What is dermatochalasis?
This is a condition where the skin of the upper eyelid becomes gradually stretched and less elastic over time, leading to overhanging eyelid skin. This excess skin often hangs down and rests on the eyelashes, and can cause a heavy uncomfortable sensation. It can also interfere with eyesight, causing a shadowing or obscuring of the upper portion of the visual field. There may also be associated changes in the eyelid tissues, such as bulging or ‘prolapse’ of the orbital fat which surrounds the eye, drooping of the eyebrow or upper lid position, and weakening of the eyelid crease.
What causes dermatochalasis?
The condition can be inherited from one’s parents, whereby the structure of the face and eyelids can predispose to an earlier onset of problems relating to excessive upper lid skin. Excessive sun exposure and smoking may also accelerate the process. The condition generally progresses with increasing age, although usually at a very slow rate.
The condition may be aggravated by swelling, bruising or inflammation of the eyelids such as may occur following trauma. Patients with Graves’ disease or ‘thyroid eye disease’ may have excessive upper lid skin and fat, and may benefit from surgery. In some cases, there can be excess upper lid skin following trauma or other eyelid surgery. Drooping of the eyebrow (brow ptosis) is a very common finding as part of the ageing process, and may cause problems earlier in people with certain anatomical predispositions; it can worsen the effect of dermatochalasis since more upper lid skin is allowed to rest in a lower position.
How is dermatochalasis diagnosed?
Presenting symptoms are typically a heavy sensation in the upper eyelids, droopiness or awareness of excess skin, or interference with the peripheral vision, particularly upwards and to the sides. For the surgery to be covered in part by Medicare and Health Insurance, the upper lid skin must be resting on the lashes in straight ahead gaze, and this must be documented photographically prior to surgery. Other conditions where a Medicare rebate can apply are thyroid eye disease, facial palsy and post-traumatic scarring.
How is dermatochalasis treated?
Dermatochalasis is typically treated by surgery (upper lid ‘reduction’ or ‘blepharoplasty’). Occasionally injections of fillers can help problems of contour in the eyelid. Other procedures may be done at the same time, such as correction of eyelid ptosis (drooping of the upper lid position).
What sort of anaesthetic will be used?
Upper lid reduction is most commonly performed under a local anaesthetic because this allows the surgeon to more accurately determine how much skin to remove, and where to set the skin crease. Before any local anaesthetic is injected into the skin of the upper eyelid, your anaesthetist will give you some medicine in the form of a sedative and pain killer so that the eyelid injection will not be painful and is often not even noticed or remembered. During the operation, you will however be aware that the eyelid is being operated on but it will rarely be painful. It is important for you to say if there is any pain during the operation. A full general anaesthetic is rarely required, for example if performed in conjunction with other surgery (e.g. lower lid blepharoplasty).
What is the aim of the surgery?
The most common aim of surgery is to reduce the symptoms of ‘heaviness’ in the upper eyelids, or to improve the peripheral vision (above), or both. Other symptoms may lead to surgery being performed, such as discomfort in the upper lids. Another aim is to have the two eyelids even with each other (symmetrical), but again, in some less common circumstances, this may not be possible or advisable.
It can be performed in conjunction with other surgery (e.g. lower lid blepharoplasty).
Where is the incision made?
The incision is made in the fold or crease of the eyelid so that the scar is largely hidden here and not visible when the eye is open. If the eye is closed, a thin fine scar may be visible in the early months after surgery but is typically very difficult to see after that. Sutures are typically removed at about 1 week after surgery: this is usual painless, but can cause minor discomfort.
How long will I stay in hospital?
Most patients can go home on the day of surgery, but a few are kept in overnight after the operation. You will be told at the time the surgery is booked how long you will stay in hospital.
What problems can occur with dermatochalasis surgery?
A large majority of people having upper lid reduction surgery have a successful outcome with a high satisfaction rate. In a small proportion of cases however, the result may be less than expected or desired. There may occasionally be some residual skin excess (‘under-correction’) or asymmetry (mismatch), which can require further surgery if the outcome is not acceptable. This is uncommon, and it is important to note that any revision surgery may not fulfil the Medicare criteria, meaning any additional surgery may not be covered at all by Medicare / Health Insurance; however, this is quite uncommon. Rarely, the eyelid(s) may become more droopy than before the surgery (‘ptosis’). If any of these problems occur and are noticeable enough to be a concern, it is nearly always possible to correct them with a second operation to adjust the eyelid, and very rarely, more than two operations may be required. In most patients however, only one operation is required to achieve a satisfactory result.
Other problems with upper lid reduction are uncommon, but may include:
- A dry eye after the surgery: this is often temporary and will settle after some weeks, but if it does not, then lubricating drops and ointments may be required.
- Difficulty closing the eye: this can occur especially in the first few weeks after the surgery and can lead to dryness of the eye. In most cases, the eyelid closure will return to normal.
- Prolonged swelling is rare: usually the swelling settles over a period of 2-4 weeks, most within the first week, and mostly within 2 weeks. Ice packs in the first week or so are helpful to control swelling.
- Infection: this is very rare with eyelid surgery and can be treated with antibiotics.
- Bleeding: bleeding from the eyelid requiring further surgery is very rare indeed.
- Change in the vision: rarely, the eye can be a little different in its focus after upper lid reduction surgery. This usually settles after several weeks but occasionally, glasses may need to be slightly adjusted.
- Scarring: there is always a thin scar hidden in the fold of the eyelid and this is not visible when the eye is open. In the first weeks after surgery, the scar may feel tight, look quite red or pink, and can be a little “lumpy”, but over several months, this feeling of tightness and hardness of the scar passes so that the scar can no longer be felt and the scar is barely visible with the eye closed.
- Wound healing problems: wound healing problems, such as dehiscence (gaping), prolonged redness, pain, are very rare.
- Eyelid surgery on one side: if surgery is performed on one side only, sometimes the other opposite eyelid may appear to have more excess skin, and may benefit from or require surgery. However, in the vast majority of cases, both eyelids undergo surgery at the same time.
- Lash numbness: the upper lashes and skin above the lashes may be numb for some weeks after the surgery. This is normal and recovers over about 2 months.
- Corneal abrasion: inadvertent damage to the eye, e.g. corneal abrasion, is very rare indeed, usually minor and heals without significant problems.
- Exposed sutures: sometimes dissolving sutures are placed beneath the skin and can become exposed in the weeks following surgery. If this happens, they are easily removed.