Eyelid Lift (Blepharoplasty)

As we age, the skin around our eyes becomes more lax and the tissues weaken. Additionally, there are changes in the surrounding bones and a loss of volume in the area. This can lead to issues like excess or drooping skin on the upper eyelids and bags underneath the eyes. Patients seeking a blepharoplasty may describe their eyes as appearing “tired” or “baggy,” or have general concerns of looking older than they would like to.

The goals of cosmetic eyelid surgery are to enhance the appearance of the eyes and create a more youthful, refreshed look. While many people opt to treat both the upper and lower eyelids simultaneously, “upper blepharoplasty” and “lower blepharoplasty” are distinct procedures. Upper blepharoplasty targets the hooding of the upper eyelid skin, whereas lower blepharoplasty addresses bulging fat and the tired appearance associated with aging in the lower eye and cheek areas.

As you and your surgeon discuss which procedure best suits your needs, you must be as transparent as possible regarding your desired outcomes. Try to use visual language to describe your eyelid concerns, such as “droopy,” “puffy,” “loose,” or “bags under the eyes.” Also be sure to ask about any functional concerns, such as impaired vision due to droopy eyelids. Any details you offer will help aid the surgeon in planning their surgical approach.

Comparison photos can be especially helpful. The surgeon should provide examples of their previous work, to demonstrate their aesthetic vision and show successful outcomes they achieved for patients with similar concerns.

Keep in mind that the brows and cheeks are adjacent structures that can also impact the eyes and affect the result of cosmetic eyelid surgery. The brows can deflate and droop, which may exaggerate areas of concern around the upper eyelids, while the cheeks may deflate and sag, impacting lower lid aesthetics. In many cases, the brows and cheeks can be addressed at the same time as a blepharoplasty as part of a holistic rejuvenation approach.

As noted above, there are significant differences between performing an upper eyelid lift and a lower eyelid lift surgery.

When performing an upper eyelid lift, a subtle incision is made in the natural crease of the upper eyelid. Excess skin, and in some cases muscle and fat, are modified conservatively to address the changes resulting from the aging process. (In recent years, more and more surgeons have been limiting the removal of fat and muscle in order to preserve a more natural appearance.) The upper eyelid incision is then closed with the finest sutures.

The surgeon’s artistic vision and surgical skill are crucial to the success of the procedure; they must accurately determine how much skin, fat, and muscle to modify, as well as orchestrate the placement and closure of the skin. As the incision heals, a scar is rarely visible due to the location in the natural eyelid crease.

In some cases, there may be a functional issue called ptosis (pronounced “TOH-sis”), which occurs when the muscles that lift the upper eyelid weaken, causing the eyelid to droop. This drooping can be so severe that the eyelashes can cover the pupils, obstructing vision.This condition requires a separate procedure called “ptosis repair”; it can be done simultaneously through the same incision made in an upper eyelid lift or through a separate incision internally.

Lower eyelid lifts can be done using two approaches.

With the “transconjunctival” approach, an incision is made through the inner surface of the lower eyelid; this technique is suitable when the primary aim is to address and redistribute fat “bags” from under the eye. The technique leaves no external scars and also minimizes the risk of complications and changes to the eyelid shape and position. External skin changes that occur as a result of the aging can, in most cases, be managed with laser resurfacing. Some surgeons use fat grafting to the cheeks to further refine outcomes.

The second approach involves the removal of lower eyelid skin and may be required if there is excessive skin laxity or an inflammatory condition called “malar edema” or “festoons.”  This approach is powerful but can potentially have long-term effects on the lower eyelid position, especially if the procedure is not done by an expert surgeon or is accompanied by lower lid tightening procedures.

Be sure to discuss all your options, along with possible outcomes and risks, with your surgeon.

Before you go

Before surgery, you should review your medical history with your surgeon. It is critical for them to be aware of any conditions that could affect the outcome of your blepharoplasty. This includes having dry eyes, excessive use of artificial tears, use of Visine and similar eye drops, a history of LASIK or cataract surgery, and any prior cosmetic procedures around the eyes and eyebrow areas.

Discuss your medications and supplement use; some may need to be temporarily stopped or augmented prior to surgery. You should, for example, avoid taking aspirin and anti-inflammatory drugs, as they can increase bleeding and bruising. As with any surgery, it is advised to stop smoking several weeks prior to the procedure. You should also plan for someone to drive you home and stay with you for at least the first few days of your recovery.

Finally, prioritize clear communication with your surgeon. Discussing your aesthetic goals, risks of blepharoplasty and possible alternatives are all critical to obtaining the best possible outcomes.

During the procedure

Blepharoplasty can be performed under local anesthesia, sedation or general anesthesia. In any case, you can expect the procedure itself to be pain-free. You can also expect to go home the same day as your procedure (though someone else will need to drive you).

If you are having an upper eyelid lift surgery, your surgeon will make an incision along the natural crease of the upper eyelid to modify excess skin, fat, and muscle. The incision will be closed with very fine sutures, which typically do not leave any visible scar.

If you are having a “transconjunctival” lower eyelid lift, the surgeon will make an incision through the inner surface of the lower eyelid. They will then remove or redistribute the bulging fat to reduce shadows and puffiness under the eyes without leaving any visible scars.

Your surgeon may recommend “fat repositioning” with lower blepharoplasty to address under-eye puffiness and hollowness (tear trough deformity) by redistributing excess fat to the upper cheek area. Additionally, laser resurfacing and fat grafting may be needed to improve the skin and address hollowness in the cheek area.

A “transcutaneous” lower blepharoplasty involves making an incision just below the lash line to remove excess skin, muscle, and bulging fat. Additionally, a tightening procedure, such as a canthopexy or canthoplasty, may be performed on the lower eyelid tendon to minimize post-procedure complications and enhance the results. The incision typically heals extremely well, but this approach is more involved than transconjunctival blepharoplasty.

Aftercare

Upon completion of the procedure, you will be taken to a recovery area. Your incisions may be covered with ointment. Before returning home, you will be provided with post-operative care instructions, medications, if needed, and instructions for a follow-up appointment.

The recovery period usually lasts for a few days to weeks. In the period immediately after surgery, it is essential to keep the incision wounds clean, to avoid strenuous activities (in order to allow for proper healing), and to lubricate your eyes with drops or ointments.

Bruising and swelling around the eyes are common and can last several days and, rarely, longer before subsiding. You may experience some discomfort; depending on the severity, this can be managed with over-the-counter medication acetaminophen (Tylenol) or with a prescription from your surgeon. You should avoid ibuprofen and other non-steroidal pain medications in the first two weeks as they may increase the risk of bleeding and bruising. As with all other surgical procedures, eyelid surgery has a small risk of bleeding or hematoma (localized collection of blood). If you experience significant pain, changes in vision, or eye bulging, contact your physician immediately, as urgent intervention may be needed to prevent long-term issues.

You will typically be seen for a follow-up the day after, a week after, and a month after surgery.