Upper and lower eyelid surgery with dry eyes
First of all, it is very important to document the extent of the dry eyes with a Schirmer's test done by your ophthalmologist. Secondly it's important not to take any strip of orbicularis oculi muscle when the upper lids are performed.Thirdly it's important to be conservative on amount of skin removal on the upper lids. In the rare event that you do end up with dry eyes, punctual plugs, eye lubricants and Restasis eyedrops can all help with dry eyes. For many examples, please see the length below to our eyelid photo gallery
Best surgical technique to avoid dry eyes after upper blepharoplasty
Dry eyes result from the eye aperture (the
lid opening) being too wide. As a result there is excessive evaporation of the tears
from the surface of the eyeball, especially in people who have a weakness of
tear film quality, which tends to occur with aging. Interference with a good
blink also contributes as the tear film is not evenly placed on the eyeball.
The standard technique of upper lid surgery
depends on removal of lid skin for its result. This is a risk, because it is
usually necessary to tighten the lid skin for it to be smooth. Whereas, when
the tarsal fixation technique is used, the desired aesthetic result is obtained
without depending on skin removal.
This is a point of key importance. The tarsal
fixation technique first contours the ‘apparent skin excess’ into the depth of
the lid crease. Only then can it be determined if there is any ‘true skin excess’,
which is removed. As a result, compared to a standard lid operation, less lid
skin, if any, removed. The remaining skin is stored in the lid fold and crease as
a functional reserve. As the upper lid
‘lengthens’, as occurs when looking down and in lid closure, this skin
reserve is automatically released so there is no interference with lid closure.
I am about to publish on a series of patients
who had secondary upper lid surgery, on average 8 years after their primary.
All had the tarsal fixation technique and not one of the 100 patients developed
Blepharoplasty and dry eye
The majority of patients do not get dry eye after surgery that is permanent. Sometimes patients have it initially due to the surgery. As the swelling subsides and the healing continues usually normal tear production and drainage improves. It is sometimes hard to predict, but some patients can be prone to it with some tearing issues. Schirmer's tests are not always accurate and can be an unreliable test. One key thing is to be conservative especially with the upper lids to avoid exposure at night or the inability to close with blink. Good luck.
Any surgeon who has never seen dry eye after eyelid surgery does not know what to look for.
In fairness, general plastic surgeons, facial plastic surgeons, dermatologists, basically any surgeon who is not board certified in ophthalmology, lacks the training, skill, and even the equipment to diagnose dry eye. So it should not be surprising that someone has posted the statement that eyelid surgery does not disturb the lacrimal gland. While that is true, it is simply not the reason people get dry eye after eyelid surgery.
I am a little discouraged that you are planning to have eyelid surgery with an oculoplastic surgeon but the surgeon did not perform a schirmer's test. While the Schirmer's test is not that great a test for predicting a post operative dry eye, it is an important diagnostic test that has some predictive value and it is very easy to perform. Not performing it is like cutting a corner. If you have had your preoperative assessment with this particular surgeon and they did not perform a Schirmer's test, you should be concerned about the diligence of the surgeon in my opinion.
There are very good strategies for avoiding dry eye. First is deciding if the eyelid surgery is even needed at this time or if there are non-surgical options for accomplishing you goals. Second there are excellent surgical strategies to minimize the risk of post surgical dry eye. Dry eye after surgery has nothing to do with disturbing the lacrimal gland at the time of surgery. It has everything to do with compromising orbicularis oclui muscle function by surgery. When incisions are made through the orbicularis oclui muscle, the function of this muscle is eyelid closure and it can be permanently effected by surgery. For individuals very concerned about or at risk for dry eye, depending on your surgical needs, the best option is to avoid procedures that cut through the orbicularis oculi muscle: Skin only lower and upper eyelid surgery preserving the orbicularis oculi muscle. Other options include lower eyelid transconjunctival surgery or chemical peels to remove lower eyelid rhytids.
Dry eyes from Blepharoplasty
The only sure way of avoiding this possible complication is to not have the surgery. Less than that, you can ask the surgeon to be conservative and not remove too much skin. A temporary tarsorraphy stitch will also help ensure good eyelid closure in the early healing phase. Use a lot of artificial tears after surgery.
Permanent Dry Eyes Rare
If you have extremely dry eyes, possibly it is best to do just upper or lower separately and see how you do. If your eyes are normal you can do both. The actual glands producing tears are not or should not be disturbed during eyelid surgery, but nevertheless there can be a temporary decrease in tear production. In 30 years I have never seen a permanent dry eye situation in over 1500 surgeries but it has been reported. I am not a fan of transconjuctival eyelid surgery because in general this is a procedure done with removal of fat. Fat removal produces hollowness sooner or later. The fat puffs are not excess fat but rather normal fat that is showing because of slight herniation or because your normal fat has atrophied a bit showing the periorbital fat as puffs. You should have fat removed only if you have true congenital excess of orbital fat (RARE). Consider getting 3 opinions about your surgery and then proceed as you see fit. My Best, Dr C