Eyelid Surgery 101: The Ultimate Guide to the Transformative Procedure

Eyelid Surgery 101: The Ultimate Guide to the Transformative Procedure featured image
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In my 10-plus years at NewBeauty, I’ve seen a lot of dramatic before-and-after photos, and blepharoplasty (aka eyelid surgery) cases have always stood out as some of the most incredible transformations. A person’s eyes say a lot about them—they are the windows to the soul, after all—and when their appearance doesn’t reflect how a person feels on the inside, it can belittle self-confidence and change how others perceive them.

One of the most common complaints surgeons hear from patients is “I look tired,” whether that’s due to sagging upper eyelids, protruding fat in the lower eyelids, or a combination of both. But in the right hands (a qualified, board-certified plastic surgeon with plenty of experience), cosmetic eyelid surgery can not only make you look wide-awake, but also turn back the clock. Here’s what to know about eyelid surgery, according to top surgeons.

What is blepharoplasty?

“The word blepharoplasty is derived from the Greek words blepharon, meaning eyelid, and plastos, meaning formed,” explains San Diego oculoplastic surgeon Allison McCoy, MD. “Blepharoplasty is a type of plastic surgery that rejuvenates the upper eyelids, lower eyelids, or both, in order to improve appearance and vision. An upper eyelid blepharoplasty involves removal of excess eyelid skin with sculpting or repositioning eyelid fat, as needed. A lower eyelid blepharoplasty involves altering the fat, muscle and/or skin below the eye to restore a smooth, youthful contour.”

Woodbury, NY oculoplastic surgeon David Schlessinger, MD says blepharoplasty is the medical term for eyelid surgery. “The procedure is often performed with the objective of restoring a youthful appearance to the eyes by altering the shape or function of the eyelid. A large part of my practice involves removing eyelid bags of the upper or lower eyelids.”

Eyelid surgery can be cosmetic or functional, but blepharoplasty is predominantly cosmetic. “Blepharoplasty—upper or lower—is primarily for cosmetic changes and improvements involving excess skin that develops as the eyelids and the skin around the ocular area stretch,” explains Beverly Hills, CA oculoplastic surgeon Raymond Douglas, MD. In some cases, saggy upper eyelids can impair the patient’s field of vision, and therefore the blepharoplasty would be considered a functional procedure.

What are the most common reasons people seek out eyelid surgery?

The eyes often show the first visible signs of premature aging because the skin is thinnest around the eyes. Patients either want to lift droopy eyelids or remove under-eye bags, says Dr. Schlessinger, noting that almost anyone who needs it is a candidate (except those on blood thinners who can’t safety stop taking them). “Genetics, aging, muscle atrophy, skin laxity, and fat and collagen loss from the brow bone all contribute to excess skin on the upper eyelid dropping down to the lash line,” Dr. Douglas explains.

“Over time, the muscles supporting the upper lids and a breakdown of collagen and elastin in the dermis, as well as rubbing, contact wearing, makeup application, and exposure to UV rays, contribute to free-radical damage and loss of dermal structure,” Dr. Douglas continues. “As a result, both excess skin and adipose movement can become prominent, gathering below the lids and presenting in heaviness or sagging in the brows, drooping lids and bulges or bags underneath the eyes.” Upper or lower blepharoplasty will correct these issues.

Who is a good candidate for blepharoplasty?

Good candidates for upper blepharoplasty are people who have sagging skin of their upper eyelids that are hooding over their lashes, affecting their vision, causing unwanted wrinkles, or in some cases, making it difficult to put on eye makeup or mascara, says Dr. Douglas. “For lower lid blepharoplasty, the best candidates are patients who have prolapse or herniation of their lower lid fat bags, also known as lower lid bags,” he explains. If they need it, patients can also choose to do both an upper and lower blepharoplasty in tandem.

“Unfortunately, nationally, blepharoplasty is the highest revision surgery behind rhinoplasty,” Dr. Douglas adds. “When done right, however, it’s still a great option for patients who want a more refreshed look to their eyelids. Both the candidacy of the patient and the skill of the surgeon matter.”

What does blepharoplasty surgery involve, and what is the recovery like?

During an upper blepharoplasty, the surgeon cuts into the crease of the eyelids to eliminate the excess skin and then stitches up the area. “Stitches are most often dissolvable, however if they are not, they are removed in approximately a week to 10 days,” says Dr. Douglas. There are varying degrees of upper blepharoplasty depending on the extent of the skin laxity: “Moderate is a crescent pinch of skin; Medium involves a greater amount of excess skin and fat; and Severe may include a ptosis correction, which means cutting and shortening the eyelid muscle,” Dr. Douglas explains.

“Lower lid blepharoplasty techniques most commonly reposition the fat, creating an improved contour to the cheek,” says Dr. Douglas. “In cases where there is excess skin and laxity, a small skin pinch procedure can be performed just under the lash line to remove excess skin.”

Dr. Schlessinger says the surgery is usually done under local anesthesia or sedation. “It is usually painless,” he adds. “The recovery is also quick and painless. We recommend no heavy physical activities for two weeks after surgery to avoid complications.” Most patients can return to work and social activities after a week or two (some may need three), depending on the degree of the surgery and resulting healing.

The eyes may be bruised and the eyelids may be swollen for a few days to a few weeks. “The area may be sore, tight and itchy during that time period as well,” Dr. Douglas says. “The eyes may be sensitive to light or continue to water, too. Medication can be given for any pain, and it is important not to irritate the area.

What are the risks associated with blepharoplasty, and how can they be minimized?

According to Dr. Schlessinger, blepharoplasty is remarkably safe. “Although bleeding and infections can occur, these are very rare,” he says. “We recommend avoiding blood thinners such as Aleve or aspirin around the time of surgery. Avoiding alcohol, smoking and sun exposure also reduces the risk of complication. In general, after eyelid surgery, you should rest and ice. We give an extensive list of instructions to our patients to insure a quick recovery.”

To minimize your risk for complications, make sure to do thorough research when selecting a provider. “You should only choose an experienced board-certified surgeon who does a lot of eyelid surgery,” says Dr. Schlessinger. “Oculoplastic surgeons are an excellent choice, as they specialize in eyelid surgery.” Facial plastic surgeons and plastic surgeons are also trained in this procedure, but may focus on other parts of the face or body, so asking to see before-and-after images of recent cases can be helpful.

If too much fat is removed, Dr. Douglas says the eyes can look hollow. “If too much skin is taken from the upper lid, it can result in the patient looking startled or too taught,” he adds. “This can also cause incorrect lid positioning or a retracted lid. Other complications include asymmetry in the eyes, changing the shape of the eye and the ability to close both eyelids properly.”

What are some alternative treatments to blepharoplasty for those who aren’t ready for surgery?

For patients with droopy lids (aka ptosis), Dr. Schlessinger says it can be temporarily treated with Upneeq, a first-of-its-kind, FDA-approved, prescription eye drop that lifts the upper eyelids to open the eyes. “It’s a simple and safe daily drop, and a very good way to test the waters or push back surgery for one to five, or even more, years,” adds Dr. Douglas.

Other options Dr. Douglas considers for certain patients are an eyebrow thread lift, which can help temporarily remedy a droopy lid; PlasmaPen treatments for mild laxity on the lids; radio-frequency (RF) microneedling; and Tixel. “With PlasmaPen, scarring is possible if post-care instructions are not followed, as they help with the scab formation, healing and sloughing off,” he explains. “RF microneedling with Vivace Ultra is a great way to tighten tissue and help with collagenesis in an area that’s super difficult to ‘tone,’ and Tixel provides similar benefits, with the addition of helping with dry eyes, so there will be less rubbing and irritation.”

Dr. McCoy also uses “neurotoxin injections to lift the lateral eyebrow, which can give a temporary, modest improvement in eyelid drooping for the outer portion of the eyes. This is repeated every 10 to 12 weeks to maintain the results,” she says. “In patients who have brow drooping due to genetics, aging or weight loss, surgery to lift the brows can simultaneous improve the appearance of the eyes and eyelids. Browlifting and blepharoplasty are complementary procedures that can be done separately or together, depending on a person’s unique anatomy.” 

Dr. Schlessinger notes, however, that “if you have truly heavy eyelids and/or protruding fat bags, then there is no substitute for surgery.”

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