Dear Dr. Pat,

I am 54 years old and want to have surgery to correct the droopy skin of my upper eyelids and the puffy bags of my lower eyelids. People who know me well tell me that I look tired all the time even though I sleep well and am fortunately in good health. I am, as so many of us are these days, in a competitive job market and can not afford to be thought of as “tired.” I understand that eyelid surgery can result in dry eye, and I really would not want that. What are the chances that I will have this problem?

Sharon

Dear Sharon,

Many men and women choose to have eyelid surgery, or blepharoplasty, to correct the problems that you have just described. The eyelids themselves stretch as we get older, and the muscles that support the eyelid skin also weakens. This often allows fat to accumulate above and below the eyelids. This surgery is done not infrequently for functional change in vision when the skin hangs over the eyelashes and affects peripheral vision. The end result of this change in tissue of eyelids and under the eyes is often sagging eyebrows, drooping upper lids and bags under the eyes. We are delighted to introduce our readers to a new Medical Advisory Board member, Dr. Elizabeth Jelks, who after a successful first career as an emergency physician is now an expert on reconstructive eyelid and facial surgery, as well as cosmetic surgery. An expert in oculoplastic surgery, Dr. Jelks has co-authored medical journal articles and chapters related to oculoplastic surgery and conducts courses in the subject as well.

I have sent this question to Dr. Jelks for an opinion on this important question. It will be nice, Sharon, to look alert and to look as good as you feel!

Patricia Yarberry Allen

Dear Sharon,

Your question is a common one for patients considering having blepharoplasty. There is a misconception that blepharoplasty causes dry eye. In some patients, the surgery causes a response that affects the tear-producing glands, and this is perceived as “dry eye.”

There are multiple tear-producing glands in the conjunctiva, which is the thin tissue lining the eyelids and covering the white part of the eyeball. These various glands, plus the lacrimal gland at the outer top of the upper eyelid, produce three layers of the tear film.

• First, there is an inner mucinous layer that attaches to the cornea, a middle aqueous “watery” layer, and an outer oily layer that helps to keep the tear film together between blinks. These tear producing-glands are affected by the edema (swelling) and inflammatory response that occurs in the immediate post-operative period. When the glands are not producing normally, the result is tear-film dysfunction (TFD). This can result in blurry vision and sometimes sensations of irritation.
• Second, as we age the amount of tears we produce decreases; we are more sensitive to hot, dry climates, wind, airplane flights and similar situations. Thus, the older patient having a blepharoplasty may be prone to a period of tear film imbalance.
• And some patients would have a greater tendency to develop temporary post-operative tear film dysfunction: those with immune disorders such as thyroid disease and rheumatoid arthritis, patients with rosacea, and patients on medications such as anti-histamines and anti-depressants.

The blepharoplasty patient is evaluated pre-operatively to determine if there is any lid margin disease to be treated before surgery. We test for something known as the “tear break-up time,” a test that judges the stability of the tear film. If there are abnormalities, medication is available to treat the lid margin and stabilize the tear film prior to surgery.

As the post-operative edema and inflammation resolves, which takes the first several weeks, the tear film should return to its pre-operative baseline. All blepharoplasty incisions are designed to minimize damage to our tear-producing glands.

To summarize: No surgery is without potential risk. But if you choose a surgeon who is experienced and does many of these procedures on a regular basis, you are unlikely to have this problem.