Excess skin of the upper eyelid
Excess skin of the upper eyelids (dermatochalasis) occurs in most people with age. It is due to a combination of factors, including loss of elasticity in the skin, redundancy of skin and thinning of the outer layer of the skin. It is also made worse by drooping of the eyebrows above.
Excess skin in the upper eyelid hangs in folds, particularly in the middle and outer aspect of the eyelid. This will mask the natural crease of the eyelid and may also overhang onto the eyelashes themselves. It is often accompanied by bulging of fat in the inner corner of the upper eyelids, which appear as “bags”.
Excess skin in the upper eyelids can cause multiple problems including:
- Loss of the upper and outer field of vision as the excess skin hangs down. This may lead to problems with driving or reading
- Irritation of the eyes, as excess skin pushes the eyelashes and eyelid margin onto the surface of the eye
- Heavy tired feeling in the eyes, especially toward the end of the day
- Frontal headache, as compensatory lifting of the brows is used to try and lift the excess skin off the eyelids
- Unsatisfactory tired and aged look to the face
This excess skin is often accompanied by other problems, in particular drooping of the eyelids (ptosis) and the eyebrows (brow ptosis). For the best surgical result to improve function and appearance, these conditions may need to be treated at the same time as the excess skin.
It is common to also have “bags” in the eyelids together with the excess skin. These bags or swellings are most commonly in the inner aspect of the upper eyelid. They are due to prolapse of internal fat in the eyelid.
This fat prolapse is constant but may appear more pronounced first thing in the morning. This is because the fat swells with fluid whilst lying flat overnight. The swelling goes down as the day progresses.
The only way to successfully remove these fat bulges is to surgically remove them. Unfortunately, non-surgical treatments (such as creams, “freezing” cryotherapy, laser) are not very effective and do not produce a lasting suppression of the fat.
Fat reduction or removal is usually done at the same time as removal of the excess skin.
During surgery, the excess fat is identified and removed. This procedure requires expertise and care as there is often significant bleeding associated with fat removal which can (rarely) threaten the vision of the eye if not controlled properly. It is also important not to remove too much fat, which leaves the eyelid looking hollow and unnatural.
Sometimes, the fat is repositioned within the eyelid to cover any hollows that form with age. Dr Then will discuss this additional technique with each patient if suitable.
Blepharoplasty is the name of the surgery which removes this excess skin from the eyelids.
This surgery aims to improve both the function and appearance of the upper eyelids. The overall effect will also help to rejuvenate the whole face, often giving a marked improvement in the youthful appearance of the face.
Upper lid blepharoplasty surgery performed for excess skin in the upper eyelids may be classed as non-cosmetic (functional) if it is severe and obscuring the vision.
Dr Then will thoroughly assess and advise each patient as to whether their blepharoplasty surgery meets the functional criteria, or whether it is cosmetic.
If classed as functional (non-cosmetic), then the costs of surgery may be partially covered by private health insurance.
Drooping upper eyelid (ptosis)
Ptosis is drooping of the upper eyelid margin (where the eyelashes are) to an abnormally low position. Normally, when your eyes are looking straight ahead, the upper eyelid should sit just at the top of the iris (the coloured part of your eye). In ptosis, the upper eyelid margin sits much lower, and may cover all or part of the pupil of the eye.
In adults, ptosis can be due to many causes, and it is crucial that the correct cause is identified for the correct treatment to be applied.
There are many causes of ptosis however, in most cases, ptosis is due to aging of the muscle and its tendon that lifts the upper eyelid. We all develop varying degrees of ptosis as we get older, leading to the “sleepy-eyed” look. It usually affects both upper eyelids, but one side may appear lower than the other. Age-related ptosis is often accompanied by other aging changes in the eyelid, including excess eyelid skin and droopy eyebrows.
Some forms of ptosis are best treated with surgery, whilst other forms are best treated medically. Dr Then will determine the correct cause and treatment for your ptosis.
Patients with age-related ptosis will experience one or more of the following symptoms:
- Looking tired or “sleepy-eyed”
- “Heavy” discomfort in the eyelids, especially at the end of the day
- “Tired” eyes when reading, watching TV, computer work
- Blockage of the superior or central vision from the droopy eyelids
- Frontal headaches, from having to lift the eyebrows to help lift the droopy eyelids
In severe cases of ptosis, some patients may have to lift their chin or use a finger to manually lift their eyelids to see.
Symptoms which may indicate a more unusual form of ptosis include:
- Ptosis which is significantly worse at the end of the day or when tired
- Double vision
- Weakness in the arms or legs, or difficulty swallowing, or changes in the voice
Dr Then will comprehensively examine your eyelids and eyes to determine the severity and type of ptosis that you have. Sometimes, special tests and investigations will need to be performed to find the cause, and occasionally a neurologist may also need to be involved.
Age-related ptosis is treated with surgery. Surgery aims to identify, tighten and reattach the levator muscle and its tendon to improve the height of the upper eyelid to a more normal position.
Scroll down for more information on ptosis repair surgery.
Upper lid blepharoplasty surgery
Upper lid blepharoplasty surgery aims to remove the excess skin in your upper eyelids to improve both eye function and appearance of the eyelids. The overall effect will help to rejuvenate the whole face, often giving a marked improvement in the youthful appearance of the face.
Patients will undergo blepharoplasty surgery for different reasons. For many, it will be to improve vision or comfort, and for others it will be a mostly cosmetic procedure to improve appearance.
The benefits of blepharoplasty surgery include:
- Improvement in upper and outer field of vision
- Improvement in comfort of the eyes
- Elimination of forehead headaches from compensatory brow overaction
- Improved and more youthful appearance to the eyelids
Dr Then will carefully examine your eyelids and will discuss the best treatment options for you, to help you achieve the goals that you have in mind.
It is important that expectations are realistic about what blepharoplasty surgery can achieve for your face. Age, skin type, structure of underlying bones and soft tissue, and any other associated problems, will all influence the results of your blepharoplasty surgery.
As with any surgery, knowing what you want to achieve, and whether these expectations can be met, are crucial.
Surgery is performed under local anaesthetic, and as a day case procedure either in-hospital or in-rooms.
If performed in-hospital, you will be given light intravenous sedation by our anaesthetist. If performed in-rooms, you will be given the option to be prescribed a mild oral sedative (Valium) and have local anaesthetic cream (Emla) applied one hour before your surgery.
Before commencing the procedure, Dr Then will mark your natural skin crease in the upper eyelid, and then make further markings to map out the degree and contour of excess skin to be removed.
An injection of local anaesthetic is then given beneath the skin of the upper eyelid to completely numb the area. An incision is made into the natural crease of the eyelid, which will minimise the visibility of any future scarring. The marked area of excess skin is then removed. If necessary, any excess and bulging fat is also removed at this time. Finally, the wound is carefully closed with fine sutures, which will also minimise the risk of significant scarring in the natural skin crease.
After surgery, the eyes will be padded for a short time with cold compresses to minimise bruising and swelling. The eye pads are removed before you are discharged home.
Most patients do not experience significant complications with blepharoplasty surgery.
However, the risks of blepharoplasty surgery include:
- Bleeding and bruising
- Infection
- Over or under-correction of skin removal
- Asymmetry of skin removal between the left and right eyelids
- Dry eye
- Poor eyelid closure
- Unsatisfactory scarring, or cysts/whiteheads along the suture line
- Temporary patches of numbness in the eyelid
- Persistent eyelid swelling
- Bleeding in the orbit of the eye, leading to loss of vision (only if fat removed)
Many patients are concerned that they will be left with a “surprised” look after blepharoplasty surgery. If performed properly, this is very unlikely, and Dr Then is careful to remove only as much skin as is required. The removal of too much skin will lead to an unsatisfactory appearance as well as the risk of not being able to close the eyes properly, which leads to dry and uncomfortable eyes.
Loss of vision is a very rare complication, and only occurs when orbital fat is removed at the time of blepharoplasty surgery. Every precaution is taken during surgery to minimise this rare risk.
Many patients will experience dry eyes after the surgery. Whilst this is temporary, if you suffer with dry eyes prior to surgery, surgery may worsen your dry eye symptoms. Dry eyes can be easily treated with artificial tears readily available at any pharmacy.
Early bruising and swelling of the eyelids are very common. Bruising usually resolves within 7-10 days. Swelling occurs in the upper eyelid and may extend to below the eye. This swelling can take up to 6 weeks to disappear completely. However, it is important to remember that it can take up to 6 months for the wound and eyelid to settle to its final shape and appearance.
Unsightly scarring of the eyelid is very uncommon. However, the eyelid wound will initially appear lumpy and pink for the first few months. Usually by 6 months, the wound has healed to a minimal line, which is hidden within the natural skin crease and only visible when the eyes are closed.
The cost of surgery is variable depending on whether or not your procedure is deemed cosmetic or functional (for medical purposes), and whether or not you have private health insurance.
- If your procedure is for functional purposes and you have private health insurance:
We recommend contacting your health fund to check if you are covered, before proceeding with any bookings.
You will be quoted for any out-of-pocket expense (gap) for your surgical fee, prior to making any booking for surgery. Dr Then is committed to capped gap agreements to minimise patient costs. Your health fund will advise you if you have any hospital excess to pay for your admission, and our anaesthetists kindly do not charge an out-of-pocket expense for cataract surgery.
Using your private health insurance gives you the choice of hospital for surgery and allows you to book surgery at your convenience.
- If your procedure is NOT for functional purposes and/or do not have private health insurance:
Self-funding surgery is an option for patients who do not have private health insurance, do not want to wait (or do not qualify) for public surgery. Cost can be variable depending on Concession and Medicare eligibility.
Feel free to contact our team for further details.
Upper lid ptosis surgery
Ptosis surgery can be performed in different ways, dependant on the type and severity of the ptosis, and the preference of your oculoplastic surgeon.
Ptosis surgery is usually performed as a day procedure, and under local anaesthetic with a light sedative. Patients will return home the same day.
If ptosis surgery is required to both eyes, it is Dr Then’s preference to complete each eyelid surgery separately, usually 1 to 2 weeks apart to allow time initial swelling to settle so that the first eyelid is close to its final height and contour before operating on the second eyelid.
In this surgery, an incision is made in the natural crease of your upper eyelid and the levator muscle is identified and tightened with internal sutures. The skin is then closed with external sutures. These sutures are a combination of self-dissolving and non-dissolving sutures.
If the patients also has excess skin or fat in the upper eyelid, this will be removed at the same time as the ptosis surgery if appropriate.
After the surgery is complete, an eye pad is placed over the eye. This eye pad is worn overnight and removed by the patient when they wake the next morning. Once the eye pad is removed, the patient will commence cold compresses and an antibiotic eye ointment to the eyelid.
Dr Then will generally review the eyelids 10 days after surgery, at which time the non-dissolving sutures are removed from the eyelid. There may also be a further review 3 months later if there are any concerns about the healing process.
Some benefits of ptosis surgery:
- More “awake” and refreshed appearance
- Improved field of vision
- Reduced “heavy” or tired feeling to the eyelids
The aims and goals of surgery will be individualised to each patient, and be comprehensively discussed before surgery to ensure an optimal outcome.
The risks of any anaesthesia or sedation used during surgery will be discussed with you by your anaesthetist.
It is important to remember that ptosis surgery is not an exact science. Whilst every effort is made to achieve the desired height, contour, shape and symmetry between the eyelids, the final result may occasionally be unsatisfactory. Approximately 1 in 20 patients will require “touch-up” surgery to address any sub-optimal results.
The risks of ptosis surgery include (but are not limited to) the following:
- Over-correction
- Under-correction
- Asymmetry between the eyelid heights or contours (shapes)
- Infection
- Scarring of the eyelid
- Cysts or whiteheads along the skin suture line
- Temporary numbness of the eyelid skin
- Dry eyes
Very rarely, vision loss can occur if there is bleeding into the orbit around the eye. This is more likely to occur in ptosis procedures where excess fat is removed from the eyelids, or in patients who are on anti-coagulant medication (eg warfarin, clopidrogel).
Ptosis due to aging is unlikely to spontaneously improve. There are no medications or eye drops that will definitively treat age-related ptosis. Eye “exercises” also have not been shown to be of any benefit in improving ptosis.
There will be bruising and swelling of the eyelids after surgery which will involve the upper eyelids and often “drip down” into the lower eyelids and cheek. The amount of bruising and swelling will vary between patients. The bruising will often subside within 2 weeks. The swelling can take longer to subside, up to 6 weeks in some patients.
The eyelids may initially appear over-corrected (“over-done”) or the eyes may not fully close, in the first few weeks. This is normal, and usually settles as the swelling subsides within the first few weeks. This may lead to dry eyes, for which we recommmend treatment with artifical tears until it improves.
The final eyelid height, contour and symmetry should not be judged until 4-6 weeks after surgery, when the optimal outcome is usually reached.
The cost of surgery is variable depending on whether or not you have private health insurance.
- If you have private health insurance:
We recommend contacting your health fund to check if you are covered, before proceeding with any bookings.
You will be quoted for any out-of-pocket expense (gap) for your surgical fee, prior to making any booking for surgery. Dr Then is committed to capped gap agreements to minimise patient costs. Your health fund will advise you if you have any hospital excess to pay for your admission, and our anaesthetists kindly do not charge an out-of-pocket expense for cataract surgery.
Using your private health insurance gives you the choice of hospital for surgery and allows you to book surgery at your convenience.
- If you do not have private health insurance:
a) Public
Public surgery is available at Peel Health Campus for Medicare card holders. There is no cost involved with public surgery however there is a wait list. The length of time waiting for surgery is unpredictable and can vary with government restrictions. Some restrictions for surgery may apply depending on your locality.
b) Self-funded surgery
Self-funding surgery is an option for patients who do not have private health insurance, do not want to wait (or do not qualify) for public surgery. Cost is variable depending on Concession and Medicare eligibility.
Feel free to contact our team for further details.
