Many patients who present for an eyelid evaluation complain of heaviness of their lids and an inability to see objects from above. It is important to differentiate between the various diagnoses that can cause these symptoms: dermatochalasis, which can cause a ‘pseudoptosis’, blepharoptosis, or brow ptosis.
Once a diagnosis of true dermatochalasis has been made, next is to discuss the procedure with the patient, including pre-operative instructions, the intra-operative procedure and post-operative expectations and precautions.
It is wise to have patients stop blood thinners at least 2 weeks prior to surgery (with the exception of Coumadin which should be stopped for 5 days) in order to minimize the chances of excessive bleeding during and after the surgery. More important is to communicate with the patient’s internist or cardiologist. If there is a significant medical condition that requires the patient to be on a blood thinner and the risks outweigh the benefits of stopping the medication, an elective blepharoplasty should be reconsidered.
The surgery can be performed under local anesthesia alone. If the patient is very nervous or has an elevated blood pressure, sedation can be used. Variations exist amongst surgeons as to what tissues to remove during a blepharoplasty. Some take skin only. The orbicularis is tightly adherent to the skin and is easy to remove as one unit. If a patient has prolapsing fat, the orbital septum must be opened and the fat pads removed. Fat should be removed very carefully, by gently teasing and dissecting it off of the underlying levator aponeurosis. The fat should be clamped, incised and cauterized before release back into the orbit, as many blood vessels course through the fat and a loose bleeder can lead to a retrobulbar hematoma. Once all the tissues have been removed, the wound is closed with several interrupted sutures taking small bites of the septum/levator to reform the crease, followed by a running suture.
Post operatively, the patient should use ice packs 20 minutes on and 20 minutes off for the first 48 hours to minimize edema and constrict the blood vessels. They should keep their heads elevated and refrain from heavy lifting, bending or straining. Water should not get into the wound for the first 2 weeks and antibiotic ointment is applied three times per day for the first week.
The patient should be instructed to notify the doctor immediately if pain, loss of vision and/or proptosis occurs, as this may indicate an orbital hemorrhage, which requires immediate attention.
Potential complications of blepharoplasty will be discussed next month.