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Blepharoplasty for women: Before & After

Blepharoplasty is one of the most common cosmetic surgical procedures performed worldwide.

The primary goals are to improve vision and to improve facial beauty by removing excess skin and fat from around the eyes please see my Blepharoplasty blog for more detailed information about this procedure.

 

However, to achieve these goals, we often find that blepharoplasty alone is insufficient. Many patients require adjunct procedures that are combined with blepharoplasty such as droopy eyelid surgery (ptosis surgery), brow-lifting (forehead lift), tendon-tightening, and or lacrimal gland repositioning. In order to give our readers a better understanding of these nuances when considering blepharoplasty or droopy eyelid surgery, 5 case examples of real patients are presented below. The clinical presentations are described with blepharoplasty before and after photographs to highlight the main points.

 

Blepharoplasty Case Studies

 

Case 1:

This 62-year-old lady presented to Eye Face Institute (EFI) with complaints of heavy upper eyelid skin that was making it difficult for her to read for long periods of time. Her job required that she spend 6-8 hours per day in front of a computer screen and it was getting difficult for her, especially towards the end of the day, to keep her focus. In addition, her friends and coworkers regularly asked whether she was feeling tired, even at times when she felt great. Some of them believed that her lower eyelids looked tired and the “bags” were present because she was working so hard and not getting enough sleep. During her consultation at EFI, she told us that she wanted to “see better, look better, and feel better”.

 

 

From the before photograph, we can see that our patient has lovely and bright eyes but these are shadowed over by the redundant upper and lower eyelid excess skin and the herniating fat pockets. There are clearly visible and deep tear troughs just below the lower eyelid fat pockets that are causing shadowing and a “hill-valley” contour, which makes the eyes look fatigued. Her eyebrows and forehead, however, are in a stable position with minimal descent. She does not need droopy eyelid surgery (ptosis surgery).

 

After her clinical examination, we discussed management options and she decided to proceed with quad (four eyelid) cosmetic blepharoplasty with laser eyelid skin resurfacing. The procedure was performed under light sedation and took 2.5 hours to complete. Post-surgery, she experienced some bruising and swelling for 10 days with no impact on her vision. With respect to eyelid surgery recovery, she was happy to return to work wearing glasses to cover up some of the swelling after just 4 days time (she is a very dedicated employee who didn’t want to miss too much work).

 

 

After only 8 weeks after blepharoplasty, she had almost complete recovery and was very happy with the functional and aesthetic results achieved. She stated that now she “felt like [her] old self again” and received many compliments from her family and friends. From the blepharoplasty before and after photos, we can appreciate the tremendous impact blepharoplasty surgery can have on facial vitality and beauty.

 

Case 2:

This 49-year-old lady presented to EFI mostly concerned with the appearance of her dark undereye circles. She is a very healthy individual who eats well, exercises daily, and “drinks lots of water”. She was perplexed as to why she takes such great care of her skin (using the “most expensive” eye creams) and yet she still has those dark circles, which won’t go away. She wanted to pursue a non-surgical option such as botulinum toxin injection (Botox, Xeomin, Dysport) or hyaluronic acid filler (e.g. Restylane, Juvederm, etc) to get rid of the dark undereye circles. She also felt that her upper eyelids became more heavy over the years and she now finds it very difficult to use eyeshadow.

 

 

If you view her before photograph, you’ll notice that this patient does indeed have excellent facial skin quality and that her lower eyelids stand out in stark contrast to the surrounding structures. The lateral canthal tendons are lax with herniating lower eyelid fat pockets, dark shadows, and prominent tear troughs/orbitomalar junctions (this junction separates the lower eyelid from the cheek anatomically). She also has upper eyelid ptosis (tendon laxity) as well as redundant excess upper eyelid skin with hooding in the outer corners.

 

We explained to the patient that although hyaluronic acid filler injection into the orbitomalar junction and cheek would help partially camouflage the contour discrepancy, it wouldn’t be her best option long-term. One reason is because of her fair and relatively thin skin, she would be at a higher risk for developing unnatural noticeable swelling and possibly a bluish discoloration under the skin (called Tyndall effect) if filler was used.

 

We discussed other management options including lower blepharoplasty alone or in combination with upper blepharoplasty, droopy eyelid surgery (ptosis surgery), and lateral canthal tightening. She said she was very keen on a natural result and absolutely did not want “to look like someone else”. We reassured her that this would not be the case and she proceeded with quad cosmetic blepharoplasty, lower eyelid fat transpositioning, eyelid laser skin resurfacing, and droopy eyelid surgery. The procedure was done under moderate sedation because she was feeling nervous and wanted to be more asleep.

 

 

Eyelid surgery recovery was ahead of schedule and even after 3 weeks, our patient was very happy with the natural results achieved and admitted that her upper field of vision had noticeably improved.

 

Case 3.

This 76-year-old lady presented to EFI a few months after undergoing cataract eye surgery, which caused her upper eyelids to droop. She had several medical comorbidities including diabetes, high blood pressure, cholesterol, and arthritis, all of which were well-controlled with medications. Her main goal from blepharoplasty was to see better and she was particularly concerned about how long eyelid surgery recovery would take given her multiple medical issues.

 

 

During our examination, we reviewed findings including quad-eyelid dermatochalasis (excess skin), steatoblephara (herniated fat pockets), droopy upper eyelids (ptosis), as well as anteriorly protruding and descended lacrimal glands. We offered a variety of surgical options including upper blepharoplasty with levator advancements (droopy eyelid surgery) and possible adjuncts such as lower blepharoplasty, orbitomalar ligament release with fat transpositioning, and lacrimal gland resuspension. Again, because our patient was so worried about eyelid surgery recovery, she wanted detailed information about how all these adjunct procedures would impact her ability to see after surgery and how much extra time would be needed to recover. Once we explained that the adjunct procedures would only add 1-2 weeks of extra downtime, she decided to optimize the entire periocular region and proceed as recommended. Her blepharoplasty with adjunctive procedures took 3.5 hours to complete (she needed more time for sedation and to review vital signs, check blood sugars etc. during surgery to ensure that all intra-operative care was optimized for her active medical issues). Her eyelid surgery recovery took 10 weeks because of her diabetes and consumption of blood thinners, which delayed swelling resolution. After this time, she felt great and admitted that she was very pleased because she could see better and she experienced the natural results she wanted.

 

 

When performing Asian eyelid surgery, including blepharoplasty, there are unique anatomical considerations that must be understood and respected to avoid complications. For any patients of Asian descent who are interested in proceeding with blepharoplasty, please ensure that your eyelid plastic surgeon has a lot of experience operating on Asian eyelids.

 

Case 4.

This 58-year-old lady presented with concerns of looking tired and experiencing difficulty while reading due to droopy eyelids. She was fortunate enough to retire 3 years prior, so she invested her free time working out at the gym 6 days per week. She felt that her body looked and felt great but that her face didn’t match. She said her face looked “haggard” and unhealthy and wanted to know about all possible treatment options available to improve this. It is important to note that decreasing levels of estrogen during the peri-menopausal years (combined with active working out and weight loss) can dramatically decrease the volume of fat in the various facial compartments. This deflation of fat pads and other soft tissue structures often results in hollowing and shadowing over time.  

 

 

Examination revealed a lot of laxity in the forehead and eyebrow region, which caused deflation and descent of the brows and skin into the outer corners of the upper eyelids. She also had redundant upper and lower eyelid skin with early herniation of the lower eyelid fat pockets. In addition to this, our patient had descent of the cheek (malar) fat pads as well as overall deflation and descent of most of the soft tissues in her midface. When we asked her what types of interventions she would like to consider, she wanted to be as minimally-invasive as possible. She was not interested in having a full-face lift, fillers, or fat grafts done. Ultimately, she underwent a staged treatment plan. Initially she underwent endoscopic frontal advancement brow ptosis repair, thread-lift midface suspension, droopy eyelid surgery (ptosis repair from a transconjunctival approach), and conservative quad blepharoplasty.

 

 

Three months after surgery, she underwent pan-facial Sculptra injections to improve overall facial volume/projection and skin quality. 

 

Case 5.

This 87-year-old lady presented to EFI with concerns of poor vision due to her progressively heavy upper eyelids. She admitted that she was shocked at her herself because she was never someone who would get “plastic surgery” done. She felt that her sense of humility guided her to “age gracefully” and that she thought that she would never have invested time or money towards elective surgery. Unfortunately, she said that her eyelids became worse and worse over the years, and now even her great grandchildren were asking her why her “eyes disappeared”. With the support of her family, she ultimately decided to come and see us for a consultation.

 


During the examination, we reviewed the clinical findings with our patient including the eyebrow and forehead descent and deflation, the severely ptotic (droopy) upper eyelids due to weak tendons, lateral canthal laxity, dermatochalasis (redundant excess skin) and steatoblephara (prominent, herniated fat pockets). Because our patient had clearly expressed that her main goal was simply to “see better” we focused on the functional aspects of her condition that would require droopy eyelid surgery, lateral canthal tightening, and removal of some excess skin that was blocking her central vision. As we discussed her concerns in greater detail, and looked over some old photographs she brought in (from her 30s), our patient became more inclined to optimize her eyelid and facial cosmesis by adding a conservative forehead lift and cosmetic blepharoplasty surgery with eyelid laser skin resurfacing. She figured that while she was “under the knife” she would go ahead and treat herself. She did insist that she wanted a relatively quick eyelid surgery recovery period, and so we elected to do the forehead lift by direct temporal hairline frontal advancements rather than the more extensive endoscopic approach.

 

 

She recovered beautifully and was very happy with her functional and aesthetic results after blepharoplasty and adjunctive procedures including droopy eyelid surgery.

 

Summary.

These 5 cases highlight just a few of the nuances that must be considered when blepharoplasty, droopy eyelid surgery, and other adjunct eyelid and facial surgical procedures are performed. As you can now tell, we must carefully balance unique patient medical history, eyelid, and facial anatomy, and desired results in order to formulate a customized surgical plan. Please stay tuned for future blogs in which I will discuss eyelid surgery for men, Asian eyelid surgery, and more.

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