Eyelid surgery (blepharoplasty): the procedure and recovery week by week

Upper eyelid surgery usually removes excess skin that hangs down towards the eyelashes, and where needed some fatty tissue. The incision is made in the natural crease of the eyelid, so the scar is later usually hidden in that crease when the eye is open. The outer end of the incision sometimes extends into the fine lines at the corner of the eye. When excess skin gets in the way of your vision, the procedure may also have a functional reason, which the doctor decides on after the consultation.

Excess skin is not the same as a drooping eyelid itself (ptosis) or a drooping eyebrow. These are different conditions that are treated with different procedures, so at the consultation the surgeon assesses the cause: excess skin, a drooping eyelid or a drooping eyebrow.

Lower eyelid surgery deals with bags under the eyes and loose skin on the lower eyelid. The incision can be made just below the lash line or on the inside of the eyelid, in which case there is no visible incision on the outside. The choice of approach depends on whether skin needs to be removed, whether fatty tissue needs to be repositioned or removed, and how elastic the skin is. Darker skin under the eyes and fine lines are usually not changed by this procedure. Recovery after lower eyelid surgery may take a little longer, because swelling in that area often settles more slowly.

The upper and lower eyelids can be done in the same procedure or separately. The price depends on what is done, and current prices are listed in the plastic and aesthetic surgery price list.

The first step is a consultation with a plastic surgeon. The doctor assesses your skin, the fatty tissue and the position of your eyebrows and eyelids. They will ask about eye conditions (for example glaucoma), dry eyes, previous eye operations and whether you wear contact lenses, as well as about high blood pressure, thyroid conditions, diabetes, a tendency to bleed and any medicines you take regularly. Based on this, they suggest the type of procedure and anaesthetic and explain what you can realistically expect.

Basic blood tests are usually done before the operation, and other examinations where needed, for example an eye examination by an ophthalmologist. Do not stop medicines that affect blood clotting on your own; discuss this with your surgeon and with the doctor who prescribed them. Also tell your surgeon about any herbal remedies and supplements you take, as some of them affect bleeding. Smoking slows down healing, so a break from smoking before and after the procedure is advised.

It helps to arrange in advance: - transport home, as you should not drive after the procedure - someone who can stay with you on the first day - an extra pillow so you can sleep with your head raised - sunglasses and a few days without commitments

With local anaesthetic, the eyelid is numbed with an injection. When the injection is given you feel a brief prick and stinging, and after that you usually feel no pain during the procedure, only possibly touch and pressure. A medicine to help you relax (sedation) can be given alongside the local anaesthetic, while general anaesthetic is used less often, for example when several procedures are done together. The type of anaesthetic is decided by the surgeon after the consultation, and when sedation or general anaesthetic is planned, an anaesthetist is also involved in the decision.

The procedure itself usually takes from about half an hour to about two hours, depending on whether the upper, lower or both upper and lower eyelids are done. At the end, ointment is applied to the incision and, where needed, thin strips or a light dressing. Eyelid surgery is usually done without an overnight stay in hospital, and the doctor decides whether you go home or stay overnight in your case.

Straight after the procedure your vision may be blurred because of the eye ointment and swelling. This is usually temporary, eases over the first few days and often clears when you blink. Do not drive while your vision is blurred. If your vision is still very blurred after one to two days, contact your surgeon.

Swelling and bruising are usually at their worst in the first two to three days and then gradually ease. Your eyelids may feel tight and numb and may be harder to close fully, and your eyes may water, feel dry or be sensitive to light. Pain is usually mild to moderate and is relieved with medicines prescribed by your doctor.

In the first week you will usually be advised to: - use cold compresses over gauze, gently and without pressing on the eye, several times a day for 10 to 15 minutes, for the first two to three days - sleep on your back with your head raised - avoid rubbing your eyes, bending over, lifting heavy objects and strenuous activity - care for the incision and use eye drops and ointment exactly as your doctor instructs - avoid contact lenses and eye make-up - keep reading and screen time short, with frequent breaks

Stitches are usually removed between the fifth and seventh day, at a check-up with your surgeon. If dissolvable stitches were used, they are not removed.

After the stitches are removed, the swelling and bruising continue to go down. Yellowish traces of bruising may be visible until the end of the second week, and sometimes longer. Office work and lighter duties are usually possible after 10 to 14 days; if your work is physically demanding, you will need more time off.

As a rough guide, subject to your surgeon's approval: - eye make-up: once the incision has fully closed, usually 10 to 14 days after the procedure - glasses: usually before contact lenses, as long as the frames do not press on the swollen area or the incision - contact lenses: usually after about two weeks, once the swelling has settled - driving: not for the first few days, and only once your vision is no longer blurred, your eyelids open normally, you are not taking medicines that cause drowsiness and your surgeon has approved it - moving around: walking and light housework, without straining

From the third week, most of the swelling has gone, but mild swelling, especially in the morning and on the lower eyelids, can last for several more weeks. More strenuous exercise, swimming and saunas are usually allowed gradually, after three to six weeks, once the surgeon judges that the incision has healed.

At first the scar is reddish and slightly tight, and it fades over several months. Protect the fresh scar from the sun with sunglasses and, once the incision has fully healed, with a sunscreen recommended by your doctor. The final appearance of the eyelids is usually assessed after three to six months, as by then the tissues have settled.

The result depends on the structure of your skin and tissues, on healing and on following the instructions, so no one can promise it in advance. That is why it is important to talk openly at the consultation about what the procedure can and cannot change.

Every surgical procedure carries some risk. After eyelid surgery, the most common are temporary swelling, bruising, dry or irritated eyes, increased watering and temporary numbness of the eyelids. Less common are infection, bleeding, uneven-looking eyelids (asymmetry) or a more noticeable scar. If too much skin is removed, the eye may be harder to close, and after lower eyelid surgery the eyelid sometimes droops or turns outwards.

Very rarely, bleeding behind the eye can threaten your sight, so the warning signs in the next section should not be ignored. Some changes settle on their own during recovery, and sometimes a further procedure is needed. At the consultation the surgeon explains the risks in your case, and before the procedure you give written consent.

Discomfort, swelling and bruising are an expected part of recovery. Contact your surgeon without delay if you develop: - severe pain in or around the eye that is getting worse - sudden, severe swelling, especially of only one eye, or an eye that looks as if it is bulging - worsening vision or double vision that does not clear when you blink - vision that is still very blurred after one to two days - bleeding that does not stop after gentle pressure with clean gauze - redness, warmth, a pus-like discharge or a high temperature

If your vision suddenly gets worse together with severe pain and swelling, do not wait for your check-up. If your surgeon cannot be reached at that moment, call the emergency medical service on 194 or go to the nearest emergency department and say that you have had eyelid surgery.

Before you are discharged, ask for written instructions and the phone number to call after the procedure.

A consultation with a plastic surgeon at Maja Hospital, at Vizantijski bulevar 39 in Niš, is the first step to finding out whether eyelid surgery is right for you and what your recovery would look like.