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Eyelid Surgery

An eyelid lift, also known as blepharoplasty, is a procedure to recontour the upper and/or lower eyelids. Most blepharoplasty patients are unhappy with bagginess along the upper eyelid and puffiness below the lower eyelid. These types of changes involving the eyelids contribute to a tired or prematurely aged look.

Aging changes involving the upper eyelid typically reflect too much skin that appears to hang over the eyelid margin. When this occurs, you lose the normal crease just above the eyelid and this leads to that baggy, tired look. Many women are also frustrated by the inability to apply make-up to the upper eyelid because of excessive skin folds. Whenever upper eyelid blepharoplasty is being considered, one must also assess whether the eyebrow has descended enough to contribute to the problem. If this is the case, a browlift may need to be performed in conjunction with upper eyelid blepharoplasty to achieve optimal results. The upper blepharoplasty incision is designed to blend in with the existing but hidden natural skin crease. Redundant skin is removed and excess fat is taken out as needed. The incision is closed with the end result being a sharper, well-defined upper eyelid crease with a refreshed new look.

In contrast to the upper eyelid, lower eyelid blepharoplasty emphasizes removal of excess fatty tissue. Only in certain instances is it necessary to remove lower eyelid skin. Typically, there are no external incisions with lower lid blepharoplasty. The incision is usually hidden on the inside of the eyelid (termed transconjunctival blepharoplasty). In rare cases where an external incision is required (for excess skin), it can be readily hidden just below the eyelashes. Excess fat is removed from the individual fat compartments below the eye and the incision is allowed to heal from the inside out. The result is restoration of a smoother, more youthful lower lid contour.

Eyelid Surgery Candidates

Healthy men and women who are looking to improve aging changes of the upper and/or lower eyelids may be good candidates for blepharoplasty. Upper blepharoplasty is typically performed on patients complaining of heaviness of the upper eyelid and/or decreased definition of the skin crease extending across the upper lid. Lower blepharoplasty is typically performed on patients bothered by unwanted bags or puffiness along the lower eyelid, which may also be accompanied by dark shadows or dark circles under the eyes.

” I am so blessed and so happy I chose Dr. Hilinski. He is an artist and a very skilled facial plastic surgeon . The results were spectacular, my eyelids are perfect, and my eyes look like they did 20 yrs. No one can even tell I had my eyes done!”

The Eyelid Surgery Procedure

Blepharoplasty is usually performed under local anesthetic with sedation as needed. The procedure typically takes place in an outpatient surgery setting, though the upper eyelid lift can be performed in the office setting with just local anesthesia. Upper blepharoplasty generally takes less than an hour to complete while lower blepharoplasty may take up to one and a half hours to complete.

Recovery from Eyelid Surgery

Patients are able to go home soon after the surgery is completed. Swelling and bruising can be minimized by elevating the head while sleeping and applying cold compresses. Any pain that patients experience can be controlled with low-dose prescription medication. The sutures are removed within four to seven days after surgery. Swelling subsides within a few days and patients are usually presentable in public and able to return to work within seven to ten days. By 2-4 weeks, it is difficult to tell that you ever underwent surgery.

Lower Eyelid Lift Case Example

This is an example of a lower eyelid lift, or blepharoplasty, to address unwanted shadowing around the eyes. This particular patient exhibits what many patients classically refer to as ‘bags’ under the eyes. Others describe eyelids like this as being excessively puffy. Most lower blepharoplasty patients like this one present to the facial plastic surgeon complaining that they look excessively tired all the time, despite feeling just fine. In many cases, patients are more bothered by other people constantly asking them if they got enough sleep the night before. Since we typically interact with others while looking at their eyes, issues like this can be quite distracting.

The puffiness under the lower eyelid really represents abnormal protrusion of the fat that originates underneath the eye. In fact, most patients have three different pockets of fat under each eye. As shown in the adjacent photo diagram, you can see where the three different fat pockets are situated under the eye. Some plastic surgeons describe this protruding fat as acting like a hernia does in that tissue pokes out through an abnormal opening in a wall. However, this is not entirely accurate when it comes to lower eyelid fat. It is technically called ‘pseudoherniation’ because the fat does not come through an opening under the eye. It actually pushes against a weakened thin wall called the orbital septum that normally has enough strength to keep the fat back underneath the eye. When the orbital septum can no longer contain the fat underneath the eye, it pushes forward and creates this unwanted puffiness. The orbital septum can be congenitally weak, as in this case example, contributing to onset of eyelid puffiness at even a young age. In other cases, the orbital septum becomes weakened due to aging changes with onset of eyelid puffiness later in life.

There are two main options for removing this type of excess lower eyelid fat. One involves making an incision in the skin just under the eyelashes. The other, which was used in this blepharoplasty case example, involves making an incision inside of the lower eyelid (called a transconjunctival blepharoplasty incision) to avoid any external scarring. The conjunctiva refers to the lining around the eye and the inner surface of the eyelid. Transconjunctival implies that we are making an incision across (trans) this lining during the eyelid lift. In this particular San Diego eyelid lift patient, we opted for the transconjunctival incision since the goal was to remove only the excess fat and there was no need to trim any of the eyelid skin given her young age. As you can see in the adjacent blepharoplasty diagram, the lower eyelid is pulled outward and down to allow exposure of the conjunctival surface where the incision is made (see red arrow showing the surgical approach). The excess fat is then exposed by very careful surgical dissection. In many cases, like this one, the excess eyelid fat is simply removed. In others, we actually will redrape the fat into a new position. This is called a ‘lower eyelid fat repositioning’ procedure. This option is used in cases where the fat can be ‘recycled’ by placing it in an adjacent area next to the cheek to help provide a smoother lower eyelid contour. Once the fat has been reshaped under the eyelid, the incision is allowed to close.

This type of eyelid lift can be done under IV sedation (or a general anesthesia if you prefer) in less than an hour typically. Most patients look fairly presentable in the public eye within 7 days with only mild swelling and bruising noted during the first few days of recovery.

Here are the before and after photos of this particular lower eyelid lift patient. As you can see, she has a fairly marked visual improvement in her lower eyelids. She no longer has the bulging contour under her eyes and the abnormal lower eyelid shadowing has been greatly diminished.

Eyelid Lift FAQs

Q – What is an eyelid lift?
The eyelid lift, also known as blepharoplasty, is a plastic surgery procedure designed to rejuvenate and reshape an aging upper and/or lower eyelid. The eyelid lift can improve the appearance of bagginess along the upper eyelids and puffiness below the lower eyelids. The surgery may be performed on the upper eyelids, the lower eyelids, or on both. When a combined upper and lower blepharoplasty (called a ‘quad bleph’) is performed, it may be described as periorbital rejuvenation.

Q – Who is a good candidate for an eyelid lift?
Good candidates for the eyelid lift include healthy men and women who are bothered by aging changes of the upper and/or lower eyelids. The eyelid lift may not be appropriate for individuals with chronic tearing of the eye, dry eye, eye muscle weakness (ptosis), or other vision problems that may negatively impact the healing process.

Q – Who is a good candidate for an upper eyelid lift?
Upper blepharoplasty candidates include individuals who are concerned with heaviness of the upper eyelids or a loss of definition of the upper eyelid crease resulting from excess skin. Excess fat is typically not a concern with the upper eyelids. Female patients will often express difficulty with makeup application along the upper eyelid. In severe cases, there may be some loss of peripheral vision caused by excess skin hanging over the lid.

Q – How do I know if I need an eyelid lift or a brow lift?
Patients who are considering  upper blepharoplasty will need to have the eyebrow position thoroughly assessed during consultation. Upper eyelid heaviness may indeed be a result of excess eyelid skin, in which case an upper eyelid lift is appropriate. Heaviness caused by drooping of the brow will require a brow lift.

Q-Who is a good candidate for a lower eyelid lift?
Lower blepharoplasty candidates include individuals with unwanted bags or puffiness along the lower eyelids. These patients often note the appearance of dark shadows or dark circles under the eyes. These abnormalities are typically the result of the aging process which may include pseudoherniation, or bulging, of fat beneath the eye, skin laxity, muscle weakness, and hollowing between the lower eyelid and cheek. One or more of these finding are usually present in lower blepharoplasty patients.

Q – Where is the eyelid lift procedure performed?
Dr. Hilinski performs most eyelid lift in an outpatient surgery setting. When performing just an upper eyelid lift, the procedure can also be performed in the office setting.

Q – What type of anesthesia is used for the eyelid lift?
Upper eyelid lifts may be performed with just local anesthesia. Lower eyelid lifts and combined upper and lower eyelid lifts require at least some form of sedation.

Q – How is the eyelid lift performed?
For both upper and lower eyelid lifts, the patient’s eyelids will be carefully marked while they are sitting upright or standing. This ensures the proper location of the eyelid skin, muscle and fat that will be addressed and the amount of change that will be made. For upper blepharoplasty, an incision is made across the upper eyelid within a natural skin crease. In most cases, the underlying orbicularis oculi muscle will be conservatively reshaped by removing a very narrow strip of muscle or by contouring the muscle with a  bipolar cautery instrument. Any excess upper eyelid fat this is present will be meticulously removed. Fine sutures are then used to close the incisions.

For a transconjunctival lower blepharoplasty, a hidden incision is made along the inside surface of the eyelid. Excess fat is then removed with careful surgical technique and the incision is closed with an absorbable stitch. Any slight skin excess and/or fine wrinkling present after fat removal through the transconjunctival approach can be addressed with a resurfacing technique such as laser skin resurfacing or a chemical peel. These will help to tighten the excess skin, remove wrinkles, and provide a smoother and more youthful appearance to the lower eyelid skin.

For a subciliary lower blepharoplasty, an incision is made just below the eyelashes and extending into the natural skin crease at the corner of the eye. Excess fat is removed and the muscle is typically lifted and tightened. In some cases, the canthal tendon may also be tightened. Excess skin is removed and the incision is closed with very fine sutures. Narrow strips of tape are applied across the lower eyelids to ensure a tighter, more shapely lower eyelid contour.

Patients with excess shadowing due to a loss of tissue volume between the eyelid and cheek (along the nasojugal groove), may benefit from fat transfer or injectable fillers combined with lower lid blepharoplasty. This helps to smooth out the transition from the lower lid to the cheek.

Q – How long does the eyelid lift procedure take to perform?
Upper blepharoplasty takes approximately one to one and a half hours to complete while lower blepharoplasty takes approximately one and a half to three hours to complete.

Q – Where are the incisions made for the eyelid lift?
The location of the incisions will depend upon the technique used. For upper blepharoplasty, an incision is placed within the natural skin crease of the upper eyelid, resulting in a scar that is essentially invisible. In some cases where excess skin extends to the side of the upper eyelid, the incision may extend a short distance away from the crease. There are two different approaches for lower blepharoplasty. For a transconjunctival lower blepharoplasty, the incision is hidden on the inside of the lower eyelid. This technique addresses excess fat but not excess skin. For a subciliary lower blepharoplasty, in which excess fat, excess skin and muscle may be addressed, an external incision measuring 1 to 3 millimeters is made just below the eyelashes with a short extension into the natural skin crease at the corner of the eye.

Q – Are there scars after an eyelid lift?
The incisions made for the eyelid lift do result in scars, though they tend to be well-concealed. For an upper eyelid lift the incision is made within the natural skin crease of the upper eyelid, which results in a scar that is essentially invisible. For a transconjunctival lower eyelid lift, the incision and resulting scar are completely hidden on the inside of the lower eyelid. For a subciliary lower eyelid lift, a small incision is made just below the eyelashes with a short extension into the natural skin crease at the corner of the eye, resulting in a well-concealed scar.

Q – Is the eyelid lift a painful procedure?
Patients may experience some pain or discomfort after the eyelid lift, though this can be controlled with low-dose prescription narcotic medication.

Q – What is the recovery like after an eyelid lift?
Swelling and bruising may occur after the eyelid lift. Patients should sleep with the head slightly elevated at a 30 degree angle for the first few days to help minimize the swelling. It’s also recommended that ice compresses or small bags of frozen peas be applied for twenty minutes on and then twenty minutes off during the first three to four days to control swelling and bruising. Any pain that patients experience is well controlled with low-dose prescription narcotic medication. Patients will be seen within four to seven days after surgery for suture removal. Most patients are presentable in public within seven to ten days after surgery. In general, the upper eyelids tend to recover more quickly than the lower eyelids.

Q – When will I be able to return to work after undergoing an eyelid lift?
Patients are usually able to return to work within seven to ten days after the eyelid lift, or sooner if they are not bothered by the tape and bandages.

Q – When will I be able to exercise after my eyelid lift?
Aerobic activity can usually be resumed within ten to fourteen days after the eyelid lift while more strenuous activities like resistance workouts may be resumed within three to four weeks.

Q – When are the stitches removed after the eyelid lift?
The stitches are removed within four to seven days after the eyelid lift.

Q – Are there risks or complications with the eyelid lift?
As with all types of surgery, there are potential risks associated with the eyelid lift. The risk of infection is generally very low. Bleeding complications are also quire rare provided that patients follow instructions and stop taking blood thinners for two before surgery and quit smoking for at least two to three weeks before surgery. As with any surgery involving the eye area, there is the potential risk of damaging the eye, though this is fortunately quite rare. There is a risk of removing too much skin from the upper eyelid which may result in incomplete closure of the lid (lagophthalmos), though this rarely occurs, particularly with proper measurement and marking. Too much excess skin removed from the lower eyelid and/or abnormal scarring occurring across the lower lid muscle and septum may cause the lid to retract downward, a complication which can also be prevented with proper measurement and conservative skin removal. Unwanted eyelid changes can be further minimized by using stabilizing sutures, which Dr. Hilinski does use. Many cases of lid retraction can be alleviated with a combination of massage, steroid injections and taping of the eyelid. More severe cases of eyelid retraction, known as ectropion, may require revision eyelid surgery to reposition the lid.

Q – Does insurance cover the eyelid lift procedure?
The eyelid lift is generally not covered by insurance when performed solely for cosmetic purposes. Some coverage may be available in cases where drooping upper eyelids interfere with vision. Patients should be sure to talk with their own insurance carrier.

Read more about eyelid lift procedures.

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