the closing of the lid.⁷ In a review pooling randomised trials, difficulty closing the eye was reported more often in the group in which muscle was removed along with skin than in the group in which skin alone was removed; the odds ratio is given as 7.98, with a 95 per cent confidence interval of 1.41-45.21.¹⁰ In the same review no significant difference in the frequency of dry eye was found between the two groups.¹⁰ That comparison, with its wide interval, is not an absolute frequency and should not be read as everyone's risk increasing 8 times.

Removing too much fat can lead to hollowing of the upper lid.⁷ Fullness in the outer part of the lid is not always fat; where it arises from forward displacement of the lacrimal gland, the gland is repositioned rather than removed.⁷ Which tissues are operated on is determined at the examination.

Where is the incision made?

The incision is planned along the natural upper lid crease; the aim is to place the scar in keeping with that crease.¹¹ The distribution of the excess skin on the outer side can affect how far the incision extends laterally, while extending the incision too far medially is limited because it can lead to webbing at the inner corner of the lid.⁷ Making the incision within the crease does not mean there will be no scar.¹²

Both dissolvable stitches and stitches that need removing can be used for closure; which is used varies from surgeon to surgeon.¹³

How is the anaesthetic planned?

An operation directed at the upper lid skin alone is performed under local anaesthetic, and the person is discharged the same day. Once the lid is numbed no pain is expected; there may be a sensation of pulling.¹³ The operation takes 30-60 minutes.

Where another procedure is added, the form of anaesthetic can change and a general anaesthetic may be used. In that case the duration, the hospital stay and the recovery timetable are set again according to the added procedure.⁵

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹⁴ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁵ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹⁶ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹⁷ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹⁸ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹⁸ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Preparation relating to the eyes: Existing eye complaints, drops in use, contact lenses and previous eye procedures are reported before surgery.⁵ Where contact lenses are worn, the instructions given for the day of surgery are followed.

What is recovery like?

The timetable below is the framework of clinical practice for an operation directed at the upper lid skin alone. The physical demands of your work and the course of healing can change these times. If another procedure is added, this timetable is assessed again.

The first check-up is within the first week. The stitches are removed after 1 week; where dissolvable stitches are used, a separate removal may not be needed.¹³ 1 week is allowed for returning to desk work. A return to driving can be assessed within 1-3 days. 2 weeks is expected for returning to sport, and 2-4 weeks for a full return to daily life.

Bruising is expected to settle over 7-10 days and marked swelling over 1 week. These intervals do not mean everyone reaches the same appearance on the same day. Vision can be blurred in the first few days.¹³

The shape becomes possible to assess over 1-2 months, while residual mild swelling can last up to 2-3 months. Assessing the shape therefore does not mean that all swelling has finished by that day. The direction of healing is monitored at check-ups; swelling that increases, is painful or is markedly one-sided is not explained by recovery time alone.

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

The incision and strips: Wound closure strips are applied to the incision line. When the strips are removed is decided at the check-up. Covering the eye for the first 2-3 nights may be advised; your surgeon says whether that is needed.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing your face: A return to washing the face is decided according to healing and is assessed within 3-7 days on average. The incision line is not rubbed, and directing water into the eye is avoided.

Eye care: Eye drops or ointment are given routinely after surgery. Hands are washed before applying them.¹³ The eyes are not rubbed and the incision line is not pulled at.¹⁹

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be mild pain and tenderness in the lid.¹³ The painkillers provided are used as instructed. Pain that keeps increasing, becomes severe eye pain, or comes with a reduction in vision should not be watched and waited out.¹³ The surgical team is told if a new painkiller or additional medicine is to be used.

Returning to work and sport: 1 week is allowed for returning to desk work; for physically demanding work, healing is assessed separately. 2 weeks is expected for returning to sport and 2-4 weeks for a full return to daily life. The type of sport and the demands of the work should be stated when the plan for returning is made.

Driving: A return to driving can be assessed within 1-3 days. Do not drive while your vision is blurred.¹³ Do not take the wheel before the effect of the anaesthetic on attention and reflexes has passed and you have seen that the painkiller does not make you drowsy.

Make-up and contact lenses: Make-up around the eyes and contact lens wear are not planned before 2 weeks; after that time, a return is decided according to assessment at a check-up with your surgeon.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and around the eyes, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising and tenderness in the lid, and numbness or altered feeling around the incision, can occur.¹² Irritation, watering and a feeling of dryness in the eye can also occur.²⁰ What matters is less the presence of a mild finding than how it changes. Swelling that increases rather than settling, pain that progresses, or vision becoming impaired should not be judged as ordinary healing.¹³

How do the scars change?

Upper eyelid incisions leave scars. Placing the incision within the lid crease does not mean there is no scar. A conspicuous scar is among the reported risks of eyelid surgery.¹² The scar being visible and feeling tight can last a few months.¹⁹

Maturing of the scar is expected to take between 4 and 6 months. An incision line that looks red, firm or more prominent early on is assessed over that period. The final appearance of the scar is not settled on how it looks at the first check-up.

Silicone gel and massage are advised for the upper lid scar. When they are begun and how they are applied are determined by the surgeon according to how the incision is healing. The plan given by the surgeon is followed for care of the incision.

Small lumps around the incision are not always the same problem; thickening of the scar and a small cyst developing under the skin are told apart, because the two are managed differently.⁴ Care is taken to protect the area from the sun, and darkly tinted sunglasses are advised.²⁰ Where there is wound separation, discharge or increasing tenderness, it is not treated as merely part of the scar maturing; assessment is requested.

Risks and complications

The risks are assessed according to whether the procedure stays limited to the skin, what else is added, and the person's eye health.⁹ The headings below are not an order of frequency. Eyelid skin heals better than most areas of the body, and true keloid formation is rare here.⁴

Problems of shape, symmetry and the scar

A difference can remain between the two sides in the lid crease, in the amount of skin left or in the fullness. Asymmetry is among the most frequently reported problems of eyelid surgery.² Some differences can settle as the swelling reduces; further correction can be assessed for those that persist. Minor corrections are generally advised to be delayed, where possible, for at least 3 months after the first operation, because intervening early means deciding on an appearance that has not finished healing.⁴

Removing too much skin or fat can create hollowing of the lid and difficulty closing the eye, while removing too little can leave the complaint unchanged.⁴ A conspicuous scar, a change in sensation and persisting pain are also possible problems.¹² The possibility of further surgery does not mean everyone will have another operation.

The lid looking low after surgery may not be due to the remaining skin alone; the ptosis present at the outset, the brow position and lid movement are reassessed.⁴

Problems of dry eye and the lid closing

Dry eye can begin, or existing complaints can increase.¹² The lid not closing fully is called lagophthalmos and can affect the ocular surface.⁷ Difficulty closing in the early period can arise from swelling or from temporary involvement of the muscle related to the anaesthetic and to surgical trauma, while removing too much skin can lead to a more lasting problem.⁷

Dryness and difficulty closing are not the same thing and are assessed separately. Where the lid does not close, the ocular surface can be left exposed; lubricating drops and ointment provide protection, and surgical correction may be needed where there is a lasting tissue deficiency.⁷

The research on this is not one-sided. In a review of 12 randomised trials covering 450 people, dry eye complaints were reported less often after surgery than before it; the odds ratio is given as 0.22, with a 95 per cent confidence interval of 0.13-0.36.¹⁰ In another review, the meta-analysis of tear film break-up time found no significant change; no study reported a significant effect on the tests that measure tear production, and the results of the dry eye questionnaire went in opposite directions between studies.⁹ These measures do not summarise the same thing as the analysis of symptom frequency. These data show neither that the surgery creates dryness in everyone nor that it treats dryness.

Bleeding, the wound and infection

Bleeding from the incision line, a collection of blood under the skin, separation of the wound or infection can develop.¹² Superficial bruising and bleeding that creates pressure within the eye socket are not the same thing.⁷

Where redness spreads, or there is discharge, worsening pain or separation of the wound edges, assessment is needed.¹³ Prevention of infection and treatment where needed are decided according to the person's situation; there is no single medication plan for everyone.

Rare situations that threaten sight

Retrobulbar bleeding, which develops behind the eye, can raise the pressure within the eye socket, impair the blood supply to the optic nerve and threaten sight.⁷ In one review, the frequency of orbital haemorrhage with loss of vision after eyelid surgery is estimated at between 1 in 2,000 and 1 in 25,000.⁴ That is an estimate the review cites from another publication, and it is not a risk figure for an individual. The same review lists high blood pressure, the use of blood thinners or medicines that prevent platelets sticking together, a long and difficult operation, and reoperation through scarred tissue among the risk factors.⁴

Sudden reduction in vision, severe eye pain, rapidly increasing tight swelling or the eye protruding forwards calls for urgent assessment.⁴ These signs are not expected to appear all together. Recognising the problem early and intervening where needed is decisive; time is not spent applying something cold at home or waiting for the day of the check-up.⁷

Anaesthetic and general surgical risks

Unwanted effects related to the anaesthetic and allergic reactions are assessed together with the form of anaesthetic used and the health history.¹² General surgical risks apply to every operation and are covered in the preoperative assessment.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Risks related to added procedures

Adding ptosis repair, a brow lift or lower eyelid surgery calls for different tissues and different risks to be assessed as well.⁹ Results belonging to an operation directed at the upper lid skin alone do not represent the whole of these combined procedures.

Ectropion, meaning the lower lid rolling outwards, is a risk related to lower eyelid surgery; it is not a typical outcome of an operation directed at the upper lid skin alone.¹² Lower eyelid surgery, canthoplasty, forehead lift and ptosis repair are outside the scope of this article. An added procedure is not presented as an obligatory step.

Does the result change over time?

The operation can reduce the excess skin, but natural ageing continues; it cannot be said that the result will be maintained for the same length of time in everyone.⁶ Where bunching or a low appearance is noticed again later, the skin, the brow and the lid margin are assessed separately.³

A decision to operate again is not made straight away on the swelling and the appearance of the crease during the first period of healing. A lasting problem of shape and a change belonging to early healing are told apart from one another.⁴

What can be expected from the result?

Reducing the excess skin can make the lid crease more defined. Where there is a functional aim, reducing the effect of the skin obstructing the view is assessed separately.¹ A change in the visual field does not mean that all of the eye's visual problems have been resolved.⁹

In a study of 18 lids in 9 people who had skin excision alone and whose lid margin was not low, the mean area of the superior visual field plot recorded with the Goldmann test 3 months later rose from 1,706.33 mm² to 4,973.66 mm².⁸ In the same study the greatest improvement was seen in the upper outer quadrant.⁸ These values are the area of the test plot; they are not the physical area of the eye or visual acuity. This finding, from a small and selected group, does not mean that everyone gains the same amount of visual field.

In one review, the 2 studies that examined surgery with skin excision alone found no significant change in visual acuity.⁹ Opening up the area the skin was covering and an expectation of making out smaller letters are therefore told apart from one another.

What can be expected from the result is determined by the person's lid and brow position at the outset. No promise of complete symmetry is made, and it is not said that one operation will change every feature around the eye.⁶ The scope of correction in one area does not show that there is no need in another.

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Sudden reduction in vision, loss of vision or newly developed double vision
• Severe eye pain, rapidly growing tight swelling or the eye protruding forwards
• The eye not closing, marked stinging or an increasing complaint of the ocular surface
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• Pain that increases rather than settling, or becomes marked despite the pain treatment given

Bleeding within the eye socket can threaten sight.⁷ Where there is a sudden visual problem or severe eye pain, urgent assessment should not be delayed while trying to reach the surgeon.¹³

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing problem in particular, urgent assessment is not delayed.

About the numbers in this article

The intervals given for the operation, stitch removal and returning to activity, and for bruising, swelling, the shape settling and the scar maturing, are a framework of clinical practice. The summary box covers an operation directed at the upper lid skin alone; where another procedure is added, the timetable is set again.

The follow-up time in the research is not a recovery timetable. The measurement at 3 months in the visual field study does not show that healing takes 3 months in everyone.⁸ The number of people and the number of lids, and the visual field plot and visual acuity, are not used in place of one another.⁸⁹

An odds ratio is not an absolute percentage of complications, and where the confidence interval is wide the uncertainty of the estimate is greater too.¹⁰ Because the smoking studies cover different operations, the relative reductions in the shared paragraph should not be read as a risk percentage specific to upper eyelid surgery.¹⁵¹⁶¹⁷

References

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