Blepharoplasty

The tired or heavy look around the eyes is rarely one thing. On the upper lids it is usually spare skin, sometimes a pocket of fat at the inner corner, and often a brow that has settled and is folding skin onto the lid. On the lower lids it is usually fullness from fat that has herniated from the eye socket, laxity of the lid itself, and the way the lid meets the cheek. The lid may also sit lower than it once did, either as a natural characteristic or as a change over time.

Upper eyelid blepharoplasty is therefore assessed with the position and shape of the brow, not in isolation. Lower eyelid blepharoplasty is analysed with the shape of the cheek and the cheekbones. Treating one surface and ignoring the neighbour is how an eyelid operation starts to look like an eyelid operation.

The aim of the upper eyelid operation is to reduce excess skin. That excess is only partly in the eyelid skin itself. Part of it is generated by the position of the eyebrows. A low brow, or a low tail of the brow, stacks skin onto the lid; taking that skin without looking at the brow can leave a lid that is tighter but still heavy, or a lid that has been emptied while the brow continues to sit low.

Frequently, in the inner corner of the upper eyelids, a pocket of fatty tissue herniates from the eye socket. It produces a fullness that can contrast with volume loss more centrally under the upper orbital rim. The plan is to reduce the skin excess, to deal with that inner-corner fat when it is part of the problem, and to leave an opener expression around the eyes — not a scooped, hollow one.

When the volume under the upper orbital rim is significantly deficient and the eyes already appear hollow, reducing more fat is the wrong move. Fat grafting to the upper orbital rim can then contribute to a softer contour. That is a volume decision, not an automatic extra.

The problems of the lower eyelid are related to laxity and to herniation of fatty tissue from the eye socket. They can also be related to a lower position of the lid — present as a natural characteristic, or acquired. The contour we are after is a smoother transition between the lower eyelid and the cheek, with the impression that the lid crease has moved up, the lid appears shorter, and the cheek appears to start higher.

There is more than one way to get there. The choice depends on the skin and on the natural support of the lid.

When the skin characteristics are good, but there is herniation and fullness because of orbital fat, the work can be done through the inside of the lower eyelid. That is the transconjunctival approach. There is no external scar.

Through that access we can reduce or redistribute the fat that is sitting as fullness, including the way that fat lies over the orbital rim. The fat is not treated as something to be cleared away as a matter of routine. Redistributing it over the rim is often what softens the step between lid and cheek. Taking too much is how a lower lid starts to look hollow years later.

If spare skin is part of the problem, that skin can be reduced with a skin-pinch technique, or with the more traditional external approach to lower eyelid blepharoplasty. Which of those is safer depends on the natural support of the lower eyelid. A lid that already sits low, or that has little reserve of tone, is not treated as if it were a tight, well-supported lid with a little spare skin.

In the majority of instances it is beneficial to add support at the outer corner of the lower eyelids. That support is a lateral canthopexy. It is there to control the position of the lid and to protect it during the healing phase, when downward tensions are accentuated by swelling and by the early rigidity of the scar tissue that forms. It is a protective step, not a separate cosmetic flourish.

A brow that is low will keep folding skin onto an upper lid that has just been reduced. In that situation a brow lift — endoscopic-assisted when the whole brow needs a composite movement, or a temporal lift when only the tail is low — belongs in the same conversation as the eyelids. The brow lift pages already describe that relationship; it is the same relationship read from the other direction.

A lower lid that is planned without looking at the cheek can leave a smooth lid sitting on a cheek that still drops away. When the mid-face and the jawline are part of what is disliked, a deep plane or short scar facelift may be the neighbour operation, not a substitute for the lids and not an automatic companion.

Eyelid surgery can be carried out on its own, or in the same sitting as a brow lift or a facelift. It is not bundled into a facelift by default. The examination decides. One practical limit from earlier practice writing still holds: lower eyelid surgery and a rhinoplasty in the same operation are often better separated, because bruising and swelling from the nose can make the lower lids more difficult to protect while they heal.

Shape and texture are different jobs. Blepharoplasty changes fold, fullness and the lid–cheek step. Fine crepe, sun damage and the quality of the skin itself are only partly helped by taking spare skin. Non-surgical tightening and skin care can sit beside the operation when the surface is the remaining complaint. That is the same shape-versus-texture distinction used on the facelift and neck pages.

Volume is not only something to remove. Central hollowing of the upper lid, a sharp orbital rim, and a tear-trough step that is more hollow than full are volume problems. Fat grafting to the upper orbital rim, or redistribution of lower-lid fat over the rim, is how those are addressed. Treating every fullness as excess is how eyelids are made to look older rather than rested.

The periocular area is a fine-detail zone. We examine the lids at rest and in motion, the brow position and shape, the inner-corner fat, the central upper-lid volume, the lower-lid tone and position, and the way the lid meets the cheek. Photographs help. Three-dimensional evaluation of the face is useful when the eyelids are being planned with the brow, the cheek or a facelift, because those neighbouring shapes are what the 3D model shows well. A simulation of the eyelids themselves is still a planning aid, not a promise of the outcome. Simulations differ from what surgery produces; that caveat is the same one used elsewhere in the practice.

Asymmetry is common. The two orbits are not built identically, and the two brows do not always move the same way. The plan is a better balance, not a claim that the two sides will match.

The procedure is carried out under local anaesthetic with intravenous sedation, or under general anaesthesia. It typically lasts about one hour for the upper eyelid procedure and about one hour for the lower. When both are done at the same sitting the times sit together; they are not doubled as a matter of billing language, they are two pieces of work.

In most instances the operation is a day case. An overnight stay is a setting decision when the eyelids are combined with other facial surgery, not the default for isolated blepharoplasty.

Naturally there will be questions, and you will want to meet the surgeon who would operate. Trust in that relationship is not a small part of the decision. Surgery is unique to each person; a detailed discussion and assessment are what allow advice to be personal rather than general.

We look at your medical history, medicines, previous eyelid, brow or facial procedures, dry-eye symptoms, and history of smoking. We look at the brows, the upper and lower lids, and the cheeks in motion as well as at rest. What you dislike has to be specific: heavy upper-lid skin, a bulge at the inner corner, a hollow under the brow, bags, a step between lid and cheek, or a lid that already sits low. Those are different operations, or different combinations.

Two points need particular weight. Blood thinners increase the risk of bleeding and have to be managed specifically around the operation. Raised blood pressure also increases the risk of bleeding, and needs the same special attention. Around the eyes a secondary bleed is not only a bruising inconvenience; it can affect the health of the eyes. Neither blood thinners nor raised blood pressure is a footnote to the medical history.

If isolated blepharoplasty is not the better course — because the brow is the main source of the upper-lid fold, because the lower lid needs support it does not have, because the cheek or jawline is the real complaint, or because the safer option is to wait — that should be said directly.

No operation is planned from a website enquiry. Surgery requires assessment and discussion in person, often more than once. The written information after the consultation allows you to consider it in detail. Fees depend on whether the work is upper, lower or both, on any companion procedure, and on the setting; they are confirmed in writing for the plan that has actually been agreed.

After the surgery it is important to have a relaxed recovery. The first week is the period in which heart rate and blood pressure should not be driven up, and in which straining should be avoided. The reason is specific: a secondary bleed can have a negative impact on the health of the eyes. This is not general post-operative advice copied from another page; it is the aftercare that belongs to eyelid surgery.

Swelling and bruising around the lids are expected. The eyes can feel tight, watery or gritty. Sleeping with the head up and using the drops or ointment you are given are part of the first days. Help at home is wise if both upper and lower lids have been treated.

Where we use manual lymphatic drainage or hyperbaric oxygen after more extensive facial surgery, that is an adjunct described on those pages. Whether either is used after isolated blepharoplasty should be confirmed in the consultation rather than assumed from the facelift recovery notes.

No responsible account of eyelid surgery omits the fact that the operation sits next to the eye. Bruising, swelling, temporary tightness, asymmetry that was already there becoming more noticeable, a lid position that needs time to settle, and dryness are part of the ordinary conversation. Over-reduction of fat can hollow the lid. Under-support of a lax lower lid can let it sit lower during healing — which is why a canthopexy is so often included.

Bleeding after the operation is the risk that organises the first week. Infection is uncommon and is treated early if it is suspected. Changes in vision that are more than the blurring of ointment or swelling are a reason to get in touch without delay. A complete list is part of the written information after consultation, not a paragraph that pretends to replace that discussion.