What eyelid surgery does, how upper and lower blepharoplasty differ, and what to expect.

With age, the eyelid skin stretches, the muscle relaxes and the fat that cushions the eye can bulge forward, which produces hooding of the upper lids and bags beneath the lower lids.^1,7 Blepharoplasty treats these changes. Modern technique restores a youthful shape and preserves fat rather than removing it aggressively, which once left a hollow, unnatural look.¹

Eyelid surgery does not lift a low eyebrow, correct a drooping eyelid muscle or erase fine wrinkles at the corners of the eyes. A low brow calls for a brow lift, a drooping lid margin for ptosis repair, and fine lines for treatments such as neuromodulators, peels or lasers.^1,2

Candidates have excess upper eyelid skin, under-eye bags or both, in good general health. The evaluation checks vision, eyelid position and tone, brow position, dry eye, thyroid disease and any previous refractive surgery, since these change the plan and the risks.¹

Some people have a medical need. Upper eyelid skin can hang over the lashes and block the upper field of vision, and textbooks describe functional criteria such as loss of the superior visual field of 12 degrees or more.¹ In a cost analysis, upper blepharoplasty for symptomatic excess skin was a highly cost-effective treatment.⁸

Risk is higher with existing dry eye, a lax lower lid, eyes that sit forward relative to the cheek, previous eyelid surgery and blood thinners.^7,9 High blood pressure is the most common risk factor for vision loss after eyelid surgery.⁵

In the upper lid, the evidence favors conserving tissue. A systematic review found that removing the orbicularis muscle with the skin gave no better long-term result and caused more early swelling, bruising, dry eye and slow eye closure.¹⁰ Fat is preserved or even added in the upper lid to avoid a hollow upper eyelid.¹

In the lower lid, the goal is a smooth transition from eyelid to cheek. Bulging fat can be conservatively trimmed, released or moved into the hollow of the tear trough, and small amounts of fat grafting can restore lost volume.^1,13 When the lower lid is loose, it is tightened at the outer corner with a canthopexy or canthoplasty to reduce the risk of the lid pulling down.^1,7

• Anesthesia: Eyelid surgery can be done under local anesthesia, with or without sedation, or under general anesthesia.²
• Markings: The upper lid incision is marked in the natural eyelid crease so the scar is hidden when the eyes are open.¹
• Upper Lid: Excess skin is removed, with limited or no muscle or fat removal.¹
• Lower Lid: Through an incision inside the lid or just below the lashes, fat is trimmed, released or repositioned, and the lid is supported if lax.^1,7
• Bleeding Control: Careful hemostasis at the base of the fat pads and gentle handling of the fat lower the risk of bleeding behind the eye.¹
• Closure: Fine sutures close the skin and are usually removed at about 4 - 7 days.^1,2

Blood pressure control matters before, during and after surgery. In a series of 32 patients whose systolic pressure was kept below 120 mmHg, there were no hematomas, including patients on blood thinners.¹⁴ Tranexamic acid reduced bruising and shortened recovery by about 0.7 days in a meta-analysis of 5 randomized trials.¹⁵

Recovery milestones come mainly from surgical textbooks and vary with the extent of surgery.^1,7

Mild difficulty closing the eyes completely, called lagophthalmos, and swelling of the clear lining of the eye, called chemosis, are common early and usually resolve with lubrication.¹ Contact lenses are usually avoided for a period after surgery.⁷

Most complications are minor and temporary, such as dryness, irritation and swelling, while structural problems such as lower lid retraction and rare serious problems such as bleeding behind the eye and vision loss are less common.⁹

Bleeding behind the orbital septum is the most feared complication because pressure can damage the optic nerve. It causes severe pain, pressure, a bulging eye and reduced vision, and is treated as an emergency by opening the incision and, if needed, releasing the outer corner of the eyelid.¹ In the survey of 752,816 operations, symptoms appeared within 24 hours, peaking in the first hour and again 6 - 12 hours after surgery.⁵

Lower lid malposition ranges from slight white showing below the iris to an outward-turned lid. Recognizing a lax lid before surgery and supporting it reduces the risk.⁷ In 100 consecutive transcutaneous lower lid operations, the lid moved down by about 0.33 mm on average, and 2 patients needed revision.¹¹

Upper blepharoplasty improves function as well as appearance. Systematic reviews report a wider field of vision, fewer headaches and better vision-related quality of life, and an American Academy of Ophthalmology review found that quality of life gains persisted for several years.^3,17 In randomized trials, dry eye symptoms decreased after upper blepharoplasty, with an odds ratio of 0.22.⁴

Satisfaction depends mostly on how patients see the result. In 583 patients, the FACE-Q appearance score after surgery explained far more of satisfaction than age, sex or surgeon-rated outcomes.¹⁸ Results are long-lasting, but the eyelids, brows and cheeks continue to age.¹

Nonsurgical options can soften some changes around the eyes. Neuromodulators, peels, lasers and fillers treat lines, skin quality and hollowness, and a brow lift treats hooding caused by a low brow rather than excess eyelid skin.¹ These options do not remove excess skin or bulging fat.^1,7

• Dry Eye Over Time: Studies disagree on how blepharoplasty affects the tear film in the long term.^3,17
• Best Lower Lid Technique: Most lower lid techniques are described in single-surgeon series with few direct comparisons.^9,12
• True Hemorrhage Rate: Serious bleeding is rare enough that rates come from surveys and small series.⁵
• Tranexamic Acid: The best dose and route for eyelid surgery are not established.¹⁵