What is Blepharoplasty?
Blepharoplasty is the name of the surgical procedure to remove excess eyelid skin and or fat to improve vision, improve eye aesthetics, or both. “Upper blepharoplasty” refers to surgical manipulation of the upper eyelids while “lower blepharoplasty” refers to surgical manipulation of the lower eyelids. The term blepharoplasty is also sometimes used to describe droopy eyelid surgery, although it’s more accurate to refer to the latter as “ptosis surgery”. In total, we have four eyelids that have a very important role in optimizing the health of the eyes. These tiny structures are typically separated into four layers that consist of skin, muscle, cartilage, and a mucous membrane. They also contain important oil- and tear-producing glands that help lubricate the eyes and maintain the tear film. Eyelids must be open enough to see clearly and close fully to protect the eyes. They also act as a type of “windshield wiper” to distribute the tear film of the eyes evenly. In addition to all these important health-related functions, the eyelid shape and contour is also a vital part of facial beauty and communication.
A significant part of our non-verbal communication occurs by eye contact alone so any asymmetry between the eyelids, drooping eyelids, redundant heavy skin, protruding fat, eyelid bags, dark circles under the eyes, etc. can convey a sense of sadness, fatigue, or low energy. When the eyelids are very loose and heavy they can also block vision (upper eyelids) or cause chronic eye redness and dryness (lower eyelids). In essence, abnormal eyelid anatomy impacts people’s vision and eye health, their facial beauty, and sometimes even their psychology if emotions such as fatigue or sadness are experienced due to a saggy eyelid appearance.
The lacrimal (tear-producing) gland rests just behind the outer upper eyelid and can also fall forward over time. Similarly, the eyebrow fat pads can become deflated or the forehead can descend over time pushing more eyebrow skin into the upper eyelids and cause hooding. Other soft tissues including fascia, tendons, and cartilage structures around the eyes can also become loose. Membranes that hold the normal fat pockets in place can become thin, resulting in fat herniation over time. In summary, the structures around the eyelids are just as important as the eyelids themselves in contributing to normal, healthy, and beautiful eyelid anatomy.
When patients develop heavy upper eyelids, these will block some of the superior fields of vision to varying degrees. Usually, compensation by using the forehead muscles can temporarily help pull the skin out of the line of vision, but this becomes more difficult as those frontalis muscles fatigue over the course of the day.
Symptoms of eyelids heaviness are usually worse in the evenings and less bothersome in the morning. In addition, some of the heaviness and drooping may be a result of eyelid ptosis (drooping), also called blepharoptosis. This refers to laxity of the actual lifting muscle/tendon of the upper eyelid. When patients are evaluated for upper blepharoplasty, we must carefully evaluate all of the specific contributing elements to the “heaviness” in order to customize the best surgical plan. We evaluate the surface of the eyes using a microscope and measure the eyelids fully open and closed to determine tendon strength. In addition, the eyebrow and lacrimal gland positions are carefully evaluated. The desired surgical outcome after upper blepharoplasty is to create a natural, aesthetic result, where a medial (inner) concave eyelid blends seamlessly into a lateral (outer) convex eyelid and the brow position is appropriately positioned based on cultural and gender-specific norms. what the most natural aesthetic is for your face.
There are many unique considerations to surgery including how much skin to remove, where to position the eyelid crease, how to anchor this crease, whether or not to tighten the surrounding tendons, reposition the fat pockets versus remove them, and whether or not to anchor and or lift the eyebrows. Upper blepharoplasty typically takes 1-2 hours to perform and eyelid surgery costs can range from $3,000 to $7,000 depending on the complexity of the case and experience level of the surgeon. Droopy eyelid surgery (ptosis surgery) is typically covered by insurance.
Lower blepharoplasty involves smoothing out the contours of the lower eyelids so that they are flat and seamlessly continuous with the surrounding cheeks. We typically accomplish this by making a transconjunctival incision (through the inside lower eyelid membrane) in order to expose the fat pockets. We do not remove all of the fat, but rather transposition it to blend it into the cheek fat pockets in order to create a smooth contour. This prevents a hollow, skeletonized look after surgery. To treat the redundant skin, we typically perform ablative (carbon dioxide) laser skin resurfacing with lateral canthal tendon tightening and pinch skin removal just below the eyelash line when needed. Some patients also benefit from additional maneuvers such as malar fat pad repositioning (which acts as a type of mini-midface lift) and or autologous fat grafting. The overall goal of lower blepharoplasty is to create a smooth eyelid-cheek junction with no wrinkles or “hills and valleys” that create shadows and the appearance of eyelid bags. Lower blepharoplasty is performed under moderate sedation and typically takes 1.5-2.5 hours to complete. The eyes are protected throughout the case with shields and vision is monitored before, during, and after the procedure. Eyelid surgery costs for lower blepharoplasty typically range from $4,000 to $8,000 depending on case complexity and the level of surgeon expertise.
Although the steps outlined above for upper or lower blepharoplasty may seem complex, in experienced hands the procedures are done with minimal-to-moderate sedation and virtually no pain during or after surgery. You will go home the same day, awake and alert, with minimal discomfort, and mildly blurry vision. We do require that someone escort you home for optimal safety. There is no need for overnight monitoring because the surgery is minimally-invasive.
At Eye Face Institute (EFI), we find that most patients choose to undergo quad blepharoplasty (i.e. all four eyelids are operated upon at the same time) so that they may experience the most harmonious and aesthetically-pleasing post-surgical result. Droopy eyelid surgery (ptosis surgery) is combined with blepharoplasty when necessary and the eyelid surgery costs are less when all procedures are performed during one surgical setting.
After blepharoplasty, the first 3-7 days will involve ice compresses, elevation of the head while sleeping, limited physical activity (ie. no exercise), and no bending. Other activities such as reading, walking, watching television, or using the computer are completely fine. There is minimal pain after surgery and it takes approximately 1-2 weeks for post-blepharoplasty swelling and bruising to subside by about 90%. The final 5-10% of healing takes most patients several months (up to 6 months for some).
At EFI, we find that post-blepharoplasty results can dramatically improve vision, improve eye health, and or enhance periocular and facial beauty while maintaining your natural look and essence. Our primary goal is to perform surgery for best possible functional and aesthetic results, without creating any unnatural or overdone outcomes. Those types of complications are avoided by meticulous pre-operative planning, intra-operative focus, and post-operative monitoring by experienced eyelid (oculoplastic) surgeons
Non-surgical options for optimizing beauty around the eyes include medical-grade skincare, chemical peels, botulinum toxin (Botox, Xeomin, Dysport) and dermal filler injections (e.g. Restylane, Juvederm), radiofrequency tightening, and laser skin resurfacing. Stay tuned for a future blog where I will discuss these non-surgical treatment options in greater detail.