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The skin loses its elasticity and our muscles slacken with age. For the eyelids this results is an accumulation of loose skin which collects as a fold in the upper lids and forms deepening creases in the lower lids. At the same time there is slackening of the muscle beneath the skin allowing the fat, which cushions the eyes in their sockets, to protrude forward to give the appearance of bagginess. In some families there is an inherited tendency for bags to develop during early adulthood before any skin changes.
The problems often seem worse in the morning particularly with prolonged stress and lack of sleep. Fluid that is normally distributed throughout the upright body during the day, tends at night to settle in areas where the skin is loose, such as the eyelids. Drooping of the eyelids is also an effect of the ageing process and aggravates the accumulation of the skin in the upper eyelids. Sometimes so much skin accumulates in the upper lids that it hangs over the eyelashes to obstruct vision.
Procedure
The principle of a blepharoplasty is simple. The excess skin of the eyelids is excised and at the same time fat, which causes bagginess, is removed.
The operation begins by marking the excess skin. On the upper lid this is done by finding the edge of the tarsal cartilage, the supporting cartilage of the upper eyelid, about 9-10 mm from the eyelashes. A line is then drawn to identify the lower edge of the skin, which will be removed. This line will eventually become the scar that remains on the eyelid. The excess skin of the upper eyelid is then marked out. On the lower eyelid the incision is drawn in the crow's feet so that the scar will replace an already existing crease. The incision may then be marked just below the lashes of the lower lid. On the upper lid the area marked out in this way is then removed. The fat pads are identified by applying gentle pressure to the lower eyelid and making small "stabs" incisions through the circular muscle, which surrounds the eye. On the upper lid there are usually two pads of fat. These are carefully cauterised (sealed), usually with heat, to avoid any bleeding behind the eye when they retract to their normal position. The upper eyelid incision is then closed with stitches. It is common to use a single long stitch, called a running stitch, on the upper eyelid.
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On the lower eyelid the skin is dissected away from the underlying muscle. The fat pouches are identified by applying some pressure to the upper lid and removed using the "stab" technique mentioned above. On the lower eyelid there are usually three pads of fat. Again they are cauterised at their bases to avoid bleeding.
On the lower eyelid there are two modifications which may be made. The first is the use of a skin-muscle flap. Instead of going underneath the skin the surgeon goes beneath the skin and the orbicularis muscle. These gives direct access to the fat pads and provides a thicker layer to the skin. It is used most often in younger patients who do not have a great deal of loose skin. Another method of removing excess fat, but not skin, from the lower lid is the Transconjunctival blepharoplasty. In this operation the incision is placed on the inside surface (the Conjuctiva) of the lower lid. This avoids a visible scar.
The operation is done under either local anaesthetic (you are awake) or general anaesthetic (you are asleep). It is a day surgery operation, which means that if you have the operation in the morning you can often be home by lunchtime.
After Surgery
Following surgery it would be best to keep your head elevated for a few days to reduce swelling. Cold compresses can also help. The surgeon will normally apply some suture strips or steri-strips. | 
