Further information:

For further information visit the British Oculoplastic Surgery Society website: www.bopss.org

For further information about the risks of anaesthetics please see the booklet ‘You and your anaesthetic’ or visit the Royal College of Anaesthetists’ website: www.rcoa.ac.uk

Upper eyelid blepharoplasty repair for dermatochalasis

What is dermatochalasis?

Dermatochalasis is excess skin on the upper eyelid measured form the eyelid margin to the eyebrow often resulting in saggy skin that folds down. It is often associated with ptosis (droopy eyelid) and prolapsed orbital fat (bulgy, soft lumps within the saggy skin).

How does a dermatochalasis happen?

There are several causes of dermatochalasis. The commonest is aged related due to the stretch of skin with gravity and loss of elastic tone. This occurs slowly as we get older and in some patients, this causes the skin to sag. Other local causes such as an increase in eyelid weight from a lump, surgery involving the stretching of the eyelids using a speculum (used in cataract surgery). Rarer causes are related to inherited collagen disorders, dermatitis, infection, thyroid eye disease, weak facial muscle and renal disease. There is a condition called blepharochalasis where there are recurrent bouts of eyelid oedema from an unknown cause resulting in stretched skin and underlying tissue- this is not the same as dermatochalasis and does not follow the same course or outcome following surgery.  You can also be born with a droopy eyelid as the muscle that lifts the eyelid has never developed properly.

What are the benefits of surgery?

  • improve visual fields (peripheral and above)
  • reduce the heaviness of eyelids
  • improve hooding and cosmetic appearance

Crow’s feet are not generally improved by blepharoplasty. Smile lines are not improved by blepharoplasty and may change after surgery.

What are the alternatives to blepharoplasty operation?

Taping of the excess skin on the eyelids to keep the skin away from the visual fields is an option.

What will happen if I decide not to have the operation?

Mild dermatochalasis that does not affect vision does not need to be operated on from a functional perspective. If you choose not to have this surgery, the appearance and symptoms caused by the excess skin or fat is not likely to improve and may worsen over time, and can continue to affect vision and if the whole pupil is covered, it will block the vision in that eye, although this will not have any permanent detrimental effect on your vision or general health.

What does the operation involve?

Healthcare team will carry out a number of checks to make sure you have the operation you came in for and the correct side. You can help by confirming the operation that you came in for and the side of the operation. It is normal to have you name, operation and side repeatedly checked as this helps reduce error.

At the PRUH, a team of trained doctors and nurses will undertake your treatment and care. Dr John Bladen is the consultant ophthalmic and oculoplastic surgeon and works closely with his fellow/registrar in oculoplastic surgery. Occasionally, visiting specialist registrars from neighbouring hospitals join the team. Your surgery will be carried out either by a consultant, his Fellow or by a member of the team who is suitably experienced and qualified under appropriate supervision of a senior surgeon.

Various anaesthetic techniques are possible, although for most a local anaesthetic is used. Children are given a general anaesthetic. The procedure is normal 45 mins for one eyelid or 60 minutes for two eyelids.

The skin is measured to ensure that a recommend minimum is left behind to ensure good closure of the eyelids. Markings are made with a pen. Local anaesthetic drops and local anaesthetic is applied beneath the skin. The marked skin is removed. This can be combined with removal of fat or other tissue and with a ptosis procedure. The skin is then closed using a non-absorbable (non-dissolving) suture that you will take out in 6 days time. Non-absorbable sutures are used as they give the best scar outcome and cause the least inflammation to the eyelid after surgery. Dissolvable sutures are used in children. Paper strips are applied over the top of the wound and suture that are removed in 5 days.

An antibiotic cream may be put in the eye at the end of the procedure which can blur the vision if a posterior eyelid procedure is taken at the same time as the blepharoplasty.

What should I do about my medication?

Let the doctor know about the medication you take and follow their advice, this includes blood thinning medication as well herbal and complementary remedies, dietary supplements and medication over the counter.

Traditionally blood thinners are stopped prior to surgery but this is not the case with the oculoplastic department at PRUH. The warfarin INR should be in range though and ideally less than 3. Although bruising can be more, it does not affect the outcome of the procedure and is safer for the body to continue having the protection that the blood thinner is giving.

What can I do to help make the operation a success?

If you smoke, stopping smoking several weeks prior to the operation may reduce your risk of developing complications and will improve you general wellbeing.

Try to maintain a healthy weight as there are higher risks of complications if you are overweight and especially if you have a general anesthetic.

Regular exercise will help you prepare for the operation. Before starting to exercise you should consult your GP for advice.

To reduce your risk of infection, do not shave or wax the area where the incision is going to be made a week prior to the procedure. Try to shower or bath the day before or on the day of surgery. Keep warm around the time of the operation.

What complications can happen?

Although the healthcare team will try to make the operation a safe as possible. Some of these are serious and cause visual loss. Any numbers or percentages of risk relate to studies or published data on patients who have had this operation. You doctors may be able to tell you if the risk of a complication is higher or lower for you.

Complications of general anaesthetic.

For more information, please asked the anaesthetist more about this.

Complications of local anaesthetic (LA).

Local complication of the injection are common such as swelling and bruising. This resolves with time as the volume of the anaesthesia gets absorbed. Pain free surgery is the aim and so a generous amount of local is used (sometimes up to 30 mls) and so this volume will induce swelling. Instillation of the LA will sting before it numbs the area. This occurs will all local anaesthetic and is an unfortunate quirk of the medication. Serious side effects tend to occur with intravenous administration rather than local, however, cardiovascular or central nervous system complications can occur, but the frequency of this is unknown. Rarely, patients have an allergic reaction or anaphylaxis to the LA needing prompt treatment.

General complications of any operation on the face

  • bleeding: some bruising is common and settles over the next 10-14 days but evidence of bruising can go on for 1 month
  • pain: your eye area is naturally sensitive so discomfort in the area is common if you have had an eye operation We will try to ensure you are comfortable before you go home. Take simple over the counter painkillers on a regular basis
  • Swelling: some swelling is common and this should reduce gradually.
  • Infection: normal healing involves a little redness around the wound together with some tenderness, but there is a small risk of it becoming infected after the operation. The symptoms are: Increasing pain under your wound and surrounding area. Increasing redness of the area around your wound. Foul-smelling discharge from your wound. Temperature of 38° C (100.4° F) or greater.
  • A clot in the leg or clot in the lung (deep vein thrombosis or pulmonary embolus). This is more likely after a long operation, especially on under general anaesthetic.

Specific complications of this operation

  • over-correction from removal of too much eyelid skin and/or fat with a resultant cosmetic sunken appearance to the eyelids, hence a conservative approach is better
  • under-correction (persistent saggy eyelid skin; under-corrections generally do not necessitate revision surgery and are relatively common and preferable to overcorrections).
  • asymmetry of height and contour of eyelid margin or of skin fold compared to the other eyelid
  • hang-up on downgaze whereby the white part of the eyeball is seen by others when you look down
  • dry eye requiring the use of artificial tears drops temporarily or rarely a permanent dry eye
  • corneal abrasion causing early discomfort
  • blurred vision from a corneal abrasion
  • weak or limited eyelid closure (especially at night)
  • failure of the surgery or recurrence of the dermatochalasis
  • the need for another ptosis repair in the future
  • cysts or whiteheads along suture sites
  • temporary patches of numbness over the eyelids
  • orbital haemorrhage with a potential for permanent visual loss
  • scarring, or persistent eyelid swelling, and other unusual skin changes, especially in patients with thin sensitive skin, are rare complications

How soon will I recover?

Significant swelling and bruising will be significantly present for the first week. Blood in the tears is normal for the first few days and may persist longer if you are on a blood thinner such as Aspirin, warfarin or clopidogrel. You should refrain from heavy lifting for 2 weeks or bending down so that there is in increase in pressure to the head and also the wound. This is to prevent wound dehiscence (breakdown) or dislodgement of the clot with subsequent bleeding. Residual swelling and bruising will be present for about 1 month and the final lid position is usual stable at around 3 months after the procedure.

Returning to normal activities

Limit your physical activity to walking, over the first 48 – 72 hours. You should get up and walk about the house every two hours to help maintain your normal blood circulation. After the second day you can go for regular walks outside your home as well.

You may resume gentle exercise (swimming, jogging) after four weeks, but restrict lifting and more vigorous exercise (such as gym, squash, football) for six weeks. Do not force yourself to exercise if you still feel regular pain. Do not do any heavy lifting or excessive straining in the first four weeks

Stiffness is normal however and not harmful and remember that inactivity is bad for you. You may resume your normal diet after your surgery. However, ensure this is high in fibre (cereals, vegetables and fruit) to prevent constipation and unnecessary straining.

The future

Most patients undergo dermatochalasis repair and make a full recovery with an improvement in quality of life and a return to normal activities. However, age-related factors as well as gravity continue to act upon the eyelid which means that the dermatochalasis can come back in the future. Any persistence of an underlying causes such as dermatitis can cause recurrence of the dermatochalasis.

Summary

Dermatochalasis is a common condition caused by age-related factors in most cases. If untreated the vision can become affected making everyday tasks trickier.

Surgery is usually a safe and effective but complications can happen. You need to know about them to make an informed decision about surgery. Knowing about them will also help to detect and treat problems early.

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