LOWER EYELID CORRECTION

CAUSES

Bags under the lower eyelids are often caused by skin ageing: the fibres in the skin lose their elasticity and the skin becomes slacker. The collagen fibres soften at the same time which causes fatty fibres (which are normally found in the orbit) to be projected forwards. In younger people, bags are often caused by fat being projected forwards, although there is little excess skin.  

Young people only suffer very rarely from bags under the lower eyelids: problems of the thyroid gland (Graves’ disease), congenital illnesses and smoking are all factors that can predispose patients to them.

TREATMENT : BLEPHAROPLASTY (lower eyelid surgery).

Blepharoplasty involves removing the excess skin.

Bags under the lower eyelid caused by excess skin:

An incision is made just beneath the line of the eyelashes along the entire length of the lower eyelid, stretching to the laughter line at the outside corner of the eye.

The amount of skin that needs to be removed will vary from one patient to another. It is always important to find the right balance between cosmetic appearance and practicality: we do not want to remove too much skin otherwise there is a risk that patients will no longer be able to close their eyes properly. It is also not advisable to remove too much skin if patients suffer from dry eye syndrome, because it can aggravate the problem.

Bags under the lower eyelid and slack lower eyelids:

Some people have very slack eyelids (i.e., they can be very easily stretched if you pull on them). With these patients, there is a higher risk that the eyelid will droop when skin is removed.   If during the operation we notice that the eyelid has a tendency to droop, extra lateral reinforcement is used.   This means that the eyelid is also lifted towards the side.   For a few weeks, your eyes may appear slightly oriental, but this effect will wear off of its own accord.  

Bags under the lower eyelid caused by fat accumulation, without excess skin:

The skin is left intact, as the incision is made inside the lower eyelid. This is known as the transconjunctival technique.  

Before the operation

14 days before the operation

Anticoagulants

You must stop taking anticoagulants 14 days before the operation. However, before stopping, you must consult your doctor and check that he or she agrees that it is safe to do so. If you are taking MARCOUMAR you will be offered a plan so that you can take an alternative drug as a replacement. Your doctor will be consulted about this to make ensure that he or she agrees. If anticoagulant treatment prescribed for a general illness cannot be stopped, it is possible that the eyelid surgery will not be able to go ahead.

The day before the operation

• Go to the chemist and buy a cooling mask (ice pack).
• Make sure that you have sunglasses or a protective hat.
• Make sure that you have some paracetamol (pain killers).

The day of the operation

You may eat as normal on the day of the operation. Take all your medication as usual do (except for the anticoagulants).

Do not wear any mascara, make-up, earrings or necklaces. Wear comfortable clothes. Do not wear your contact lenses.

Bring some recent (representative) photographs of yourself with you.   You will be photographed before and after the operation so that you can judge the results for yourself.

Tell the doctor or nurse if you are allergic to any medicines.

The operation will take approximately two hours.

If it has taken longer than expected to treat the patients before you, you will also have to allow for waiting time.

During the operation

First, the doctor will draw on your skin with a felt-tip pen so that he or she knows where to make the incision.

Next, your entire face will be disinfected with Isobetadine and sterile tissues will be placed around your face like a turban. Your nose and mouth will still be free so that you can breathe normally.

During the operation you will not be able to touch your face. This is because it needs to be kept sterile.

The doctor will then give you subcutaneous (i.e., under the skin) injections (lidocaine 2% with adrenalin 1: 100,000). These injections are similar to the injections you are given at the dentist. The anaesthetic will start to work immediately and will last for about one hour.

During the operation you will have to sit up on a few occasions so that the doctor is able to judge the results more effectively.  

Small non-absorbable sutures will be used, as absorbable sutures cause a reaction which can lead to unpleasant scarring. While the sutures are being put in place, it is possible that the anaesthetic will start to wear off. Consequently, you may feel some of the last sutures slightly. We prefer not to give you any more anaesthetic for these final sutures, as this would increase the risk of swelling and subcutaneous bleeding.

At the end of the operation, an antibiotic ointment will be applied to your eyelids. You will then get a cooling mask that you will have to leave on your eyes for half an hour. When you go home, it is important that you use the cooling mask every hour for 10 minutes.   Alternatively, you may use a packet of frozen peas because they will mould to your face easily.

It is advisable to sleep with your head at a 45° angle because this helps to minimise swelling.   You should carry on with the cooling the next morning: you need to use the cooling mask or an alternative for 10 minutes every hour.    This cooling is extremely important as it helps to reduce the swelling, but it is only effective during the first 24 hours after the operation. If this causes pain, you can take some paracetamol (as this does not contain any anticoagulant substances).

How do I apply the ice?

The ice should never come into direct contact with your skin.   Wrap it in something suitable such as a bath glove.   The best technique is to push the ice against your lower eyelid and to apply pressure upwards.   You will then be literally pushing the eyelid upwards.  

The day after the operation

Cool your eyelids every hour for 10 minutes using the ice.   You will notice that the swelling gets worse up until the third day after the operation, and then it will then start to get better.

The first week after the operation

It is possible that your skin will be blue for about a week. The swelling can last for up to three weeks. Don't worry about any haematomas (blood clots under the skin), as these will gradually disappear.

While you still have the sutures, you must not get any water on your eyes. You are also advised not to wear any make-up. Do not massage your eyelids in any way during the first three weeks. Do not put any dressings on your eyelids.

Removal of the sutures and check-up  

The sutures will be removed 5 to 7 days after the operation. Once they have been removed, you may use water on your eyelids again. You will have another check-up 4 weeks after the operation.

The first three months after the operation

Stay out of the sun as it can cause nasty scars. You can avoid it by using total sun block (factor 60) or by wearing a hat. Sunglasses will not offer you sufficient protection.

SIDE EFFECTS AND COMPLICATIONS

Under-correction

In some cases, it is not possible to remove all of the excess skin, as there is a risk that you will not be able to close your eyelids properly.  

Lower eyelid traction

Sometimes the lower eyelid has a tendency to hang downwards slightly.   This is because the eyelid is a bit too slack.   To solve this problem, the eyelid can also be fixed laterally.   This is done under local anaesthetic: see text 'Bags under the lower eyelid and slack lower eyelids'.

Scars

Scars are not only caused by surgical techniques; they can also be caused by the way in which the skin reacts to the operation. Some people are naturally more prone to scars. To help any scars to heal, you are advised not to expose them to the sun. Smoking also prevents the eyelid from healing as well as it otherwise would.

Swelling of the eyelids and loss of skin sensitivity

Blepharoplasty leads to a temporary deterioration in lymphatic circulation to the eyelids, which causes increased swelling at first. Some nerve endings will be cut during the operation, which can lead to hypersensitivity in the eye area. The nerves will repair themselves within a few months.

Cysts

Small yellow cysts can form where the sutures are placed.    In most cases, these are reabsorbed after a few months.

Skin irritation caused by drying

Swelling of the eyelid can sometimes mean that patients cannot shut their eyes properly for a time. This can lead to dry eye syndrome. This problem can be treated using artificial tears.  

Bulging eye caused by bleeding

In rare cases, postoperative bleeding can cause tissues to be put under pressure. This is an extremely serious complication and can even lead to blindness. If you experience this problem, it is essential that you contact your doctor immediately.