WHAT IS OCULOPLASTIC EYELID SURGERY?
Many of our patients have benefited from oculoplastic, or eyelid surgery. This type of procedure is also known as blepharoplasty or ptosis repair. It consists of removal of excess skin and fatty tissue, combined with restoring normal tone in the eyelid ligaments to improve sagging or drooping eyelids.
With increasing age and particularly with exposure to ultraviolet light (e.g. from sunlight) and other eye irritants, it is normal for the skin tissues to relax and for the skin around the eyelids to become loose and excessive. Because we instinctively use our brow muscles to compensate for sagging eyelids, the drooping if the eyes may not always be obvious unless we relax and let our brow drop.
In the lower eyelids, bags can form and sometimes the loss of tone is sufficient to cause problems with blinking and proper tear flow. Some people have a hereditary predisposition for the eyelid tissues to lose tone at an early age. In others, frequent rubbing of the eyes (due to allergies, for example) can cause drooping and puffiness of the eyes. It is no longer necessary to accept these problems as inevitable because in many cases they can be corrected by oculoplastic surgery performed under local anesthesia in our office.
In some cases, if the excess skin is reducing the peripheral vision or causing problems with blinking or skin irritation, then it may be covered by medical insurance. To establish this, it is important to perform a visual field test, which is a test of side vision, and external photographs that can be submitted to your insurance company for pre-authorization. In cases where insurance does not approve it, the procedures can still be performed economically in our office surgery suite. Our staff can provide you an estimate of the total fees.
It is normal with age to have excess skin and reduced tone around the eyelids, especially as the eyelid skin tends to be very thin and prone to distortion by pockets of fatty tissue that normally surround the eyes. By treating the underlying laxity of tissues, we can achieve a more natural result than by just removing eyelid skin. Oculoplastic surgery can improve the appearance of the eyelids and restore a more natural and youthful appearance. However, it cannot treat all sunlight damage and it particularly will not eliminate all wrinkles around the eyes.
See the Results of Oculoplastic Surgery
A comprehensive eye examination is important to rule out neuromuscular causes for drooping eyes and to determine if you are a good candidate for the procedure. High definition photographs are used to document the degree of impairment. An instrument is used to check your peripheral vision with the eyelids in their natural state and again after they are raised with surgical tape to see how much side vision can be recovered. Proper preparation is essential for best results. It is important to avoid any blood thinners for at least two weeks prior to surgery, and ideally for a whole month. If you take blood thinners on a regular basis for a specific medical condition, then the risks of reducing these will have to be considered carefully prior to the surgery. You should avoid over-the-counter medications like aspirin (known as NSAIDs) as well as some high dose vitamin supplements. Medications containing Tylenol (acetaminophen) normally do not affect blood clotting.
A list of common blood thinning medications is given below*
- Antiplatelet Medication : Anagrelide (Agrylin®), aspirin (any brand, all doses), cilostazol (Pletal®), clopidogrel (Plavix®), dipyradamole (Persantine®), dipyridamole/aspirin (Aggrenox®), enteric-coated aspirin (Ecotrin®), ticlopidine (Ticlid®)
- Anticoagulant Medication : Anisindione (Miradon®), Arixtra, enoxaparin (Lovenox®) injection, Fragmin, heparin injection, Pradaxa, pentosan polysulfate (Elmiron®), warfarin (Coumadin®), Xerelto
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) : Celebrex, diclofenac (Voltaren®, Cataflam®), diflunisal (Dolobid®), etodolac (Lodine®), fenoprofen (Nalfon®), flurbiprogen (Ansaid®), ibuprofen (Motrin®, Advil®, Nuprin®, Rufen®), indomethacin (Indocin®), ketoprofen (Orudis®, Actron®), ketorlac (Toradol®), meclofenamate (Meclomen®), meloxican (Mobic®), nabumeton (Relafen®), naproxen (Naprosyn®, Naprelan®, Aleve®), oxaprozin (Daypro®), piroxicam (Feldene®), salsalate (Salflex®, Disalcid®), sulindac (Clinoril®), sulfinpyrazone tolmetin (Tolectin®), trilisate (salicylate combination)
- Herbs/Vitamins : Ajoene birch bark, cayenne, Chinese black tree fungus, cumin, evening primrose oil, feverfew, garlic, ginger, ginkgo biloba, ginseng, grape seed extract, milk thistle, Omega 3 fatty acids, onion extract, St. John’s wort, tumeric, vitamins C and E
*The above list includes common medications but is not a complete list.
For the procedure, you should wear loose, comfortable clothing, remove contact lenses, jewelry, and rings. Wash your skin with soap and warm water that morning and don’t wear make-up. Let us know if you have allergies to iodine or latex, or if you have a pacemaker. You can continue your normal diet and other medications.
What does the surgery actually involve?
The excess skin is marked and surgically removed under local anesthesia. The underlying soft and fatty tissues are also removed and any stretched muscles or ligaments are tucked using sutures. A high radiofrequency surgical instrument is used to shrink and tighten the tissues as well as to seal any leaking blood vessels. The skin is closed with sutures which are normally removed in the office a week or two after the procedure. The procedure usually takes less than an hour for both eyes but you will be in the office for several to allow for preparation and observation. You will not be able to drive yourself home because of anesthesia.
Depending on the nature and extent of your problems, the surgery may include the components listed below:
- Upper Blepharoplasty – excision and removal of excess eyelid skin and underlying fatty tissue
- Levator advancement – Tucking/tightening of muscle that raises the upper eyelid
- Brow fixation – shrinking and anchoring of fatty tissue weighing down the upper eyelids
- Canthoplasty – tightening ligaments where the eyelids attach to bone
- Dacryoadenopexy – repair and reattachment of loose lacrimal gland into eye socket
Additional cosmetic procedures not usually covered by insurance may be conveniently performed at the same time:
- Lower blepharoplasty – removal of fat pockets and bags from lower eyelids
- Facial skin rejuvenation – chemical peels
It is important to follow postoperative instructions carefully as this will affect your final outcome. Immediately after the surgery, your eye blinking will be reduced and your vision will be blurred. Therefore, you will be using ointment in the eyes and on the incisions fairly regularly. For the first 24 to 48 hours, it is important to apply ice packs to minimize swelling and bruising. This can often be done by using plastic bags of frozen peas from the grocery store. You should also try and sleep upright as much as possible on the night after the surgery and plan to rest for about a week after the surgery. The eyes will be drier than usual and you may be light sensitive. Your vision will fluctuate because of the dryness of the eyes and the ointment. It is possible that several weeks after the surgery that your eyeglass prescription may have to be changed.
Summary of post-operative instructions
Apply ice packs every 30 minutes while awake for 24 hrs then warm compresses every 8 hrs for 1 wk. Sleep with head elevated for three days. 3-7 days off work. No strenuous activity for 1 week. Take pain medications for 3 days as directed and antibiotics by mouth for 14 days. Apply ointment to incisions every 8 hrs for 14 days and inside eyelids every 2-4 hrs while awake for first 3 days. Protect EYES from wind and dust. Bathe as normal.
Q: How long does the healing take?
A: Because the eyelids are usually well supplied by blood vessels, healing is usually good but swelling and bruising is common especially during the first week after surgery. This may involve one side more than the other but usually resolves during the first couple of weeks. Afterwards, you can return to most normal activities. However, there will be healing that continues for up to six months and sometimes even longer.
In some cases, additional procedures may be necessary to achieve symmetry if the healing of the eyes is uneven but these can normally be done in the office. To prevent over-correction, we tend to be conservative in the initial procedures as it is always easier to remove excess skin than to make up for deficient skin tissue. The incision is normally invisible except at the outer edges.
Q:What are the potential risks?
A:Hemorrhage, bruising and swelling can occur after the surgery, and this can potentially be serious. Therefore, it is important to follow the instructions listed above, particularly with regards to discontinuing blood thinners, resting upright, and applying the ice packs. If the eyelid muscles need to be tucked or shortened, then one in three patients may require a subsequent in-office procedure to fine-tune the results for symmetry. You will be using antibiotics to reduce the risk of infection, and it is important not to contaminate or disturb the skin around the eyes in the first week or so.
Increased dryness of the eyes may require artificial tears or closure of the tear ducts.
Q:What do I do next?
A:Ask Dr. Dudee or our staff during your consultation. We can let you know if you are a candidate. If you meet the requirements for medical necessity, we can set up an appointment for pre-operative photographs and visual field testing so this can be submitted for authorization by your insurance company.
For more information on this and other eye conditions visit our website: www.medicalvision.com
Jitander S. Dudee, MD Medical Vision Institute
181 Prosperous Place, Lexington, KY 40509 T: 859.278.9486
Our Vision: Improving Yours.