The incisions made during an upper eyelid blepharoplasty procedure.

Blepharoplasty is surgical modification of the eyelid. Excess tissue such as skin and fat are removed or repositioned, and surrounding muscles and tendons may be reinforced. It can be both a functional and cosmetic surgery.

[edit] Indications

Blepharoplasty is often done as an elective surgery for cosmetic reasons. Lower eyelid blepharoplasty is almost always done for cosmetic reasons, to improve puffy lower eyelid "bags" and reduce the wrinkling of skin. Asian blepharoplasty or double eyelid surgery is a special type of blepharoplasty that creates a crease in the upper eyelid.^[1] This "supratarsal fold" is common in many races but absent in about half of Asians. Surgery can artificially create this crease and make a 'single-lidded' patient appear 'double-lidded'. It is the most popular form of cosmetic surgery among those of east and southeast Asian background^{[citation needed]}.

Blepharoplasty is sometimes needed for functional reasons. When an advanced amount of upper eyelid skin is present, the skin may protrude over the eyelashes and causes a loss of peripheral vision. The outer and upper parts of the visual field are most commonly affected and the condition may cause difficulty with activities such as driving or reading. In this circumstance, upper eyelid blepharoplasty is performed to improve peripheral vision.

[edit] Procedure

The fat (yellow tissue) and skin (linear tissue) removed from a quadruple blepharoplasty. Lower-lid fat was removed using the transconjunctival technique.

Blepharoplasty is usually performed through external incisions made along the natural skin lines of the eyelids, such as the creases of the upper lids and below the lashes of the lower lids. Incisions may be made from the inside surface of the lower eyelid (transconjunctival blepharoplasty); this allows removal of lower eyelid fat without an externally-visible scar, but does not allow excess skin to be removed. External skin resurfacing with a chemical peel or carbon dioxide laser may be performed simultaneously.^[2] This allows for a faster recovery process.

The operation typically takes one to three hours to complete. Initial swelling and bruising resolve in one to two weeks but at least several months are needed until the final result becomes stable. Blepharoplasty's effects are best appreciated by comparing before and after photos of surgical patients.

The anatomy of the eyelids, skin quality, age, and the adjacent tissue all affect the cosmetic and functional outcomes. Factors which are known to cause complications include:

• dry eyes - which may become exacerbated by disrupting the natural tear film
• laxity (looseness) of the lower lid margin (edge) - which predisposes to lower lid malposition
• prominence of the eye in relation to the malar (cheek) complex - which predisposes to lower lid malposition

Transconjunctival blepharoplasty of the right lower eyelid.

An incision is made on the inner eyelid surface. A suture holds the inner eyelid tissue over the eye.  Fat is held with forceps (left) and clamped with a hemostat (right). A small retractor (bottom right) keeps away extra tissue.  The fat is cut away with surgical scissors (right).

[edit] History

Karl Ferdinand von Gräfe coined the phrase blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids.

The roots of the present cosmetic advancements began around 3000 years ago with the ancient Egyptians. Documents “written on papyrus text detail how surgeons, even in that primitive age performed reconstructions on lips, noses, and ears using skin grafts cut from folds from the forehead or cheek”.^[3] As techniques began developing the ancient Greeks and Romans began writing down and collecting everything they knew involving these procedures. Aulus Cornelius Celsus, a first century Roman, described making an excision in the skin to relax the eyelids in his book De Medicine.^[4] Knowledge of blood circulation and tissue health were discovered and spread throughout the ancient world allowing techniques to improve. However, during the Middle Ages, plastic surgery was prohibited because it was viewed as something that was spiritual and unethical. This ban was also due to poor hygiene. During the Renaissance, intellectuals rediscovered texts from ancient Greece and Rome illustrating surgical procedures and techniques.^{[citation needed]}

Initial incision along the upper left eyelid.

As the 19th century approached developments were being made that would eventually be the foundation to modern cosmetic surgery. The First World War was the first major event that really relied on the dedication of surgeons and advancements in cosmetic surgery. This gave doctors a chance to practice and perfect reconstructive surgical procedures. It also prepared medical personnel for the tragedies of World War II and other subsequent catastrophes. As with any medical advancements, the development of surgical techniques goes through a period of trial and error as reconstructive surgery did during World War I. Each improvement eventually becomes the root of future advancements allowing physicians to combine procedures such as a basic lid fat resection and chemical peels ensuring a speedy recovery.

[edit] Non-surgical alternatives

Non-surgical alternatives have shown improvement with patients exhibiting early indications of facial aging. Lasers, chemical peels, botulinum toxin, and dermal fillers are all used in some degree to treat periorbital tissue. Although effective, these treatments are not technically "blepharoplasty" and yet some practitioners refer to any treatment involving the eyes as such; often precededby "laser", "non-surgical" or "lunch-time". Botulinum toxin, it should be noted, is used to relax the muscles in the forehead and between the eyes, therefore not addressing most of the issues a patient seeking a blepharoplasty would want fixed.^{[citation needed]}

In so called "non-surgical blepharoplasty" topical applications of acids and/or the use of lasers are used to tighten and decrease skin volume in the upper and lower eye lids. Injectable dermal fillers are also used to temporarily increase volume in the trough area between the lower eyelid and the cheek. These techniques are effective yet have not replaced surgical treatments, and should not be confused with blepharoplasty, which treats not only the superficial skin tissue, but also underlying connective and muscle tissues.

[edit] See also

• Eye surgery
• Oculoplastics
• Cosmetic surgery
• Plastic surgery
• Maxillofacial surgery
• Asian blepharoplasty

[edit] References