• Blepharoplasty Surgery

  • What is Blepharoplasty?
    Eyelid surgery to remove excess skin and fat is referred to as “blepharoplasty”. Motivation for this procedure may be either functional (to improve visual field) or cosmetic.

    Functional Blepharoplasty
    As one ages, the upper and lower eyelid tissues begin to relax. These nonspecific changes may be accelerated by sun exposure , allergies or recurrent swelling and result in stretching of the skin. In some individuals, this process may be hereditary. The result is an excess of eyelid tissue referred to as “dermatochalasis”. Stretching and relaxation of the orbital septum (middle layer of the eyelid) allows orbital fat to move forward. As a result, a “fullness” to the eyelid develops and increases over time. Excess eyelid tissue may create a tired look, a heavy feeling to the lids, and may make patients look and feel older. With time, the excess eyelid tissues in the upper eyelid may hang over the eyelid margin and cause an upper visual field restriction. In the lower eyelid, excess skin and fat occasionally affect the bifocal portion of a patient’s spectacles, but functional problems are less frequent than with the upper eyelid. Surgical removal of the excess skin, and fat if needed, leads to an improved and more comfortable field of view. S

    Cosmetic Blepharoplasty
    Your eyes are often the first thing people notice about your face and are an important aspect of facial attractiveness. Unfortunately, with age, the upper and lower eyelids become “droopy” or “baggy” in appearance. Aesthetically, such conditions may detract from the overall attractiveness of ones eyes and cause a “tired” or “older” appearance. This situation bothers some individuals more than others and at different ages. Removal of the excess skin and fat can restore a younger, more rested appearance.

    Preoperative Considerations
    A preoperative comprehensive eye examination is essential to document a patient’s visual acuity, baseline tear function, tear film stability, strength of eyelid closure, symmetry of palpebral fissures (eyelid height), previous eyelid surgery, etc. For those considering surgery for functional reasons, a visual field test (with the eyelids relaxed and elevated) is required. Preoperative photos are routinely performed prior to both functional and cosmetic blepharoplasty.

    Patients considering cosmetic eyelid surgery need to discuss with the eyelid surgeon what they want to achieve from a blepharoplasty. Blepharoplasty is able to remove the bulges created by fat herniation and remove excess skin that is becoming redundant. Skin discoloration, deep creases, and cheek fullness are not corrected by eyelid surgery. Patients also need to know that enough skin has to remain after surgery to allow proper eyelid closure. Blepharoplasty surgery can not remove “all” the fine lines in the eyelid. With skin removal, the fine lines will diminish a great deal, but to remove them all may prevent normal eyelid closure. Many patients also have a droopy eyebrow which must be addressed when considering upper eyelid surgery. The goal of surgery is to remove the excess skin and fat. In doing so, patients often look more alert and healthy, less tired, and generally have a younger, more rested appearance. It is important for patients to understand that although they will look better and may feel better about themselves, they should not expect their lives to change dramatically.

    Does Insurance Cover Eyelid Surgery?
    There are certain criteria that must be satisfied for most insurance carriers (including Medicare – see below) to pay for part or all of your eyelid surgery. For any health care plan to cover surgery, a patient’s eyelids must restrict the superior field of vision resulting in some limitation of daily activities such as reading, writing, driving, sewing, etc. Photographs must be submitted and demonstrate significant narrowing of eye opening with a diminished distance from the upper eyelid to the light reflex (near the center of the pupil). Visual fields may also be required to further document constriction of the superior field. Visual fields are performed with the eyelids at rest and with the eyelids elevated to demonstrate the improvement expected with surgery. The predetermination process for commercial insurance may take a few weeks to a few months to complete. Lower eyelid blepharoplasty surgery is rarely covered by insurance or Medicare and is considered cosmetic in almost all cases.

    What Is Different About Medicare Coverage?
    With Medicare, the decision to cover surgery is not made until after surgery when the claim (with the photograph and/or visual field) is submitted from the doctor’s office. Medicare does not have a pre-approval (predetermination) process. Dr. Klapper will discuss with you whether your photographs and/or visual fields meet the criteria outlined by the local carrier for Medicare. Dr. Klapper can not, however, guarantee whether your surgery will be a covered service. Lower eyelid blepharoplasty surgery is rarely covered by Medicare and is considered cosmetic in almost all cases. A referral from your primary care physician or eye doctor does not insure that Medicare will cover your eyelid surgery. All Medicare patients considering functional blepharoplasty and/or ptosis surgery will be asked to sign Medicare’s Advance Beneficiary Notice (ABN) indicating that you understand your financial responsibility if Medicare does not cover your surgery.

    Surgery
    Blepharoplasty surgery is an out-patient procedure performed under local anesthesia, with intravenous sedation if desired. During surgery, incisions are made in the natural folds of the eyelid (in the crease of the upper eyelid and just beneath the eyelashes in the lower eyelid) so they are well hidden after proper tissue healing.

    If only fatty tissue needs to be removed from the lower eyelids without any skin, the surgery can be performed from inside the eyelid. This is known as a “transconjunctival blepharoplasty” and is the most common technique utilized by Dr. Klapper.

    In cases where the eyebrows area also droopy (brow ptosis), a procedure to elevate the eyebrow may be appropriate. This procedure known as a “brow lift”, may be done directly above the eyebrow, within the forehead creases, or endoscopically behind the hair line. It is important to recognize that a droopy eyebrow may be contributing to the excess skin and fullness seen in the upper eyelids. Blepharoplasty surgery will not correct redundant tissue resulting from brow ptosis.

    After Surgery
    Following surgery, cold compresses (ice packs) and a topical antibiotic ointment are applied for 3 to 4 days followed by warm compresses. Eye patches are not required. Discomfort is usually minimal and is typically handled by acetaminophen (Tylenol®). Aspirin containing compounds and non-steroidal anti-inflammatory products (Advil, Ibuprofen, etc.) should be avoided 2 weeks prior to surgery and up to 1 week following surgery. Most individuals will have swelling and some degree of bruising that will gradually improved over the first 1 to 3 weeks. Patient healing, however, is variable with some individuals healing much quicker than others. Near complete tissue healing usually occurs by 2 to 3 months. For upper eyelid blepharoplasty, 5 to 7 days off work is average while up to 10 to 14 days may be best for those patients having both an upper and lower eyelid blepharoplasty. Patient’s with occupations requiring minimal physical activity may return to work sooner. Makeup can be applied to help hide residual bruising after two weeks. Contact lens wear is typically avoided during the first 3 weeks after surgery or until adequate blinking and eyelid closure returns.

    Complications
    After surgery, the patient should expect to temporarily experience minor discomfort, tightening or numbness of the eyelids, swelling, bruising, and dryness of the eyelids. The eyelid blink rate also temporarily slows down following surgery leaving the eyes with a gritty or sandy feeling. Artificial tears during the day and a lubricating ointment at night are commonly recommended to keep the eyes moist during the healing process.

    The upper eyelids will have diminished sensation (and feel numb) for several weeks. As the incisions heal and the eyelid mobility returns to normal, these symptoms will usually resolve.

    Excessive pain, bleeding, and infection are very uncommon. Blurry vision may occur during the healing period as a result of the decrease in eyelid blink rate or ointment getting into the eye but should return to normal in 1 to 2 weeks. Loss of vision following surgery has been reported but fortunately is extremely rare (approximately 1 in 2,000 cases). It may occur if deep orbital hemorrhage occurs postoperatively following fat removal.

    Once the healing process has settled (at around 2 to 3 months), eyelid asymmetry requiring a touchup procedure is required in fewer than 3% of patients.

    Summary
    Patients considering blepharoplasty should assess their goals and expectations of surgery and discuss them with their surgeon. Blepharoplasty surgery can provide both functional and cosmetic improvement with minimal risks of serious problems. A brow lift procedure is frequently necessary to adequately treat the redundant tissue of the upper eyelid area. Most patients are quite pleased with the results of their eyelid surgery.

    Stephen R. Klapper, M.D., F.A.C.S. is a board certified Ophthalmologist and has completed extensive fellowship training in Ophthalmic Plastic and Reconstructive Surgery. In addition to his clinical practice Dr. Klapper has published numerous scientific articles in peer reviewed journals and presented several papers at regional, national, and international meetings on topics related to the field of eyelid and facial plastic surgery. Dr. Klapper’s practice is limited to adult and pediatric cosmetic and reconstructive eyelid and facial surgery, tear duct surgery, orbital disease, thyroid eye disease and the anophthalmic patient. Dr. Klapper also has extensive experience performing facial Botox® injections and Restylane® lip and facial fold injections.

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