Blepharoplasty to improve visual function

Eyelid skin often loosens with age and can drape over the lashes, which impairs the vision - particularly the outer part of the upper lid. This can be cosmetically unappealing but it also impairs the visual field and is therefore worth attending to. Surgery to remove excess skin may also involve remodelling of orbital fat to reduce the bulky appearance of the upper lid.  

The procedure takes around 45 minutes, and is performed with mild sedation and local anaesthetic, either at the North Adelaide rooms, or in an approved day surgical facility (depending on the level of sedation required). It is common to have bruising for around one week afterwards but most patients return to normal activities thereafter. 

Cosmetic Blepharoplasty

Some patients request eyelid re-shaping to improve the appearance of their upper or lower eyelids. This usually involves reducing the bulk of the lid by removing or remodelling fat pads, but is may also involve creating a new eyelid crease (also known as Asian Blepharoplasty). Eyelid structure differs greatly between patients and the surgical plan plus expected outcome need to be discussed at length. Prior to the first consultation, consider what bothers you the most:

• Eyelid skin contour or skin excess (usually involves wrinkles)
• Puffiness of the upper or lower eyelid
• Droopy appearance of the upper or lower lid
• Asymmetry (differences) between the left and right eyelids

The best approach to all cosmetic procedures is to do the least amount possible in order to gain the desired effect. Further touch ups are sometimes required but those are usually quick and easy and will not involve any further expense. 

Cosmetic upper eyelid surgeries offered:

• Blepharoplasty: with or without fat pad remodelling; ptosis repair is sometimes required which is a non-cosmetic component and will be discussed in length prior to surgery. 
• Asian blepharoplasty (creating a new eyelid crease)
• Brow lift: usually combined with blepharoplasty if required but it is better to avoid a brow lift when possible because it is the most likely procedure to result in an "operated" or "surprised" appearance if overdone. 

Cosmetic lower eyelid surgeries offered:

• Removal or festoons or "eyelid bags" from lower lid: generally also requires skin tightening and sometimes tightening of the eyelid itself. This is quite an involved procedure with posterior approach (through the conjunctiva) and anterior approach (through the skin) but scarring is minimal.
• Skin tightening: reducing wrinkles and giving a more youthful appearance is relatively stright forward. The main consideration is to tighten without removing too much lower lid skin. 

All cosmetic procedures involve out of pocket expenses of between $1000 and $3000 for surgery done at the North Adelaide rooms or up to $6000 if surgery is performed in a day surgery (depending on the level of sedation required). A favourable outcome is best achieved when the surgeon and patient understand each others expectations, and a lengthy discussion with use of diagrams and patient photos is always employed. 

 Other non-surgical cosmetic services:

• Anti-wrinkle injections
• Dermal fillers
• PRP facial and hair regeneration
• Agnes non-surgical eye lift and acne treatment
• Skin consultation and Cosmeceuticals

Ptosis repair

Ptosis is a drooping of the upper eyelid itself rather than just a draping of excess skin over the lashes. This drooping may lead the upper lid to overlap the pupil and it can therefore severely affect the vision. Ptosis is usually age-related but there are rare and serious causes and ptosis must therefore always be assessed by an Ophthalmologist or Neurologist. 

Ptosis repair requires a reattachment of the muscle that lifts the eyelid so that the lid can rest in a more natural position. Even if only one lid appears to be drooping, both lids may require surgery to get the balance right. 

Surgery is more involved than a blepharoplasty and it usually takes around 1 to 1 and a half hours. The eyelid position and function needs to be checked during the procedure to ensure optimal positioning and balance between the two lids. Even with perfect technique and careful assessment, ptosis repair is difficult to get exactly right and some patients will need to have a second procedure to correct the imbalance. 

Entropion Repair

Entropion is a "turning in" of the eyelid. Typically occurring on the lower eyelid, the skin and lashes rub painfully against the cornea. The condition may cause the lid to turn in constantly or only at times when the eyes are closed tightly. 

Lubricating eye drops may be used to lessen certain symptoms such as dry eyes. Temporary relief can also sometimes be found by using Botox, skin tape to hold the eyelid in place or strategically placed stitches. Ultimately if the lid is frequently rubbing against the eye, a surgical procedure to correct the lid position is required and this usually takes one month to recover. During that time the eyelid can be swollen and bruised but the overall cosmetic outcome is usually excellent. 

Ectropion Repair

Ectropion is a "turning out" of the eyelid. Typically occurring on the lower eyelid, the skin of the inner lid is exposed, either in one section of eye or across the entire lid. This prevents tears from draining correctly and this leads to excess watering.  

Ectropion is either due to weakness of the muscles and tendons around the eye or due to tightness of the skin below the eye (usually related to sun damage).

Artificial tears can help provide temporary relief from dryness but some patients require surgical eyelid repositioning, which may involve a skin graft from the upper eyelid. Recovery from this surgery is either 2 weeks if simple repositioning is performed or 3 - 4 weeks if a skin graft is required.

Eyelid cancer excision and repair

Safely removing skin cancers from around the eyelid is a challenging procedure and can require complex surgical reconstruction. Each cancer is treated differently according to how large the cancer is, where it is located in relation to the eye and what type of cancer it is (some cancers need a larger margin of clearance than others). Fortunately most eyelid cancers can be cured with surgery and there is very little risk of spread or recurrence thereafter. 

Tear Drainage Surgery: External Dacryocystorhinostomy (DCR)

What is a DCR?

A Dacryocystorhinostomy (DCR) is an operation to establish free drainage of tears into the nose. The operation involves removing a piece of bone from your nose to bypass a blockage in the tear drainage system. Surgery is usually performed under local anaesthetic with intravenous sedation by an anaesthetist. A minimal incision is made on the side of your nose. The lining of the tear drainage system is attached to the lining of the nose to create a new passageway. A fine silicone tube (stent) is sometimes placed in the tear drainage system during surgery to help maintain an opening. Whilst the stents are in place, symptoms of watering can sometimes continue. The stents are easily removed in clinic approximately 6 weeks after surgery.

Why do I need a DCR?

Tears are normally produced by the lacrimal gland , and they travel across the eye, to help moisten and protect the eye (see diagram below). The tears drain into two little holes in the inner corner of the eyelids known as puncta. Once through the puncta, the tears drain through a system of small passages that lead through to the nose and back of the throat. If this system is blocked in any way, it can cause excessive tearing and overflow of tears. Blockage can result from many causes such as scarring from injury, recurrent infection and age-related narrowing.

How successful is the surgery?

Continued improvement in watering can occur upto several months following surgery. The vast majority of patients experience success rates in the region of 90%. However these rates can vary and be significantly less in some, depending on the level and extent of the blockage.

What are the possible complications?

Most complications from this surgery are amenable to successful treatment. Serious complications are very rare and every possible precaution is taken to avoid them. Risks include:

• Bleeding from the nose – this usually subsides spontaneously or with ice packs and pressure
• Infection – extremely rare
• Scarring of the new tear drainage pathway – this will lead to failure of the operation and the need for further surgery
• Skin scar – this will be present but is usually minor and the incision is designed to minimise any risk of prominence
• Prolapsing of the stent – if this occurs, the stent will need to be repositioned in clinic or removed earlier than planned

Reconstructive Socket Surgery 

Surgery to either remove an eye (usually if the eye has cancer or severe trauma) or improve the cosmesis/function of patients who already have an artificial eye. Recovery after socket surgery is around 6 - 8 weeks for the bruising and swelling to resolve. 

If an eye has been removed, an orbital implant is inserted behind the conjunctiva and secured to the muscles that normally move the eye. This implant is never removed, it just creates volume in the orbit so that a prosthetic shell can be fitted to create a normal appearance. We are lucky to have Peter Knowles (specialist Ocularist) in the same building to create a perfectly fitted prosthetic that is well matched to the other eye. 

With time, some patients who have had an eye removed can have a loss of fat from within the orbit and might require their eyelids to be retightened or lifted. These operations are usually performed as day surgery and recovery is relatively fast.