Blepharoplasty with Preservation of Periocular Volume

Upper blepharoplasty with preservation, repositioning and restoration of periocular volume addresses heavy upper lids, a low or absent crease and hollowing under the brow. When the eyelid margin itself is low — ptosis — the operation is combined with ptosis repair, otherwise removing skin alone does not open the eye. This is assessed at the consultation by measuring the eyelid position.

Two techniques are used depending on the findings. Transconjunctival blepharoplasty is performed through the inside of the eyelid, leaves no external scar and is suited to bags without excess skin; the fat is repositioned rather than removed, and fat grafting may be added for the tear trough. Lower blepharoplasty with tailored skin excision is used when there is loose skin as well; the incision is placed below the lash line.

Upper eyelid surgery is usually performed under local anaesthesia with sedation; combined or lower eyelid procedures may be performed under general anaesthesia. The procedure takes one to three hours depending on what is done. You go home the same day. Sutures are removed at 5–7 days.

Swelling and bruising are expected for the first one to two weeks; most patients return to desk work within 7–10 days. Contact lenses are avoided for about two weeks and strenuous exercise for three to four. The final result settles over two to three months. Individual recovery varies.

Bleeding, infection, asymmetry, dry eye, difficulty closing the eye fully in the early period, visible scarring, and the need for a revision. Rare but serious complications include damage to vision. Risks are discussed at the consultation and recorded in the informed consent.

Consultation with the Specialist Ophthalmologist: AED 1,100. The cost of surgery is confirmed in writing after examination and depends on the technique, whether one or both eyelids are treated, whether ptosis repair or fat grafting is included, and the type of anaesthesia.

Upper and lower blepharoplasty may involve removal of orbital fat. When more fat is removed than the eyelid anatomy can tolerate, or when age-related volume loss continues afterwards, the eyelid may develop a deep superior sulcus — a hollow or sunken upper eyelid — and the skin of the lid may look thin and shadowed. In some patients the eye itself sits further back within the orbit, a condition called enophthalmos, which may also follow orbital trauma or long-term use of certain glaucoma eye drops.

Assessment includes examination of eyelid position and skin, measurement of the position of the eye with a Hertel exophthalmometer and, where indicated, orbital imaging, so that hollowing of the soft tissue is distinguished from a true deficit of orbital volume. The two situations are managed differently, and not every hollow-looking eyelid needs volume to be added.

Volume restoration with the patient's own fat. Autologous fat grafting uses a small amount of the patient's own fat, usually taken from the abdomen or thigh, processed and placed through a blunt cannula. Where the hollowing is confined to the eyelid and brow, the fat is placed in the periorbital tissues. Where the eye itself has moved backwards, fat may be placed deeper within the orbit, in the retrobulbar or intraconal space, to increase orbital volume and bring the eye forward. This is a specialised orbital procedure, distinct from superficial periorbital fat grafting, and it is performed at ELEMENTAL by Dr. Hanna Barinova, Specialist Ophthalmologist.

Risks and limitations. Grafted fat is partly resorbed and the degree of resorption cannot be predicted in advance; a proportion of patients need a second grafting session. Described complications include swelling, asymmetry, overcorrection, palpable lumps or fat cysts, migration of the graft and inadvertent injection into an eye muscle. Injection of fat in the periorbital region carries a recognised risk of vascular occlusion, including occlusion of the ophthalmic or retinal arteries with loss of vision; this is uncommon but has been reported. Because deep orbital injection is close to the optic nerve, overcorrection and compressive effects are additional concerns. Alternatives such as dermal fillers, dermis-fat grafts, local flaps or observation may be appropriate depending on the findings. Treatment is decided individually after examination, and the expected outcome, the alternatives and the possible need for more than one procedure are discussed before anything is scheduled.