Patients who have eyelid surgery alone typically experience a very tolerable and relatively comfortable recovery.
If laser resurfacing is performed, the recovery issues relate to the laser resurfacing treatment. Laser treatment adds oozing of the skin and swelling to the recovery process. Usually there is minimal pain, but because of the redness and swelling, patients look like they must be in a lot of pain. Fortunately, the benefits justify this added nuisance to the recovery.
Recovery from blepharoplasties entails a variable amount of swelling and bruising. Occasionally, the eyes are swollen shut on the morning after surgery, but this is unlikely with proper elevation and the use of ice packs during the first 24 hours. The eyes are usually swollen about halfway shut the morning after surgery.
Recovering from Laser Resurfacing and Eyelid Surgery
When laser resurfacing is performed simultaneously, there is increased swelling and oozing of the treated skin. Postoperative care is the almost the same as for laser resurfacing without blepharoplasty (except for corneal lubrication). The face is cleansed with soap and water at least three times daily. Vaseline ointment is applied to keep the skin from drying. As the new skin cells resurface the area, the oozing lessens and stops five to seven days after surgery. The skin is now healed and is usually pink, indicating the presence of new skin cells. The eyelids are still swollen which temporarily accentuates the creases around the eyes.
Lubricating the Eyes during Recovery
Patients may not be able to close their eyes fully for several days. During this time, it is imperative that the eyes be kept well lubricated with drops during the day and ointment at night. The drops are used during the day because they do not blur the vision as much as the ointment, which lasts longer and is therefore used at night. If the eyes are swollen shut, it is unnecessary to pry the eyelids open, because the eyes are already protected from drying by the closed eyelid. Ice packs are used to reduce swelling on the day and evening after surgery. Head elevation by sleeping in a recliner or using pillows to prop up the upper body is helpful. Some patients have used foam wedges to elevate the upper body about 30 degrees in bed.
The Healing Process
At first, the skin is gathered along the incision lines, causing little bumps. These irregularities smooth out after the sutures come out and the skin starts to relax. It can take a few months for the little bumps at the incision ends to settle down.
The patient is seen in the office between three and five days after surgery. The skin is almost healed, but there may still be a crust present on the lower lids. The upper eyelid sutures are removed, which is momentarily uncomfortable as the suture slides out. When a traditional lower transcutaneous blepharoplasty is performed, the lower lid suture is pulled out at the same time. The eyelid skin relaxes and the eyelids feel more comfortable after suture removal. There is usually slightly improved eyelid closure after the sutures come out because the skin that has been gathered by the sutures can now relax.
Sometimes, patients who have had transconjunctival (incision inside the eyelid) blepharoplasties notice the sensation of the dissolving suture in the lower eyelid for a few weeks but the feeling goes away as the incision heals.
Patients may notice a small bump at either end of the upper eyelid or external lower lid incision. Skin removal causes bunching of the skin at the end of the incision which causes these "dog ears."
Gradually, the bump goes down as the tension on the surrounding skin is relieved. Occasionally, I have touched-up this area with the laser or by removing a tiny area of persistent puckering under a local anesthetic- this is called "revision of a dog ear." The only way to avoid dog ears is by making the incision longer which would increase the length of the scar. I try to strike the right balance between minimizing the length of the incision and avoiding dog ears. In my experience, it is better to avoid longer scars and treat the little "dog ears" if necessary. The majority smooth out on their own with time.
The Healing Process: Persistent Droopy Eyebrows
It is important to recognize that a drop in the position of the eyebrow may contribute to hooding of the skin of the upper eyelid. Some degree of hooding may persist after eyelid surgery in patients with droopy eyebrows. Eyelid surgery will not correct saggy eyebrows.
For patients wishing to correct droopy eyebrows, an endoscopic forehead lift is often done at the same time to help correct both sources of redundant tissue, trimming skin from the upper eyelid and also elevating the fallen eyebrow (see R.M.'s photographs). Over-resection of eyelid skin can make it impossible for the patient to fully close the eyes, which can lead to dry eyes. Experienced surgeons avoid this problem by being conservative in their skin removal and recognizing the importance of brow position.
Sometimes, older patients will return to me and show me that there is still some loose skin on their upper lids. They may be unaware that when they close their eyes, this loose slack is completely taken up. Any additional removal of eyelid skin would restrict eyelid closure, particularly at night when eyelid closure is involuntary and therefore not as tight. They understand that dry eyes pose a significant problem and incomplete eyelid closure is best avoided. Some patients may be candidates for an endoscopic forehead lift. If the skin laxity is corrected by pulling up on the skin above the eyebrow, it is clear that eyebrow elevation is the appropriate treatment, not more skin removal from the upper lid.
How Long is the Healing Process?
Healing takes place over several months. At first, the incision lines feel thickened (doctors call this "induration") and there is soft swelling of the upper lids. This swelling takes a few months to settle down. Swelling of the lower lids and over the upper cheeks ("malar edema") tends to come and go and may be better or worse from one day to the next. Patients understandably become concerned when swelling increases; they believe that swelling should gradually but uniformly go down. In fact, swelling characteristically waxes and wanes before it eventually settles down.
Characteristics of Swelling:
- Swelling may be worse in the morning than at night. During the day, the patient is sitting or standing so that gravity helps reduce swelling.
- Swelling can be aggravated by vigorous physical activity, increased blood pressure, or even a high-salt diet. Head elevation at night, using several pillows, a recliner, or foam wedge, is useful during the first several days after surgery. Then elevation becomes less important and patients need to be able to sleep comfortably.
- Patients are often concerned when they observe that one eyelid is more swollen or bruised than the other. However, this is normal and quite common. One side always seems to heal a little faster than the other -this goes for just about any bilateral plastic surgical procedure.
- Swelling of the transparent lining of the eye ("conjunctiva") may also occur and is called "chemosis." A bubble develops over the white part of the eye. It may feel like there is something in the eye, which doctors call a "foreign body sensation". This is due to swelling under the transparent lining of the eye. Redness of the white part of the eye may also occur. This redness ("subconjunctival hematoma") is caused by blood that has tracked under the transparent lining of the eye. Although it can look a little scary to patients, it is normal and no reason for concern.
Normal Findings after Eyelid Surgery
- Redness of the sclera (white part of the eye).
- Swelling of the conjunctiva or "chemosis".
- Small bumps at the end of the scars ("dog ears").
- Thickening and bumpiness along the incisions.
- Temporary oozing from the incisions.
- Blurring of eyesight, due to swelling of the conjunctiva, and by the use of the lubricating ointment.
- Inclusion cysts. Little cysts occasionally develop along the suture lines. These little cysts may be easily removed under local anesthetic in the office.