Complementary Information on Blepharoplasty

"Blepharoplasty" refers to cosmetic eyelid surgery procedures that aim to eliminate certain imperfections, whether hereditary or age-related.

They may concern the two upper eyelids or lower eyelids alone, or all four eyelids simultaneously.

A blepharoplasty may be performed in isolation or combined with another facial cosmetic surgery procedure (forehead lift, temporal lift, cervico-facial facelift), or a medical-surgical treatment (laser resurfacing, chemical peeling, dermabrasion). These procedures may be performed during the same operation or as a second stage.

The most commonly addressed imperfections are:

• Heavy, drooping upper eyelids, with excess skin forming a more or less marked fold,
• Sagging, withered lower eyelids with small horizontal wrinkles resulting from skin distension,
• Fat hernias, responsible for "bags under the eyes" on the lower eyelids or "puffy" upper eyelids.

The procedure aims to correct these imperfections durably, by surgically removing skin and muscle excess as well as fat protrusions, while naturally preserving essential eyelid functions.

Many other alterations may be present, such as forehead drooping, eyebrow sagging, "frown" lines between the eyebrows, "crow's feet" wrinkles at the outer corner of the eyes, "hollow" eyes, "sad" eyes with drooping eye corners, or small surface skin imperfections (superficial wrinkles, scars, blemishes). Their treatment calls for complementary procedures such as injections, lipostructure or adipocyte autograft, forehead or temporal lift, canthoplasty, etc.

Blepharoplasty, performed on both women and men, is commonly carried out from the age of forty. However, it is sometimes performed much earlier when the imperfections are constitutional (hereditary factors) rather than age-related, such as certain "fat bags."

This cosmetic surgery procedure cannot be covered by health insurance.

A thorough interview followed by examination of the eyes and eyelids will have been performed by the surgeon, looking for anomalies that could complicate or even contraindicate the procedure. After morphological and dynamic analysis of your gaze, your surgeon, having understood your request, will guide you in choosing the best treatment.

The surgeon will propose the safest and fastest solution to achieve the desired result. Thus, they may sometimes advise against surgery and suggest a different solution, for example, filling of dark circles with hyaluronic acid injections, combined with upper eyelid surgery.

A specialised ophthalmological examination will frequently be requested to screen for any ocular pathology (tear insufficiency, etc.).

A preoperative assessment is carried out in accordance with prescriptions.

The anaesthetist will be seen in consultation no later than 48 hours before the procedure.

No medication containing aspirin should be taken in the 10 days prior to the procedure.

Smoking cessation (or maximum reduction of consumption) is strongly recommended one month before and one month after the procedure (smoking can cause delayed healing).

Depending on the type of anaesthesia, you may be asked to fast (no food or drink) for 6 hours before the procedure.

Type of anaesthesia: Three approaches are possible:
• Pure local anaesthesia, where an anaesthetic product is injected locally to numb the eyelids.
• Local anaesthesia deepened by tranquillisers administered intravenously ("twilight" anaesthesia).
• Standard general anaesthesia, during which you sleep completely.
The choice between these different techniques will result from a discussion between you, the surgeon and the anaesthetist.

Hospitalisation: The procedure can be performed as a day case, i.e., with discharge on the same day after a few hours of monitoring. However, in some cases (hypertensive patients), a short hospital stay may be preferable. Admission then takes place in the morning (or sometimes the day before) and discharge is authorised the following day.

Each surgeon adopts a technique of their own, which they adapt to each case to achieve the best results. However, common basic principles can be identified:

Skin incisions:
• Upper eyelids: they are concealed in the crease located at mid-height of the eyelid, between the mobile and fixed parts of the eyelid.
• Lower eyelids: they are placed 1 to 2 mm below the lashes and may extend slightly outward.

The incision lines correspond to the location of future scars, which will therefore be concealed in natural folds.

Note: For the lower eyelids, in cases of isolated "bags" (without excess skin to remove), a transconjunctival blepharoplasty may be performed, using incisions placed inside the eyelids and therefore leaving no scar on the skin.

Corrections:
From these incisions, unsightly fat hernias are removed and excess relaxed muscle and skin are eliminated. At this stage, numerous technical refinements may be applied, adapted to each case and according to the surgeon's habits (canthopexy or fixation of the outer corner of the eye for lower eyelid laxity, or lipostructure for treatment of dark circles).

Sutures:
They are performed with very fine threads, usually non-absorbable (to be removed after a few days).

Depending on the surgeon, the number of eyelids to operate, the extent of improvements to be made and the possible need for complementary procedures, the procedure may last from half an hour to two hours.

There is no real pain, but possibly some discomfort with a sensation of eyelid tension, slight eye irritation or some visual disturbances. During the first days, maximum rest is required and all strenuous effort should be avoided.

Postoperative recovery is mainly marked by the appearance of oedema (swelling), ecchymoses (bruising) and tearing, whose severity and duration vary greatly from one individual to another. During the first days, occasional inability to fully close the eyelids or slight detachment of the outer corner of the eye may be observed. These signs should not cause concern as they are generally rapidly reversible.

Sutures are removed between the 3rd and 6th day after the procedure.

The signs of surgery will progressively diminish, allowing a return to normal socio-professional life after a few days (6 to 20 days depending on the case).

Scars may remain slightly pink during the first weeks, but make-up is quickly permitted (usually from the 7th day). A slight induration of the treated areas may persist for a few months but is not perceptible to others.

A period of 1 to 6 months is necessary to truly appreciate the result. This is the time required for the tissues to regain all their suppleness and for the scars to fade as much as possible.

The procedure will most often have corrected skin laxity and eliminated fat hernias, thus rectifying the aged and tired appearance of the gaze.

The results of a blepharoplasty are generally among the most lasting in cosmetic surgery. The removal of "bags" is virtually permanent, and they typically never recur. However, the skin continues to age, and the resulting laxity may, over time, reproduce eyelid wrinkling. Even so, it is rare for a new procedure to be considered before about twelve years.

They may result from a misunderstanding concerning what can reasonably be expected. This applies to forehead drooping and eyebrow sagging, which can only be corrected by a fronto-temporal lift, the persistence of fine wrinkles, or a slightly hollow eye.

They may also arise from unexpected tissue reactions or unusual scarring phenomena causing slight downward retraction of the lower eyelids, minor asymmetry, or scars that are somewhat too "white."

If they do not resolve with time, these imperfections can be corrected by a touch-up, most often under local anaesthesia, from the 6th month after the initial procedure.

A blepharoplasty, although performed for essentially aesthetic motivations, remains a genuine surgical procedure, which implies the risks associated with any medical act, however minor.

A distinction must be made between complications related to anaesthesia and those related to the surgical procedure.

Regarding anaesthesia, during the consultation, the anaesthetist will personally inform the patient of the anaesthetic risks. It should be understood that anaesthesia induces sometimes unpredictable reactions in the body. Having recourse to a fully competent Anaesthetist, practising in a truly surgical setting, means that the risks incurred have become statistically very low.

Indeed, techniques, anaesthetic products and monitoring methods have made immense progress over the past thirty years, offering optimal safety, especially when the procedure is performed electively and on a healthy person.

Regarding the surgical procedure: by choosing a qualified and competent Plastic Surgeon, trained in this type of intervention, you minimise these risks as much as possible, without however eliminating them entirely.

Fortunately, true complications are rare following a blepharoplasty performed according to standard practice. In practice, the vast majority of procedures proceed without any problems and patients are fully satisfied with their result.

Nevertheless, despite their rarity, you should be informed of the possible complications:

• Haematomas: usually not serious, they must be evacuated if too significant.
• Infection: exceptional in blepharoplasty, apart from rare micro-abscesses developing on a suture point, easily treated with local care. Simple conjunctivitis will be prevented by the usual prescription of eye drops in the first days.
• Scarring anomalies: very rare on the eyelids where the very fine skin usually heals almost invisibly; however, it may occasionally happen that scars are not, in the long term, as discreet as expected.
• Epidermal cysts: they may appear along the scars and often resolve spontaneously. Otherwise, they are easy to remove during a follow-up visit and do not compromise the quality of the final result.
• Tear secretion disorders: persistent tearing is rarer than a "dry eye syndrome" that sometimes decompensates a pre-existing tear deficiency.
• Ptosis (difficulty fully opening the upper eyelid): very rare, except beyond age 70 where a pre-existing deficit may sometimes be worsened by the procedure.
• Lagophthalmos (inability to completely close the upper eyelid): possible in the very first days following the procedure, its persistence beyond a few weeks should not occur.
• Ectropion (downward retraction of the lower eyelid): the major form is extremely rare following a correctly performed blepharoplasty. The minor form ("round eye") sometimes occurs on low-tone eyelids subjected to inappropriate scar retraction; it usually fades after a few weeks of multiple daily massages aimed at softening the eyelid.
• Finally, quite exceptional cases of diplopia (double vision), glaucoma (ocular hypertension) and even blindness following blepharoplasties have been reported in the international scientific literature.

Overall, risks should not be overestimated, but one should simply be aware that a surgical procedure, even an apparently simple one, always involves a small element of uncertainty.

Choosing a qualified Plastic Surgeon ensures that the practitioner has the training and competence required to prevent these complications, or to treat them effectively should they arise.