Blepharoplasty (eyelid surgery) is a cosmetic procedure that removes excess fat, skin and muscle from the upper and lower eyelids to create a younger appearance around the eye area. It may also be performed to correct puffy or baggy eyes that often develop as a person ages. Blepharoplasty does not remove black circles or wrinkles around the eye (crow’s feet), or lift sagging eyebrows. Patients often have other closely related cosmetic procedures, such as a browlift or facelift, performed at the same time.

There are two types of blepharoplasty. The most common type is called transconjunctival blepharoplasty and involves an incision in the inside of the lower eyelid (transconjunctival) to remove excess fat, but not skin, from beneath the eye. However, transcutaneous blepharoplasty (incision made through the skin) is necessary to treat the upper eyelids, as well as the lower eyelids in cases where loose or excess skin is present.

Prior to surgery, the physician will take a patient’s complete medical history and closely inspect the eyes (ocular examination) as part of a complete physical examination. Among other topics, the physician will discuss the patient's goals and anticipated results.   

Blepharoplasty is usually performed on an outpatient basis under local anesthesia (patient is awake) that numbs the area around the eyes. Depending on the type and extent of the procedure, blepharoplasty usually takes between one and three hours to perform.

In most instances, blepharoplasty enhances the patient’s appearance and self-confidence. However, there is always a risk that the procedure will produce undesirable results or that complications may occur (e.g., dry eye syndrome).

Blepharoplasty is a procedure in which excess fat, skin and/or muscle from the upper and lower eyelids are removed to create a more youthful appearance around the eye area. This cosmetic procedure is performed to correct droopy, puffy and baggy eyelids that commonly develop in many people with age. Blepharoplasty does not remove wrinkles (crow’s feet) or black circles around the eye, or lift sagging eyebrows.

Blepharoplasty is among the most common cosmetic surgeries performed in the United States, with over 230,000 procedures performed in 2006, according to the American Society of Plastic Surgeons. Blepharoplasty is usually considered elective (or optional), unless sagging eyelids impede vision. Otherwise, it is typically performed to minimize the effects of aging around the eyes.

Baggy or puffy eyes and droopy eyelids (medically known as ptosis) are common as people grow older. This process usually begins in the late 30s or early 40s, as eyelids begins to stretch, facial muscles weaken and excess fat accumulates above and below the eyelids. A number of other factors contribute to droopy eyelids and baggy eyes, including:

• Genetics
• The act of blinking
• Gravity
• Rubbing the eyes
• The sun
• Allergies

Baggy or sagging eyelids may first appear in the morning and then gradually occur throughout the day, making a person appear tired. In some cases, droopy eyelids may interfere with vision, which can be corrected with blepharoplasty.

This procedure may be performed on the upper eyelids, lower eyelids or both, and takes between one and three hours (depending on the technique and the extent of surgery). It is performed in a physician's office, hospital or outpatient surgery center.

Blepharoplasty may be performed alone, but is also frequently accompanied by other facial cosmetic surgeries, which can offer a smoother appearance. Because a sagging brow or face often contributes to the appearance of droopy eyelids, a browlift or facelift may also be performed along with blepharoplasty. 

In many cases, patients who believe they require blepharoplasty would see better results if a browlift were performed instead. This is especially true for patients who have a large overhang in the upper eyelids.

There are two main types of blepharoplasty: transconjunctival (incision made through the inside of the eyelid) and transcutaneous (incision made through the outer skin).  

Transconjunctival blepharoplasty is performed most frequently to remove bulging fat from beneath the eyes (“bags”), and does not typically involve the removal of skin. In some instances, some or all of the bulging fat beneath the eyes may also be transferred to more bony areas of the face to achieve a fuller appearance.

A transconjunctival blepharoplasty is performed by pulling the lower eyelid away from the eyeball, and removing or repositioning the fat. The physician may close the incision with one or two dissolving sutures. However, sutures or stitches are often not necessary.

Transconjunctival blepharoplasty is more often performed on younger patients whose skin is thicker and more elastic.

During a transcutaneous blepharoplasty, the surgeon makes incisions in areas of the lids where scarring will be the least noticeable. Typically, this is in the creases of the upper lids and just below the lashes of the lower lids. The incisions may extend outward to wrinkles or crow’s feet on the outer edges of the eyes if sagging or drooping is especially significant. Using a scalpel or laser instrument, the physician separates skin from the connected muscle and fatty tissue. The excess fat is then removed and the loose skin and muscle are trimmed. The incision is then closed with a few small stitches or sutures.

Transcutaneous blepharoplasty of the upper eyelids is particularly common among Asian women born without an upper eyelid crease (Asian blepharoplasty).

Blepharoplasty requires greater attention to detail than many plastic and reconstructive surgeries due to its close proximity to the eyes. The physician will take a patient’s complete medical history, including current over-the-counter or prescription medications, any allergies or reactions to medications or anesthesia, prior illnesses, injuries or procedures and lifestyle habits (e.g., alcohol or cigarette use).

Physicians will instruct patients to stop taking all antiinflammatory medications, including aspirin, ibuprofen and Vitamin E supplements, as well as certain herbs (e.g., St. John’s wort, garlic, Ginkgo biloba), two weeks before the procedure. These drugs and supplements can cause bleeding. Alcohol should also be avoided prior to surgery because it may cause increased bruising. Individuals who smoke will be instructed to stop smoking before the surgery. In addition, the skin may need to be protected from sunlight the week before surgery to avoid discoloration.

Some conditions may make the procedure more risky. These include thyroid disorders, dry eye and circulatory and cardiovascular disorders (e.g., high blood pressure, heart disease, diabetes). In addition, a detached retina or glaucoma also increases the risk of complications. Glaucoma is a group of diseases that affect the optic nerve, which connects the eye to the brain, and typically involves gradually increased pressure inside the eye. People who are considering blepharoplasty should first speak with their ophthalmologist (physician specializing in eyes and vision).

The patient’s eyes will be closely inspected (ocular examination) as part of the complete physical examination performed by the physician. This helps gauge the patient’s ability to distinguish detail and shape (visual acuity) before and after the procedure.

The upper and lower eyelids are examined to check for the quality and quantity of skin, location of folds, drooping, looseness and other aspects that may influence how the procedure will be performed. The physician and patient should discuss in detail the patient's goals and expectations.

The patient may be asked to look in a mirror and describe what they dislike about their appearance. This helps clearly define what is troubling the patient cosmetically as well as what method of blepharoplasty will be the safest and most effective.

The physician will need to discuss with the patient any additional procedures that may also be necessary along with blepharoplasty to correct sagging eyelids (e.g., browlift). Prior to undergoing blepharoplasty, the appearance of the patient is documented with photographs.

Blepharoplasty may be performed in a physician’s office, a surgery center or a hospital. It is usually performed on an outpatient basis while the patient is awake. A local anesthesia that numbs the area around the eyes will be administered. Oral or intravenous sedatives may be given as well. General anesthesia (patient is asleep) may also be used if several additional procedures are going to be performed.

Blepharoplasty is usually painless, though a pulling sensation or feeling of uneasiness may be experienced by some patients. Depending on the extent of the procedure, blepharoplasty usually takes between one and three hours to perform. If both of the eyelids are being treated at the same time, the operating physician typically addresses the upper lids first.

A transconjunctival blepharoplasty is performed differently than a transcutaneous blepharoplasty, and applies only to the lower eyelid. During this procedure, the incision is made inside the interior of the lower eyelid and excess fat is removed.

A transconjunctival blepharoplasty can be performed either with a scalpel, with electrocautery (an instrument with a very hot tip that is heated by electricity), or with laser technology. Electrocautery is generally preferred because it is more precise and is less disruptive to the internal tissues of the eye. The major advantage of using a laser to make the incision is that it causes no bleeding. However, this technology is relatively recent and may not be as widely used.

Following transconjunctival blepharoplasty, the incision may be closed with one or two dissolvable sutures. However, many times this is unnecessary and the cut is left slightly open. The surgical scar from the incision remains beneath the skin forever and is unnoticeable to the patient or others.

Transcutaneous (through the skin of the eyelid) blepharoplasty is most commonly used for surgeries of the upper eyelid, though it is used frequently for lower eyelid blepharoplasty as well.

Transcutaneous blepharoplasty of the upper eyelid begins with the physician marking the area of the skin where the incision is to be made with indelible ink. Because the skin folds back naturally when the upper eyelid opens, a greater area of skin may need to be removed than during a lower eyelid procedure.

After local anesthetic is applied evenly throughout the upper eyelid, the incision is then made either with a scalpel, electrocautery or laser, and a section of the skin and the underlying fat is removed. Any excess skin that remains is then trimmed and stitched or sutured closed. While this occurs, the patient may be asked to open and close their eyes to ensure the eyes are aligned evenly and look natural.

At the end of blepharoplasty, the eye is typically wetted thoroughly with saline solution or a lubricating ointment for protective purposes. The operating physician will then cover the eye area with a small bandage. Ice packs may also be applied to minimize swelling. In most cases, the patient can be taken home from the hospital the day of surgery. However, some patients may be required to stay overnight in the hospital or surgery center. Patients should make prior arrangements to have someone drive them home.

Careful monitoring of patients immediately after surgery can help identify and correct any possible problems. In addition, photographs taken following blepharoplasty will reveal any problems that may not be obvious during an examination. Patients may be examined weekly in the initial weeks after surgery. Over time, however, examinations only once or twice yearly are often sufficient.

If non-dissolvable stitches or sutures are used, they can usually be removed within about three to seven days, depending on which type of blepharoplasty is performed. However, both the patient and surgeon must wait several weeks or months for healing to occur and to judge the success of the procedure. Scars from blepharoplasty may take as long as three to six months to recede. But once this occurs they are usually unnoticeable.

As the anesthesia wears off following the surgery, patients may begin to feel tightness and tenderness in the eyelids. The eyes may also feel sticky or gummy for the first couple of weeks. Patients will be given instructions on how to properly clean the eyes. Eyedrops may also be used to relieve dryness, burning and itching.

Other temporary difficulties commonly experienced following blepharoplasty include:

• Blurred or double-vision. Usually caused by ointment or drops that are applied to the eyes during and after surgery.
  
  
• Numbness, swelling, puffiness or discoloration of the eyelids or eye area. Ice packs may be applied to help minimize swelling and bruising. Cold compresses also help guard against excessive fluid collection in tissues surrounding the eye (edema). Physicians may also recommend taking Arnica, a type of herb, to help decrease bruising. These difficulties usually go away within two to three weeks following surgery. Patients with excess coloring (pigmentation) of the skin should avoid sun exposure until skin tone returns to normal.
  
  
• Pain. Usually moderate and manageable with over-the-counter nonaspirin pain relievers.
  
  
• Excessive tearing. Exposure of the glands that produce tears (lacrimal glands) following blepharoplasty can cause this to occur. However, it is relatively common and usually lasts only temporarily.
  
  
• Light sensitivity (photophobia).  Eyes may be sensitive to sun or exposure to bright light for a few days following blepharoplasty.

Patients should seek immediate medical attention if any of these symptoms persist for longer than what is considered normal by the operating physician as they may indicate much more serious complications.

In addition, patients may be advised to take certain precautions for the first week after surgery. Such measures often help to speed up recovery and minimize the risk of complications. They include:

• Not lifting more than 20 pounds at a time
  
  
• Not bending from the waist unless knees are flexed
  
  
• Avoiding swimming, aerobics, jogging or other strenuous activities
  
  
• Using conservative head and neck movements
  
  
• Sleeping with the head elevated higher than the chest
  
  
• Not wearing contacts for at least two weeks
  
  
• Not using cosmetics for at least 10 days to avoid an allergic reaction

Patients may also be advised to avoid alcohol and nicotine.

Most patients can return to work and other daily activities in about seven to 10 days. Since people are often sensitive to sunlight and wind in the weeks following the procedure, patients may benefit from wearing sunglasses during this time. Patients may also be advised to wear a specially formulated sunscreen to protect the eyelid area when spending time outdoors.

In most instances, blepharoplasty improves the patient’s appearance. A well-performed blepharoplasty reduces the appearance of fatigue and age. In some cases, vision may improve if a drooping eyelid interfered with the patient's sight. The results of blepharoplasty can last for several years, and for many they are permanent.

Blepharoplasty is usually performed successfully without harming the patient. However, there is always a risk that the results will be cosmetically unappealing to the patient. Many aesthetic complications can be fixed by performing the procedure again.

The most common aesthetic complications of blepharoplasty include:

• Uneven folds
  
  
• Folds that are too high or too low (e.g., drooping upper eyelid)
  
  
• Multiple folds
  
  
• A skeletal appearance under the eye due to excess fat removal
  
  
• Worsening of wrinkles and lines of the eyelid skin
  
  
• An uneven appearance when compared to the mid and lower face

Some of the most serious complications of blepharoplasty include:

• Blood clot behind the eyeball (retrobulbar hematoma). A rare but very serious complication of blepharoplasty. The most common symptom of this complication is typically a steady, stabbing pain similar to glaucoma (a group of diseases that affect the optic nerve, which connects the eye to the brain). Patients may also display dilated pupils (mydriasis), abnormal bulging of the eyeball out of the socket (proptosis), swelling around the eye (chemosis) or eye redness (conjunctival injection).
  
  
• Bleeding behind the eye (orbital hemorrhage). An orbital hemorrhage is the most worrisome complication of lower lid blepharoplasty as it can cause permanent blindness. Consequently, medications that help prevent clotting (e.g., anticoagulants, antiplatelets) are avoided by patients several days before surgery.
  
  
• Slowing of the rhythm of the heart (oculocardiac reflex). Occurs in many blepharoplasty patients who receive local anesthesia. Any manipulation of the eyes (e.g., compression) during blepharoplasty can trigger this reflex. Most patients experience a moderate decrease in heart rate. However, rare cases of severe slowing or stopping (arrest) of the heartbeat have been reported.
  
  
• Dry eye syndrome (keratoconjunctivitis sicca). Most often occurs in patients with tear (lacrimal) glands that are somehow impaired or abnormal turning out of an eyelid following surgery (postoperative ectropion). Patients with dry eye syndrome must consistently use artificial tears to keep the eyes moist.
  
  
• Exposed lining of the eyelid (ectropion). Temporary exposure of the eyelid is relatively common following lower eyelid blepharoplasty. However, permanent exposure following an arcus marginalis procedure (use of fat from around the eye to reconstruct soft tissue of the lower lids) may rarely occur. Skin grafting or corrective surgery (canthoplasty) may need to be performed to correct this problem if it persists longer than normally expected.
  
  
• Watering of the eye (epiphora). A common, temporary complication that occurs following surgery. This is usually caused by irritation of the cornea which triggers excess tearing (hyperlacrimation), and exposure of the eyelid which can widen the opening through which tears pass (punctum).
  
  
• Collections of fat under the eye. The most common complication following transconjunctival blepharoplasty. These typically appear as small, painful, hard growths or lumps (nodules). The use of compresses or massage usually makes them disappear more quickly. More stubborn cases may require steroid injections into the growth for them to subside. However, this method carries with it a risk of decreased muscle mass (atrophy) and coloring (hypopigmentation) around the eye.
  
  
• Facial nerve injury. This is a rare but serious complication, particularly for patients undergoing transcutaneous (through the skin) lower eyelid blepharoplasty. Injury to a facial nerve can cause eyes to appear uneven or permanent ectropion or lagophthalmos (inability of the eyelid to close completely).
  
  
• Double-vision (diplopia). This is usually caused by injury to the muscles that control eye movement (e.g., inferior oblique). However, this is a rare complication. Permanent vision problems caused by blepharoplasty are much less common than normal conditions that affect sight (e.g., cataracts).

In addition, certain preexisting medical conditions may make blepharoplasty more risky. They include:

• Abnormal thyroid hormone levels (e.g., hypothyroidism, Grave’s disease)
• Dry-eye syndrome
• High blood pressure
• Heart disease
• Diabetes

Preparing questions in advance can help patients to have more meaningful discussions with their physicians. Patients may wish to ask their doctors the following blepharoplasty-related questions:

1. Am I a good candidate for blepharoplasty?
   
   
2. Do you primarily perform transconjunctival or transcutaneous blepharoplasty? Which do you recommend for me and why?
   
   
3. Can you explain the procedure to me in detail?
   
   
4. What results can I expect from the procedure?
   
   
5. What risks will I face by undergoing the procedure?
   
   
6. Will I experience pain during or after the procedure?
   
   
7. Are there any other non-surgical methods that may be as effective for me as blepharoplasty?
   
   
8. Are there any special steps I should take to prepare for the procedure?
   
   
9. How long will it take before I can return to normal activities following blepharoplasty?
   
   
10. What additional cosmetic procedures besides blepharoplasty might I need to get the results I desire?