Introduction:

Most of us care how we look and how we feel. We use proper nutrition and exercise to enhance our health, appearance and well being.

Cosmetic surgery and aesthetic treatments offer additional ways to ease the damaging effects of stress and the environment on our skin and face. Tell tale signs of damage include sun damage to the skin, smile and worry lines, crow’s feet and eyelid changes.

Over time, the upper and/or lower eyelids and/or eyebrows may become droopy, hooded, puffy or baggy, giving a tired appearance which distracts from the overall attractiveness of the face. The eyelid tissues stretch, the muscles thin and fat pockets bulge, becoming more noticeable. The cheek tissue descends a little and the chin line becomes “jowly”. Eyebrows become drooping, the forehead furrows and deep tear troughs appear below our eyes.

These changes may be cosmetically unattractive and when severe, may also affect eye function. This includes discomfort from the weight of excess eyelid skin on the lashes, impaired visual field from overhang of upper eyelid skin, (or) difficulty wearing glasses because of lower eyelid bulges and tearing problems. Both men and women are increasingly requesting cosmetic (aesthetic) surgery on the eyelids or face. They need to be fully informed about the surgical options for their eyelids and surrounding areas.

Cosmetic Eyelid and Facial Plastic Surgery
What is cosmetic eyelid and facial plastic surgery?

Cosmetic eyelid and facial plastic surgery is another term for cosmetic periocular (around the eyes) surgery. It embraces a number of procedures to correct hooded or baggy eyelids and improve the aesthetic appearance of the eyelids and surrounding area of the face, including the eyebrows, forehead and midface. There are also related aesthetic treatments.

What does Cosmetic Surgery include?

  • Upper eyelid blepharoplasty
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  • Lower eyelid blepharoplasty
  • •
  • Endoscopic and non-endoscopic eyebrow and or forehead lift
  • •
  • Mid face/cheek lift
  • •
  • BOTOX (botulinum toxin) for lines and brow ptosis
  • •
  • Fillers and other injections around the eyes and face

The two most common cosmetic surgery operations carried out by Oculoplastic Surgeons are:

  • Blepharoplasty
  • Brow lift

The most common aesthetic treatment carried out by Oculoplastic surgeons are: 3

What is blepharoplasty?

This is a surgical procedure to remove excess tissue – skin, muscle and sometimes fat, from the upper and/or lower eyelids. It is often done in conjunction with other treatment such as a brow lift and BOTOX. There are cosmetic and functional reasons for blepharoplasty surgery.

What is a brow lift?

This is a surgical procedure to raise the level of the drooping eyebrows and forehead, often done in association with upper eyelid blepharoplasty. The aim is to correct eyebrow ptosis.
There are several different brow lift techniques, endoscopic or non-endoscopic, with or without fixation e.g. Endotine® (http://www.mondeal.ws/html/endotine.html).

What is BOTOX® treatment?

This is injection of botulinum toxin A (BOTOX is the name of one brand of botulinum toxin) into overacting muscles which cause deep activity lines on the face, especially the forehead and around the eyes, such as the vertical frown lones and the smiles lines. Common sites for injection are the glabella lines (vertical frown lines), forehead lines and smile lines aound the eyes (crow’s feet). BOTOX causes reversible inactivation (chemodenervation) of the facial muscle causing these lines. Mulitiple small injections are made which have a peak effect one week after the injection then gradually wear off over three months approximately.

What is a filler?

A filler is an inert synthetic substance such as Restylane ® (http://www.restylane.co.uk/) which is injected into the depressions or tear troughs below the eyes and the lines between the nose and the mouth (nasolabial folds). Fillers can be temporary, semi-permanent or permanent, depending on what material is injected. Restylane is temporary The patients’ own fat (autologous Coleman fat) can also be used to fill out depressed areas around the eyelids.

Who should perform cosmetic eyelid and facial plastic surgery and aesthetic treatments?

A number of different surgeons can perform cosmetic eyelid and facial plastic surgery and aesthetic treatments

  • Ophthalmologists trained as oculoplastic surgeons
  • Plastic surgeons

Oculoplastic Surgeon Who is an Oculoplastic Surgeon?

Oculoplastic surgeons are ophthalmologists (eye doctors) who have specialised in eyelid and facial plastic surgery. Oculoplastic surgeons are trained to do many different types of eyelid and facial surgery, ranging from simple eyelid malpositions to more complex reconstruction involving the eyelids and surrounding forehead, temporal and cheek areas. They understand the delicate anatomy and function of the eyelids and their surrounding structures. As well as the eyelids, they specialise in the lacrimal (tear) system, the orbit (bone cavity around the eye), adjacent periocular (around the eyes) and facial structures and the forehead and cheeks.

Oculoplastic surgeons are also known as ophthalmic plastic and reconstructive surgeons and oculo-facial surgeons.

  • Oculoplastic surgeons assess the surface health of the eyes and function of the eyelids prior to eyelid plastic surgery
  • As dedicated eyelid plastic surgeons, an oculoplastic surgeon routinely does surgeries in these areas, and recognises potential problems
  • Oculoplastic surgeons are trained to manage the complications or eyelid and facial plastic surgery which can involve the eye itself
  • Oculoplastic surgeons have a professional society which helps them maintain a high standard of care, called the British Oculoplastic Surgey Society.

Why are Oculoplastic Surgeons important around the eyes?

Oculoplastic surgeons are trained ophthalmologists (eye doctors) who understand how eyelid surgery can affect the comfort of the eye and the clarity of vision. They are accustomed to working around the eye and face.

How do I find an Oculoplastic Surgeon?

You should look for a Consultant Oculoplastic Surgeon who is members of the British Oculoplastic Surgery Society and is listed on the website www.bopss.org.

BOPSS Members

Why Use a BOPSS Member?

BOPSS Members are trained Oculoplastic Surgeons and ophthalmologists. They have undergone rigorous oculoplastic training and have been taught oculoplastic surgery in lectures, tutorials, courses and by demonstration. In order to become a member of BOPSS they have had to demonstrate a dedication to Oculoplastic Surgery including evidence training.

1. BOPSS Members are Registered with G.M.C. BOPSS Members are on the Specialist Register maintained by the General Medical Council. You can check whether a surgeon is on the Specialist Register by telephoning the General Medical Council Registry line 0845 357 3456 or this link: http://www.gmc-uk.org/

2. BOPSS Members are all N.H.S. Consultants BOPSS Members are all eligibleto, or have taken up, Consultant Appointments in Ophthalmology with a Special interest in Oculoplastic Surgery.

3. General Practitioner Communication BOPSS Members accept referrals from General Practitioners and, if the patients are agreeable, will keep their GPs informed of their treatments and progress.

4. Continued Medical Training BOPSS Members regularly attend instruction and scientific meetings organised by BOPSS annually. They also attend scientific meetings organised by sister National and International organizations such as ASOPRS (http://www.asoprs.org/) and ESOPRS .

5. Well recognized hospitals and clinics BOPSS Members work in (r)well recognized reputable hospitals and clinics- -eg. the private sections of NHS Trust hospitals, BUPA, Nuffield, Columbia Healthcare, HCA Hospitals. Within these hospitals they are working alongside other specialists able to give supporting care, who are also on the GMC Register in their own fields.

Department of Health Recommendations about Cosmetic Surgery Cosmetic Surgery Training and accreditation

BOPSS is working with the Royal College of Ophthalmologists (http://www.rcophth.ac.uk/education/guides-curricula) and Cosmetic Surgery Interspeciality Committee (http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyA ndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=410204 6&chk=5WX0N3) to provide a high quality of Cosmetic Surgery training and accreditation, as recommended by the Department of Health for regulating cosmtic surgery. See also the press release (http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesN otices/fs/en?CONTENT_ID=4102123&chk=RczDAC).

Department of Health Cosmetic Surgery Website

Patients interested in having Cosmetic Eyelid and Facial Surgery are advised to read the DoH website (http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/CosmeticSurgery/fs/en) launched 22nd December 2005. BOPSS has contributed to the development and content of this comprehensive website. See also the press release (http://news.bbc.co.uk/1/hi/health/4548958.stm).

Cosmetic Surgery Interspeciality Committee (CSIC)

Patients interested in having Cosmetic Eyelid and Facial Surgery are advised to read the document on Cosmetic Surgery (http://www.bopss.org/download.php?dof_id=222).

Steps to take before having cosmetic eyelid surgery

Consultation

You should have a consultation with your oculoplastic surgeon. He/she will examine your eyelids and face and ask about your general health and any allergies and medications, especially aspirin and other over the counter tablets, and whether you smoke. You may be required to undergo a general health check by your general practitioner, including heart and blood tests. Your vision will be tested and the health of the eyelids, the tear film and the front of the eye checked, as well as a retinal examination. The whole face will be examined and the condition of the skin noted, and the position of the eyebrows and eyelids will be measured. Pre-operative photographs are taken as a baseline for comparison with the results after surgery.

You will be advised whether just the eyelids or the eyebrows too need operating on and whether BOTOX (botulinum toxin) or other non-surgical treatment is recommended. You will be advised what tablets to stop before the surgery and given an information sheet about your operation and the post-surgery lid care.

What are the complications of blepharoplasty?

Serious complications are rare but may occur even in the hands of trained and experienced surgeons. Every effort is made to reduce the risk of complication – in the unlikely event of a complication which can affect your vision, oculoplastic surgeons are trained to manage this. You need to help by stopping aspirin, clopidrogel and non-steroidal anti-imflammatory tablets two weeks beforehand if your physician will allow it, in order to reduce the risks from bleeding.

• Sunken appearance – a sunken-looking “cadaveric” eye appearance can occur if too much fatty tissue is removed
• Asymmetry – a minimally uneven skin crease or lid height may be noticeable if there is asymmetrical swelling, more marked on one side than the other. If asymmetry is present after two weeks, it may persist and require later secondary surger
• Scar – rare as the incisions are hidden in the natural skin folds
• Need for repeat surgery – patients should be warned of the need for further surgery if an optimum result is not achieved.
• Eyelid and cheek swelling and bruising May be noticeable for up to 6 weeks)
• Blurred vision – For a few hours or overnight, due to surface ocular drying during the procedure, from effect of the local anaesthesia and ointment instilled. If this persists more than 24 hours, inform your oculoplastic surgeon
• Watery eyes – Reflex tearing may occur for 24 – 48 hours due to mild ocular discomfort and surface dryness
• Dry gritty eyes – This may occur for the initial two to three weeks after surgery due to reduced blinking. You will be prescribed artificial tears during the day (e.g. Hypromellose, Systane or Viscotears) and an ointment at night (e.g. Lacrilube or Simple Eye Ointment) to prevent this. Topical antibiotics such as Chloramphenicol are used for 1 week if surgery has been done from inside the eyelid.
• Scratched surface of the eye. – Minor injury to the eye surface can result in pain for 24 hours. If it persists or is severe, your oculoplastic surgeon must be
informed.
• Bruising behind the eye – Bleeding behind the eye is rare but can cause the eye to go blind. This is an Ophthalmic Emergency which Oculoplastic Surgeons are trained to prevent and manage. Oculoplastic surgeons are trained to prevent and manage this (repetition).
• Wound infection. This is rare, but can result in failure of the procedure
• Acute glaucoma – Rraised pressure within the eye with nausea, vomiting and blurred painful red eye. Specific treatment must be given and review by an ophthalmologist is necessary (does this occur in an oculoplastic setting?)
• Incomplete eyelid closure – For a day or two after surgery the eyelids will feel stiff and not entirely cover the surface of the eye when closed. It usually settles in days – associated discomfort is eased by lubricant drops and ointment.
• Sunken appearance – Can occur if too much fatty tissue is removed.
• Asymmetry
• Scar
• Need for repeat surgery –

For further information about cosmetic eyelid plastic surgery, please contact an
oculoplastic surgeon in your area.
British Oculoplastic Surgery Society.
Updated 6th January 2006