Sydney

Upper Blepharoplasty

Lower blepharoplasty addresses the area beneath the eye, usually puffiness caused by fat prolapsing forward and sometimes loose skin. It is a different operation from upper eyelid surgery, with different incisions and a different risk profile, and it is more often performed for appearance alone.

Incisions may be placed just below the lash line or on the inside of the eyelid, depending on whether skin needs to be removed or only fat repositioned. The inside approach leaves no visible scar but does not address loose skin. Lower lid surgery carries its own specific risks, including changes to the position of the lower lid, so the tone and support of that lid is assessed carefully beforehand. Upper and lower can be done together, though that means a longer procedure and a longer recovery.

They are different problems needing different operations. Excess upper eyelid skin, dermatochalasis, is treated by blepharoplasty. A drooping eyelid margin, ptosis, is caused by weakness of the muscle that lifts the lid and needs a different repair altogether. The two can occur together.

This distinction matters because removing skin does not lift an eyelid that is drooping from muscle weakness, and someone treated for the wrong problem will be disappointed with the result. Ptosis often shows itself as one eye looking smaller or more tired than the other, or as the lid margin sitting low over the coloured part of the eye. It is assessed by examination rather than from a photograph. Ask specifically which of the two you have, and whether the operation being proposed actually addresses it.

Sometimes, for upper eyelid surgery. Item 45617 covers upper eyelid reduction where one of six listed indications applies and photographic or diagnostic imaging evidence is documented in your patient notes. Medicare benefits are not payable for non-therapeutic cosmetic services, so surgery for appearance alone attracts no rebate.

The six indications are a history of demonstrated visual impairment, intertriginous inflammation of the eyelid, herniation of orbital fat in exophthalmos, facial nerve palsy, post-traumatic scarring, and restoration of symmetry of the other upper eyelid in respect of one of those conditions. The descriptor was updated on 1 November 2022, when the requirement for visual field testing confirmed by an optometrist or ophthalmologist was removed, though many Australian websites still quote the old rule. Bear in mind a rebate is a contribution rather than payment: the schedule fee for item 45617 is $281.40, with a benefit of 75 or 85 per cent depending on the setting, and surgeons’ fees sit well above the schedule fee. Expect a meaningful out-of-pocket amount even where you do qualify.

No. Blepharoplasty removes excess skin and repositions or removes fat. It does not treat crow’s feet at the outer corner of the eye, fine lines caused by muscle movement, dark under-eye pigmentation, or the position of the eyebrow. Those are separate concerns needing separate approaches.

A heavy upper lid is sometimes caused by a descended eyebrow rather than by eyelid skin alone, and removing lid skin in that situation can leave the brow sitting lower still. That is one reason brow position is assessed as part of the examination rather than the eyelid being looked at in isolation. Dark circles are often caused by pigmentation or by the shadow cast by a hollow beneath the eye, and neither is improved by removing skin. Being specific about what bothers you makes for a far more useful consultation than a general wish to look less tired.

Reported risks include bruising and swelling, dry or irritated eyes, blurred or double vision in the early period, asymmetry, poor wound healing or noticeable scarring, difficulty closing the eyes fully, downward pull of the lower lid, infection, bleeding, anaesthetic complications, and the possible need for revision surgery. Loss of vision is rare but recognised.

Dry eye is among the most commonly reported problems afterwards, and it is more likely if you already have dry eyes, wear contact lenses, or have had laser eye surgery, so mention any of these at consultation. Early blurring is common and usually settles, though it should not simply be assumed to be temporary. Sudden severe pain, rapidly increasing swelling or pressure around the eye, or vision that is getting worse rather than better, needs urgent medical attention rather than waiting for your follow-up appointment. A/Prof Bish Soliman’s website has a dedicated risks and complications page.

Blepharoplasty is day surgery and can be performed under either local or general anaesthetic. Upper eyelid surgery on its own is often done under local. Where upper and lower eyelid surgery are combined under general anaesthetic, an overnight stay in hospital is generally recommended.

Local anaesthetic means you are awake with the area numbed, which some people prefer and others would rather avoid. General anaesthetic brings its own risks and usually its own cost, since the anaesthetist bills separately. Either way you will not be able to drive afterwards, so arrange for someone to take you home. Ask which is planned in your case, why that choice has been made, and what it means for the total cost, because the answer varies with how much is being done.

Bruising around the eyelids typically lasts one to two weeks. Most patients take one to two weeks off work, though some in desk-based roles return sooner. Strenuous exercise is avoided for four weeks. Sleeping with your head elevated and using a cold compress helps with early swelling.

How much time you need depends as much on how visible you are at work as on healing itself, since bruising around the eyes is conspicuous and changes colour before it fades. Reading and screen work can be tiring in the first few days, and the eyes may water or feel gritty. If your job involves heavy lifting or strenuous movement, allow longer. Ask for written instructions specific to your procedure rather than relying on general timeframes.

Upper eyelid scars sit within the natural crease of the lid, so they are concealed in an existing fold once healed. Lower eyelid incisions are placed either just below the lash line or on the inside of the eyelid, where they leave no external scar at all.

Eyelid skin is thin and tends to heal inconspicuously compared with skin elsewhere on the body, which is why these scars usually settle well. That is a tendency rather than a promise, and some people scar more noticeably than others. Scars look at their worst in the first few weeks, then flatten and pale, with most continuing to change for around 12 to 18 months. Keep healing scars out of the sun, follow the wound care instructions you are given, and ask before applying anything to the area.

These are the practical questions people forget to ask. Eye makeup is usually avoided until the incisions have fully healed, contact lenses until your surgeon confirms it is safe, and strenuous exercise for four weeks. The exact timeframes vary with the procedure performed and how you heal.

Contact lens wearers often find lenses uncomfortable for longer than expected because of dryness, so have glasses ready. Swimming and spas are generally avoided while incisions are still healing because of infection risk. Bending, lifting and anything that raises pressure around the head is usually restricted early on. Get these specific timelines in writing at your pre-operative appointment rather than working them out as you go, since they are the details that most often catch people out.

Where blepharoplasty is performed to improve appearance, the Medical Board of Australia’s cosmetic surgery guidelines apply, including a cooling-off period of at least seven days after informed consent before the surgery can be booked or a deposit paid. A GP referral is essential to see A/Prof Bish Soliman in any case.

The guidelines also require a referral from an independent medical practitioner, at least two pre-operative consultations with one of them in person with the surgeon who will operate, and assessment for psychological conditions using a validated screening tool. Patients under 18 require independent evaluation and a cooling-off period of at least three months. Where the surgery meets one of the clinical indications for a Medicare eyelid item, it is not being performed only for cosmetic reasons and the position differs. Ask which pathway applies to you at your first appointment.

Upper eyelid surgery generally gives a long-lasting result and most patients do not need it repeated, though the eyelids keep ageing afterwards along with the rest of the face. Skin that has been removed does not come back, but the remaining skin can gradually loosen again over the years.

How long a result holds varies with your age at surgery, skin quality, sun exposure and genetics. Lower eyelid results can also change as the tissues and the bone around the eye continue to age. Swelling takes a few months to settle completely, so what you see at three weeks is not the final result and judging it then gives a misleading impression. No specific duration can be promised, and anyone quoting a set number of years is guessing.