Our eyes are undoubtably one of our most important facial features, they are the point of first contact when we meet people and assumptions on a person are literally made in a Blink. This is a point elegantly described in Malcolm Galdwell’s 2005 book Blink: The power of thinking without thinking. The appearance and expression of our eyes plays a significant role in how attractive, young, alert and energetic we are perceived to be. There is no doubt that genetics and heredity play a part in eyelid ageing, some younger people notice eyelid changes more often associated with advanced age and quite understandably seek corrective treatment.
The initial consultation is an opportunity for you to talk and me to listen. I like to understand what has led to my patients seeking advice on improving their appearance. Sometimes it is functional, such as di!iculty in applying eye make up or peripheral visual field restriction, other times it is purely cosmetic. There is no doubt that for most of us, when we look our best, we have renewed confidence and energy about every aspect of our lives. This new confidence is life enriching.
In assessing the eyes, I look at them as part of the face as a whole. Occasionally the hooded appearance of the upper eyes has nothing to do with the eyelids themselves but more to do with descent of the brow. The upper eyelid skin descends with this, and by simply correcting the brow position the open eyes of youth are restored. In patients with true eyelid hooding (Blepharoptosis), it is a combination of several factors. The eyeball floats in a protective cushion of fat, as we age this fat bulges through its capsule giving rise to puffiness. You can see this yourself by gently pressing on the eyeball of a closed eye and seeing the bulge by the bridge of the nose. Overtime, this bulging fat, along with thinning of the very delicate skin, stretches the skin giving rise to a hooded eyelid. Both of these are very simple to correct under local anaesthetic alone.
The appearance of aging lower eyelids is slightly different from the upper lids. the protective fat cushion and capsule is supported in the young elastic face by the midfacial tissues. As these descend with age they cause hollowing under the eyes known as tear troughs. Stretching of the capsule allows fat to bulge above the tear trough making it look deeper and giving rise to eye bags. There are several ways of correcting this phenomenon ranging from removal of a small amount of the fat to repositioning it back over the bone in the correct place. Excess skin, if still present can be removed or more commonly in my practice, tightened with Laser resurfacing or peeling.
I recognise that It is a big step when somebody asks for help with any aspect of their appearance. I see my role as an advocate in guiding you through what may seem at first a minefield of possibilities. Listening carefully to your exact concerns, explaining in clear language what the options are and then collaborating on a treatment path is so satisfying and is the key to a perfect outcome. Occasionally, I will suggest that surgical treatment may be premature and, if appropriate , suggest less invasive alternatives. I will ask you to show me historical photos so that we can really discuss what may be achievable, take baseline photography, some very specific eyelid and facial measurements and only when you really understand the options available will we embark on a treatment path together.
There are different approaches to the lower eyelid. Historically a small incision was made under the lash line and out into a crows feet wrinkle (subciliary incision). The muscle and capsule is opened and some fat is removed before excess eye bag skin is trimmed and stitched together. I rarely perform this procedure as it has an external incision, the fat capsule has to be breached and as the scar heals it can pull down the eyelid rim changing the eye shape (Ectropion). My preferred approach now is called a transconjunctival blepharoplasty. This uses a 1cm incision behind the eyelid in the conjunctiva. From here I can access the lower orbital fat to either remove a little or more commonly reposition it over the tear trough. This kills two birds with one stone! The eyelid skin then usually shrink-wraps over the new flat surface but this process may be assisted with Laser resurfacing or light chemical peeling. Very occasionally, usually in men with significant excess skin, I need to make a small pinch excision of the skin. As this pinch skin excision does not breach the muscle or fat capsule the eye shape problems of old are not an issue.
This is a very simple procedure that involves removing a small ellipse of skin (and thin sliver of muscle) in the upper eyelid crease. Through this I can access the bulging fat pads and reduce their size. The skin is then stitched together with extremely fine sutures. This incision heals beautifully and very quickly.
Cosmetic doctors often advertise non-surgical injectable eyelid rejuvenation. These are combination treatments with Botulinum Toxin to reduce surface wrinkles, weaken the brow depressor muscles, fillers to volumise folds, mask depressions and sculpt the mid face and combination Laser or peels to resurface the skin. There are few, and by few I mean one or two cosmetic doctors nationally who I would recommend to my patients to perform these treatments. They are true injectable artists and their work is often comparable to surgery in those without significant eyelid aging.
This is a vital part of my surgical philosophy. When setting out my practice I wanted my patients to ENJOY their surgical experience. This is after all surgery they have chosen to have! I could have followed convention and operated out of leased theatres in large private hospitals but this didn’t fit with this philosophy. Overflowing car parks, receptionists I didn’t know, bank staff, theatre overruns and management dictat over patient experience.
I travelled throughout Europe and the US to refine the model and my surgery is the result of this research. Custom built and registered facilities for facial cosmetic surgery, an environment that is a clinical home from home, staff hand picked not only for their expertise but their approach and interpersonal skills, and surgery that is natural, contemporary, safe and individually planned and performed by me for each and every patient from initial consultation through surgery to final follow up visit. I am constantly refining the model to give my patients the very best experience. I believe that a patient that is relaxed, calm and comfortable, not starved for general anaesthetic, and who is familiar with the environment has lower blood pressure, lower circulating stress hormones and is in a far better place to start recovering from surgery.
My assistant Lucy discusses preoperative preparation with all my patients, and everything is considered. From hair colouring to diet sheets, pre operative medications, supplements and specifics to avoid such as blood thinners - Non steroid anti-inflammatories (Ibuprofen, Neurofen, Volatarol), Aspirin and Vitamin E.
Eyelid surgery begins at the initial consultation. I want my patients to truly understand all the options available and the risks before undergoing surgery. I take written consent for the procedure(s) we have mutually agreed and give a copy to take away and read at leisure. Any queries that might arise are welcome to be clarified at a second preoperative consultation. On the day of surgery patients are escorted to the surgical suite where they are given their own temperature controlled warming gown and thick comfy socks.
After a relaxation tablet, I put anaesthetic numbing jelly and a cold pack on the eyelid which works beautifully. I then meticulously measure and mark the eyelid incisions with a semipermanent marker. A tiny volume of local anaesthetic with adrenaline is then injected into the skin and milked under the eyelid skin which performs most of the surgery before I have made an incision! This part is completely painless as the skin is pre-numbed with jelly. I then remove the thin ellipse of skin and muscle sliver and locate and reduce the fat pads above the eye. The incision is then closed with a very fine running stitch which isn’t knotted but fixed with plasters at each end to give an near invisible scar. Antibiotic jelly is then applied.
After a relaxation tablet, I put clear anaesthetic drops in the eye. These sting temporarily but work very very quickly. Once in the theatre, and connected to a monitor, overseen by a consultant anaesthetist, a small amount of sedation is given through a drip and you go off to sleep. I then place a perfectly smooth contact lens over the eyeball and inject a small amount of local anaesthetic with adrenaline into the conjunctiva behind the eyelid. This is completely painless. A 1 cm incision is made with an electrocautery needle (a hot needle that cuts and coagulates at the same time) so that there is no bleeding. A little pressure on the eyeball delivers the fat which I then reposition or remove depending on what is necessary. The small incision then heals itself within a few days without any stitches. If the skin needs addressing this is done at the same time whilst you are blissfully unaware.
My patients literally walk out of the operating theatre into the recovery room where gentle reflexology may be performed, and are back home (if local) or at the hotel within an hour accompanied by a family member or friend. It is quite normal to have some bruising and swelling. Soothing cold packs take the swelling down and ointment is given to place on the scarlines. Occasionally I also give antibiotic and lubricating eyedrops for the first few days as the eyes can feel gritty. Sleeping propped up on pillows helps take down the swelling. The upper eyelid stitches are usually taken out at 4-5 days when makeup can then be applied and non physical work resumed. Contact lenses should be avoided for 2 weeks after surgery.
I see a facial surgery as the start of my relationship with you and would hope to help you achieve longevity of your result by advising you on skin health, nutrition and treatments going forward. Specifics to eyelid scar healing relate to protection of the eyes with eyedrops and sunglasses and high factor sun protection on the scar lines to prevent prolonged redness.
Risks are minimised with adherence to pre and post operative guidance They are fortunately extremely rare with recent anaesthetic and surgical innovation and when they do they are usually a temporary inconvenience rather than a permanent problem. I do literally everything I can to minimise risks but when they occur I treat them with first class care and attention. The single biggest risk factor in facial cosmetic surgery is smoking. So much so, I do not operate on anyone who has smoked for 2 weeks before surgery.
Internal bleeding from the incision or fat pad is called a haematoma. This requires removing some stitches and washing out the blood clot. It has no long term outcome on the surgery once treated.
Is common after this surgery and is self limiting. Gentle massage with ointment really helps and we will show you how to do this. The lower eyelid may droop with the weight of the swelling initially but this corrects as the swelling subsides.
In the first two weeks it is normal for the eyes to water especially outside in cold air or windy weather. The eyes can feel dry so lubricating drops and/or ointment at night are given.