Just like our body, our eyes also go through an ageing process. Many of those who want a facial uplift also seek a cosmetic correction of their tired and ageing eyes. Cosmetic blepharoplasty is a surgical procedure for enhancing the look of the eye. Performed on the upper and lower eyelid, this cosmetic therapy is highly popular for its short recovery span and instant results. It is also favored for its ability to be performed under an outpatient ambience under local anesthesia (oral sedation), making it a comfortable and speedy process.

Upper eyelid blepharoplasty

Patients, who want to bring back the youthfulness to their drooping and haggard upper eyelids, choose to undergo upper eyelid blepharoplasty. The skin of the eyelids becomes redundant and flabby as a part of the natural ageing process. This sagging skin is called ‘blepharochalasia’.

This occurs when the skin of the upper eyelid loses its innate elasticity and suppleness, which also causes the skin and associated form of the forehead to deteriorate. Hence, the eyebrow drops over the orbital rim and sags on the upper eyelid.

A few other causes of drooping eyelids are hypertrophic orbicularis muscle, protuberant adipose tissue from the upper fat pads or a rarer factor of lateral fullness caused by a ptotic lacrimal gland. It is vital to pinpoint the causes leading to these upper eyelid syndromes in order to get optimal results from upper eyelid blepharoplasty. Generally, it is performed on patients with either one or a combination of all these conditions.

Preoperative planning

After the identification of the indications, there are a few other procedures before the surgery takes places. They are:

A routine medical history overview: This includes a mandatory inspection for a history of Graves’ disease, connective tissue diseases associated with a clinical or subclinical sicca syndrome or a history of a bleeding problem.

Physical check-up: A detailed physical examination and standardized photography to evaluate any existing asymmetry is also vital. An up-to-date and total visual investigation is also required in order to trace chances of glaucoma or macular disease. This visual examination also reviews the features and competence of the tear film.

An instructive session: Patients must also be given some idea about the procedure they would undergo. This should include a discussion with the patient on their outlook about the extent of skin removal and the associated structuring of the crease etc. A detailed discussion of the complications of this process is also essential. The patient must also be told that they cannot use lenses during the postoperative period.

Next comes a few surgical assessments like the condition of the redundant tissues of the forehead and the eyelids, an evaluation of the patient based on gender (since the anatomy of a male and female eyebrow differs), the need for a brow lift, forehead correction, evaluation of the condition of the skin tissues etc.

Preoperative marking of eyelids: This is a technical process that involves the marking of the surgical incision on the eyelids. This is crucial and must be done accurately to ensure conformity in the distance of the incisions on both eyelids.

The surgical procedure

The surgical process consists of three steps

1. Lifting the myocutaneous flap
2. Removal of surplus fat (optional, depending on patient condition)
3. Sealing of the wound

Lower eyelid blepharoplasty

Those with the common complaint of “bags under the eye” often seek lower eyelid blepharoplasty. These bags are medically defined as ‘herniated retro-orbital fat that is protruding anteriorly’. This also gives a haggard and aged look to the face. Gentle palpation often gives temporary relief from these 'bags' by a slight lifting of the globe and palpebral conjunctiva of the eye. Lower eyelid blepharoplasty is the best way to remove this sagging fat and correct this facial defect.

Lower eyelid blepharoplasty can be performed following two common approaches: the transcutaneous or subciliary approach and the transconjunctival blepharoplasty.

The latter is generally the preferred mode because it helps conceal and fade out the surgical scars better. The subciliary approach also has its advantage in its ability to remove the redundant infraorbital skin during the sealing of the incision. However, this skin elimination process involves the risk of scar contraction followed by a condition termed as ectropion. Elderly patients, who have a more sagging lower eyelid, are more vulnerable to this. Moreover, this scar contracture and ectropion cannot be easily corrected.

Surgical and pre-surgical steps

The subciliary or transcutaneous approach consists of the following steps:

• Preoperative markings
• Surgical procedure
• Removal of surplus skin
• Sealing of the wound

The transconjunctival approach involves the following:

• Preoperative markings
• Operative process
• Postoperative wound care with the use of ophthalmic ointment and artificial tears

Both these procedures also involve a crucial correction of the tear trough deformity.