Procedures : Blepharoplasty

When should you consider Blepharoplasty and what can you expect?


Comments about blepharoplasty, or eyelid procedures, should be divided into upper eyelid surgery and lower eyelid surgery as they are distinctly different with regard to the indicated operation itself as well as the risks and benefits of the procedures.

  • Upper Eyelid – It is important in the consultation to determine the cause of upper eyelid fullness. It may be caused by brow descent, excess upper eyelid skin, or both.

    Eyelid skin is very thin and is contained within the orbit. Brow lid skin has fallen from the brow above the orbit into the orbit itself and is thicker. The various contributors to fullness are best determined at consultation. It is critical to move the brow back to its appropriate position before assessing eyelid skin.

  • Lower Eyelid – Surgery may address skin, muscle, fat, or a combination of all three. Skin may have fine wrinkles or frank folds. Muscle laxity, or excess muscle tissue, called muscle hypertrophy, must also be identified and corrected if present. Finally, puffy lower eyelids resulting from fat bulging creates not only puffiness but creates dark circles under the eyes by casting a shadow over the bulging fat.

Age range for eyelid procedures varies from patient to patient, but is usually one of the earliest areas of inquiry for cosmetic patients, as the eyelids begin to show signs of age typically before any other facial structure. Subtle differences can occur in the early to mid thirties, but typically most commonly occur in the late 30’s or early 40’s.

Goals: As is true of all facial surgery, the goal of any eyelid surgery would be to restore a more youthful appearance to the eyelids, yet maintain an un-operated, natural look.

Upper Eyelids

Goals of lower lid surgery are similar. Special care is taken to avoid removing too much lower lid fat, as hollowness can be counterproductive as mentioned above. At the consultation, assessment would be made of the patient’s desires. Attention is then given to whether excess skin, excess muscle, lax muscle, or excess fat is the problem, or even a combination of all of the above. A more youthful, natural appearing lower eyelid that appears un-operated upon remains the goal.

Pitfalls of lower lid surgery: The operated look in a lower eyelid would be a rounded lower lid that is pulled down somewhat, often referred to as the “Dallas dinner party look”. There are several key elements and technical details that are carried out in an effort to avoid this post operative appearance. Unless the patient specifically dictates a proposed change in appearance of the eyes, our goal is to not change the shape of the eye at all, but rather to maintain the shape of the eye, and to restore youthfulness and improve contour and smoothness. It is not the goal of lower eyelid procedure to remove all wrinkles! If one looks in the mirror and pulls down the eyelid until all the wrinkles are removed, the rounding is absolutely unavoidable. Therefore, my goal is to take out the excess skin, but not overly remove skin so as to achieve this rounding. Some wrinkles will be left on the lower eyelid skin, as a totally smooth lower eyelid appears unnatural in most cases and leads to complications as the acceptable margin of error is almost zero.

Technical highlights:

Typically an upper eyelid blepharoplasty technique does not vary much from patient to patient. The art is in how much skin, muscle, and fat to remove. Less muscle and fat is removed in the upper eyelid in patients who want to maintain a more full appearance. Aggressive fat and muscle removal is done in patients who desire a cleaner upper eyelid appearance. Overall in the last several years there has been a decrease in the amount of fat being removed in order to avoid hollowing as described above.

Lower Eyelid Blepharoplasty:

I currently have 5 different approaches to the lower lid and the technical nuances are beyond the scope of this discussion. Suffice it to say that one can simply take the fat out from an incision inside the eye that requires no suturing if fat is the only problem. Muscle excess needs to be addressed through an external incision, and subtle skin differences can be addressed by some laser tightening. If anything more than just minimal tightening of skin is required, then an external excision is used to carry out removal of this skin excess.

Temporary tightening of the lower eyelid (canthopexy) is commonly used in conjunction with many of these techniques so as to keep the eyelid supported during the early healing process. The tightness of the skin pulling on the lower lid, as well as the weight due to swelling in the lower lid, all have a tendency to pull the lower lid down, which as mentioned above, is one of the key long term changes we are trying to avoid. Therefore, a temporary tightening with an absorbable suture is carried out and may give a mild tight look to the lower eyelid for 2-3 weeks. This will be exemplified and shown precisely at the time of consultation. Let me assure you that any tight or Oriental look in a Caucasian eyelid is typically not desired and this suture will not cause that. This tightening is used to prevent the downward rounding of the eye that is the most common problem after lower lid blepharoplasty.

What are the complications from this procedure?

  • Dry Eyes: The eyelid procedures are typically fairly straightforward; however, they can be particularly bothersome in some patients, particularly those with dry eyes. It is critical to inform our office of any dry eye symptoms. It is also interesting to note that strangely enough one of the common hallmarks of dry eyes is teary or watery eyes, which seems counterintuitive, but is absolutely true. Even in patients without dry eyes it is not uncommon to temporarily have dry eye symptoms, which are exemplified by extreme sensitivity to bright sunlight, and tearing or watering eyes post operatively. This is usually short lived; however, a handful of patients each year may have a particular problem with dry eye symptoms after blepharoplasty, usually in conjunction with approaches of upper and lower blepharoplasty combined with brow lift and face lift. However, these issues are usually temporary and are ameliorated with liberal use of eye lubricants, ointments, and drops. In rare instances temporary contact lenses or temporary lachrymal duct plugs may be necessary, and these minor procedures can alleviate symptoms until swelling subsides and the tissues regain their strength.
  • Rounded, depressed lower eyelid: This depression is usually temporary due to swelling and muscle weakness, but may be permanent if unusual scarring occurs. Fortunately a long standing problem is rare and if it occurs is correctable.
  • Change in vision: With upper and lower eyelid surgery, and especially when used in combination with other procedures, the globe itself may swell. Any swelling changes the curvature of the eye and can result in temporary minor changes of vision, which interferes with reading or watching television post operatively. This is usually a temporary problem and resolves when the swelling itself resolves.

    Many patients have had Lasik surgery and this will not affect their surgical correction in the long term, although it may temporarily change your visual acuity during the acute swelling process.

  • Blindness: I have never seen blindness after blepharoplasty, although it has been reported in the literature a small number of times. It has almost uniformly been associated with the injection of local anesthetic behind a structure called the orbital septum, and this is avoided in my surgical approach, as some type of ventilation or IV anesthesia is used and preferred in my patient population so as to avoid the need to place local anesthesia in this location. (See information on Anesthesia)
  • Infection: A recent published article of over 3500 cases performed at Dallas Day Surgery Center reported an infection rate of .53%. This is well below the national average, although infection rates of 0% are impossible.
  • Bleeding: Excessive bleeding can occur in every operation and is slightly more common in face lifts , especially in men and repeat procedures. It is important to stop all Aspirin and anti-inflammatory medication prior to surgery for at least 2, and preferably 3, weeks.

What should you expect during recovery?

All information below is based on an average patient, including two standard deviations (95 % of all patients). Some patients fall outside these descriptions and will have a better or worse recovery than the average patient, for unexplained reasons.

Social Return – Upper blepharoplasty and simple lower blepharoplasty techniques in which the muscle is not addressed aggressively usually allow the patient to return to work within a few days if bleeding and bruising are not significant. However, the eyelid is a vascular structure and once bruising is noted there is no easy way to resolve this quickly and 10 days to 2 weeks are needed to resolve bruising.

Pain – Pain is usually not a significant problem with upper and lower blepharoplasty. It is more of a nuisance with the ointments and drops that need to be applied to the eyes in the first few days.

Drains – Drains are not used

Swelling – Steroid dose pack is given for 5 days and minimizes swelling in the first 48 hours. Maximal swelling typically occurs on the 3rd post operative day and begins to decrease on day 4 or 5.

Driving – You can resume driving when you can drive to the level you were able to preoperatively. This decision is up to you. You must be able to brake and respond quickly. You must be able to quickly and easily turn to eliminate your blind spot. When these conditions are met you may resume driving, and this typically occurs in the 2nd or 3rd week. It is obvious that one must be able to see with normal, acceptable visual acuity as would be accepted under any conditions. This must return before driving.

Answers about Anesthesia?

Many patients are adverse to general anesthesia and are scared of the concept in general. However, in most cases anesthesia where the airway is controlled is much safer than anesthesia in which the airway is not controlled. In almost all of our cases an IV is started and supplemental IV anesthesia is used to create a dream sleep. Depending on the procedure, the airway may be maintained through a new device called a Laryngeal Mask in which the tube is not placed down the throat but placed in the mouth itself and the airway is controlled adequately. In any procedure where the patient has to be turned to the prone or face down position this, without a doubt, requires a general endotracheal tube and general anesthesia to maintain the airway in this position. It is very safe if done in this manner. Most patients are comfortable knowing that they will not feel anything and the techniques described above create a pleasant experience in which they drift off to sleep and wake up when the procedure is over. We will be happy to provide you with an article published by our facility that describes this approach in greater detail. This article, possibly one of the largest outpatient experiences in the world, covers both our unparalleled success and low level of complications of the procedure. We are very proud of our record and I can assure you it is because we place safety at our highest premium.

Every patient has the option to choose the anesthetist. In most cases I use a nurse anesthetist that has been with us since the inception of our practice, and even before I began my practice. We use a very small number of nurse anesthetists, typically 1 or 2 that have been with us and have provided excellent care over the years. The biggest testimony we can offer is that these nurse anesthetists have taken care of our loved ones as well as our patients. We are also very proud to have an association with Dallas Anesthesiology Associates which is a group of anesthesiologists that I believe is unparalleled in their professionalism and ability. Either option is open to the patients. There is a cost difference and this can be discussed at the time of scheduling.

What are the costs?

We do not feel that it would be appropriate or ethical to post prices for procedures on the internet. We do, however, understand that cost is a factor you must consider. We would be happy to speak with you about this so that you may determine whether the procedure you are considering falls within your budget. Our pricing structure is based on the time, complexity, and surgical costs involved. Please feel free to call our office at 214-823-1978 and speak with Leah for more details.

Click here to see before and after photos of this procedure.