“Blepharoplasty” essentially refers to reforming of the eyelid tissues. It involves the repositioning, restoration, and/or removal of the eyelid tissues and structures surgically. It can be performed on the upper and lower eyelids either simultaneously or at a different time.
Blepharoplasty may be either functional (medically indicated) or cosmetic. Medicare and commercial insurance companies have clearly defined criteria that must be met and documented for the surgery to be covered under insurance. These criteria continue to become more strict, and harder to be covered as medically necessary. Generally, an upper blepharoplasty is covered as a medical benefit if there is considerable extra upper eyelid skin that is covering a portion of the pupils and interfering with vision. This has to be demonstrable both by photography as well as by visual field testing. Photography is becoming the most important documentation factor since they may not be altered. During a functional (medical) upper eyelid blepharoplasty, a conservative removal of excess skin is performed so that the patient may see better. It is important to leave sufficient skin that eyelid closure may still occur. A functional blepharoplasty is not performed to make a patient look younger, though that may occur, or to remove cosmetic concerns such as baggy tissue, extra folds, subtle brow malpositions (e.g., too low), or wrinkle concerns.
Blepharoplasty is considered cosmetic when it is solely being performed to address cosmetic concerns such as wrinkles, fat pads, or “looking tired.” Additional cosmetic procedures during a functional blepharoplasty may be performed to remove prominent fatty bags, sagging eyebrows, and wrinkle reduction. These cosmetic adjuncts are not covered by the insurance and are paid separately by the patient.
Blepharoplasty may be performed under minimal to no sedation or under deeper forms of anesthesia. Most patients do fine with just minimal sedation as the tissues are locally and comfortably anesthetized with local anesthetic through a small needle. Patients are able to mostly keep their eyes closed during the procedure, and most cases take less than 30-45 minutes, and just under an hour if both the upper and lower eyelids are done simultaneously.
Postop care involves a few days of cold compresses, an use of ointment to the eye surfaces at bedtime and may also be applied to the sutures. Patients should not strain or bend over for about a week, and then most regular activities may be resumed. Heavy or strenuous exercise or activity should be deferred for about 10 days. Most bruising resolves in 2-3 weeks. The postoperative pain is not significant and many patients get by with Tylenol alone. The surgical incisions are hidden in the upper eyelid crease and initially are red then fade to a thin white line or no line in 3-6 months.
Serious complications with blepharoplasty surgery are fortunately very rare. The most feared complication is a severe orbital hemorrhage, which is generally under 1 in 10,000 case. Risk factors that can increase the risk for excessive bleeding and bruising is excess activity following surgery particularly if there is uncontrolled hypertension and/or the use of blood thinners or herbals with blood thinning properties (e.g., garlic, ginkgo biloba and many others). Abnormal or excessive scarring in the eyelids is rare, and can usually be managed by scar/steroid creams, massage, and time. Very rarely old scars have to be removed or revised. In Colorado, the most common patient concern is that the eyes may be drier for a few months following surgery that is usually adequately managed with over-the-counter artificial tears. Vision loss is extremely rare and Dr. Burroughs has not had any patients lose any permanent vision in the 17 years he has been a blepharoplasty surgeon.
Lower eyelid blepharoplasty to remove skin or excess fat is always cosmetic. Some patients, however, may have large fluid in the lower eyelids that can pull the eyelids downward causing what is called retraction. In these rare circumstances, reconstructive lower eyelid surgery may be covered under insurance. Lower eyelid incisions are made oftentimes on the inside of the eyelid to access the lower eyelid fat bags, and on the outside just below the eyelashes to address excess or wrinkled skin. Some patients when undergoing a lower eyelid blepharoplasty enjoy having their skin smoothed by a chemical peel or conservative skin tightening procedure. The lateral (outside) cheek tissues below the eyes can also be nicely elevated at the same time as a blepharoplasty. This is known as a midface lift.
There is almost no age limit for when blepharoplasty surgery may be performed. Dr. Burroughs has patients in their 20’s to their 80s seeking both functional and cosmetic eyelid surgery. Whether a patient will achieve a significant benefit is determined best by an in person consultation. Prior to surgery there is some preparation and avoidance of certain medications and herbal supplements or vitamins that will help prepare for a safer and quicker recovery, so planning ahead is optimal.