How It's Done
When you arrive in the doctor's office, you'll be given a mild sedative to help you relax. In most cases, patients also receive some intravenous sedation (sometimes general anesthetic is used, but this is not necessary). You'll also be given some special eye drops to numb the eyelids, and this usually prevents you from feeling the local anesthetic which is injected next. These injections are given with a tiny needle and numb the area around the eyes. During the procedure, you may be awake enough to hear the doctor's voice, but you shouldn't feel any pain or discomfort. Most of my patients don't remember anything. If a laser is being used, steel eye covers are placed over the eyes to protect them.
Blepharoplasty can be done on the upper or the lower eyelids. Let's begin by addressing the lower lid first.
Under the Eye
An incision is made into the "conjunctiva" or the inside part of the lower eyelid. Blepharoplasty is still done by some surgeons by making a small smile-like incision beneath the eyelash on the outside of the lower lid. However, an external incision like this more frequently leads to complications, including bleeding, excessive bruising and what is called "scleral show." This means that the lower eyelid is pulled down so far that too much sclera (the white part of the eye) shows. Many doctors, particularly ophthalmologists, think that this is a risky, outdated technique, and that it should virtually never be used. However, a little of the outside skin can be safely trimmed to improve wrinkles. This superficial skin trim can be combined with the internal fat removal. Alternatively, if appropriate, the laser may be used in a de-focused, "resurfacing" mode to shrink the lower eyelid skin.
Once the incision is made, fat deposits which have built up inside the lid are simply removed with the laser. Whether the procedure is done with a laser or a scalpel, stitches inside the eyelid are not necessary, and healing is usually rapid if there is no bruising.
Many people with upper eyelid problems not only have cosmetic concerns, but may have so much excess fat and skin that the eyelid can actually drop low enough to block vision and cause fatigued eyes. The treatment for this is to remove a crescent of skin on the eyelid, along with a small amount of eyelid muscle and fat. The incision is closed with stitches. This procedure can be done with a scalpel, as with the lower lids, but laser technology has improved the process. As with the lower lids, the results may be improved if a laser peel is also done on the outside of the upper lids to improve the texture.
Standards of beauty are different in different cultures, and there have been stories about Asian people having eyelid reconstruction in an attempt to "Caucasianize" their looks. While this may be true for a handful of individuals, most patients want their natural looks enhanced rather than changed. Asians typically like a low natural crease in their eyelids. About 40 percent have never had the kind of crease they desire. Also, when Asian people get older, that crease can sometimes drop down so far that it actually sits right on top of the eyelash line or lower. It's not desirable to make high creases like a Caucasian or a shape reminiscent of a Disney character, which is totally unnatural for Asians. Asian blepharoplasty is a specialty, and some doctors do only this surgery.
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