Eyelid surgery (blepharoplasty)

Eyelid surgery (blepharoplasty) addresses excess skin and muscle and protruding fat in the eyelids. The upper eyelids may have excess skin, while the lower eyelids may show bags, wrinkles, and a change in the angle of the eye opening as the outer corner moves downward. We can perform upper and lower eyelid surgery separately or in the same operation.

During your consultation, you can point out the eyelid appearance you would like to change, such as the upper skin fold or lower eyelid bags. When examining the eyelids, which consist of mobile tissue layers, we also look at brow position and the midface, meaning the cheek area adjacent to the lower eyelids. We use these relationships to explain which tissue the proposed procedure addresses.

The structure of the upper and lower eyelids

Sagging skin in the upper eyelid can form a fold over the lid. In the lower eyelid, we reach the fat pads responsible for bags and reduce or reposition them.

Thin skin covers the outer surface of the eyelid. Beneath it lies a ring-shaped muscle involved in closing the eye, with the eyelid’s supporting structures deeper still. The thin connective tissue covering that forms the front boundary of the fat in the eye socket is called the orbital septum. Fat becoming prominent toward the eyelid surface is one cause of the appearance described as bags around the eyes.

The levator muscle opens the upper eyelid through an attachment extending to the lid’s supporting tissue. The skin fold over the eyelid and the margin bearing the eyelashes are different structures. Excess skin can gather over the fold. How high the eyelid opens relates to the function of the opening muscle and its attachments.

The lower eyelid meets the cheek along the lower bony rim of the eye socket. The thinness of the eyelid skin, the position of the fat beneath it, and cheek volume affect this transition. When a bag sits beside a hollow area beneath it, the boundary between them may become more noticeable. For surgical planning, the area where fat protrudes and the area with reduced volume are marked separately.

Folding of eyelid skin and expression lines at the outer side of the eye are different appearances. The amount of skin is central to a fold, while muscle movement is central to expression lines. Whether the area that concerns you is beneath the brow, in the eyelid crease, or at the outer corner of the eye changes which procedure may be considered.

Excess skin, ptosis, and brow drooping

Ptosis means that the lash-bearing edge of the upper eyelid sits lower than expected. With excess skin, the skin over the lid folds and covers the crease, while the lash-bearing margin may remain in its usual position. Eyelid surgery addresses skin and fat, whereas ptosis surgery is planned according to the condition of the muscle that opens the lid and its attachments.

During the examination, the position of the upper eyelid margin relative to the pupil is measured while the person looks straight ahead. If the lash-bearing margin remains low when the skin fold is lifted by hand, this suggests eyelid drooping separate from excess skin. Eyelid movement between downward and upward gaze is also checked while limiting assistance from the forehead muscle. These measurements help clarify the function of the structures that open the eyelid.

Upper eyelid sagging may also result from a low brow position. If brow drooping is present, we can plan eyelid surgery together with a brow lift.

Supporting the brow in its anatomical position changes the distribution of skin gathered over the upper eyelid. The fold that remains in this position provides information about excess skin belonging to the eyelid itself. If a brow lift is also planned, the skin to be removed from the eyelid is marked with this new position in mind. This distinguishes tissue gathering caused by brow drooping from the eyelid’s own tissue.

Brow drooping, excess upper eyelid skin, and ptosis can occur in the same person. In this situation, surgical planning is needed for brow position and the eyelid-opening structures as well as the amount of skin. Because the degree of these findings may differ between the right and left sides, measurements are taken separately for each eye.

The upper eyelid skin fold may extend as far as the eyelashes and, in some people, cover the upper visual field. When this is a concern, the way the skin shifts when the brow is supported and the position of the lash-bearing margin are assessed separately. If considered necessary, an ophthalmological evaluation and visual field examination are included in surgical planning. You can mention any visual field concerns along with the changes you would like in eyelid appearance.

Under-eye bags and the tear trough

When describing a lower eyelid bag, you may also notice the hollow immediately beneath it. Since the prominence of the bag relates to the volume of this adjacent area, fat distribution is examined along the transition between the eyelid and cheek. Separate anatomical targets are identified for skin folding, forward prominence of fat, and the hollow beneath it.

The tear trough is the hollow transition beginning near the inner lower corner of the eye and extending toward the junction of the lower eyelid and cheek. The term describes an anatomical boundary visible from the skin surface. Bone support, connective tissue attachments, and the distribution of neighboring fat affect its appearance.

If there is a pronounced groove directly beneath a fat bag, the decision to reduce fat takes this neighboring area into account. In some anatomical situations, a portion of the existing fat can be repositioned toward the hollow transition. Which part of the fat is moved depends on the bag’s location and the volume distribution between the lower eyelid and cheek.

A dark area beneath the eye may relate to a shadow cast by the groove or to the skin’s color characteristics. Surgery addressing fat bags and the eyelid-cheek transition targets the volume and shape components of the appearance. If color is a concern, the skin’s own color and the shadows created by tissues are distinguished during the examination.

A fat bag immediately beneath the lower eyelid and skin and muscle folds over the cheekbone occupy different locations. Pointing out the lower boundary of the fullness you describe as under-eye fullness in the mirror may help distinguish these areas. The tissues accessible through a lower eyelid incision and the anatomical origin of a cheek fold are examined separately. This is why adjacent cheek tissue position is also considered when choosing surgery for a fat bag.

Who may be a candidate, and what does the examination involve?

Blepharoplasty may be considered for folded upper eyelid skin, prominent lower eyelid fat bags, or changes at the eyelid-cheek junction. Identifying which tissue accounts for the appearance that concerns you indicates which area surgery may address. Skin removal, fat adjustment, and procedures supporting the eyelid are chosen according to these findings.

The upper eyelid skin fold, the location of lower eyelid bags, and contact between the eyelids and the eyes are starting points for the examination. Eye opening and closing and eyelid tension are also observed during movement. The height of the upper eyelid crease and the boundary of excess skin extending toward the outer corner are recorded for each eye.

How the lower eyelid rests against the eye surface and how it moves when gently pulled provide information about the supporting tissues. The outer corner’s position, the lower bony rim, and the forward projection of the cheek are considered in the same examination. These findings help determine whether corner support is needed in addition to tissue adjustment in the lower eyelid.

You can share details of previous eye surgery and eye conditions during the consultation. Medications, contact lens use, and treatments around the eyes are also part of the assessment before eyelid surgery. An ophthalmological examination may be requested if the eye surface and tear function need separate assessment.

The decision about cosmetic eyelid surgery may be postponed if there is active eye disease or an uncontrolled general health condition. If the lash-bearing eyelid margin sits low, the cause is investigated first. When the concern relates to skin color or brow position, the discussion focuses on which procedure could address that area.

A front-facing photograph can show the eyelid fold and location of fat bags, but eyelid tension and its relationship with the eye surface are understood through examination by hand and in motion. Raising the brows while taking photographs can change the appearance of excess upper eyelid skin. During the consultation, you can describe your eyelids at rest and anything you notice as you open and close your eyes. This information helps relate the photographic appearance to examination findings.

Upper eyelid surgery

We determine the area of skin to be removed from the upper eyelid through markings and measurements. After addressing excess skin and muscle, we close the incision with sutures. When explaining the surgical plan, we can show you the eyelid crease and the skin gathered at the outer side.

In upper eyelid surgery, the incision follows the eyelid’s natural fold. The location of the fold and the distribution of excess skin determine how far the incision extends. If skin gathers at the outer side, the incision plan includes the boundary of that area.

The upper boundary of the skin to be removed is determined with consideration of the tissue beneath the brow and the eyelid’s closing movement. During skin markings, the fold formed when the eye is open and the skin distribution when it is closed are observed. Since skin amounts or crease heights may differ between the right and left eyelids, markings follow each side’s anatomy.

If upper eyelid fullness includes prominent fat, the fat compartments may also be included in the surgical plan. The need to treat skin, muscle, and fat is determined separately. Whether the muscle is preserved or an excess portion is treated relates to the eyelid crease and tissue structure.

Fullness beneath the brow and prominent fat at the inner upper eyelid belong to separate areas. Examination by hand and eyelid movement help identify which tissue causes the fullness above the crease. When choosing which tissue to remove or preserve, the relationship between volume beneath the brow, the eyelid crease, and the upper boundary of the eye socket is considered.

Lower eyelid surgery and incision approaches

We can reach the lower eyelid through an incision beneath the eyelashes or on the lid’s inner surface. We adjust the lower eyelid surface by reducing or repositioning the fat pads responsible for bags. During the consultation, we point out the location of the bag and explain which portion of fat will be treated and how.

Incision beneath the eyelashes

An incision beneath the eyelashes is placed on the outer surface of the lower eyelid, below the lash line. This approach reaches the skin and, when needed, the muscle layer; fat can also be treated within the same plan. The distribution of excess skin and eyelid support determine the tissue area to be removed and how far the incision extends toward the outer corner.

Approach through the inner eyelid surface

An approach through the inner surface of the eyelid is called transconjunctival. The fat compartments are reached through the conjunctiva, the tissue lining the inside of the eyelid. This approach may be considered in anatomical situations with fat bags that do not require substantial skin removal. The access route and the procedure performed on the fat are separate decisions.

An incision on the inner eyelid surface reaches fat, while an incision beneath the lashes also provides access to excess skin. Different approaches may therefore be considered for the same appearance of bags. Whether protruding fat is accompanied by skin folding is one finding that guides incision selection.

Fat removal and repositioning

Fat removal reduces a planned portion of the fat that protrudes forward. In fat repositioning, existing tissue is spread toward the hollow area at the lower rim of the eye socket and the cheek transition. This choice depends on the condition of the tissue beneath the bag as well as the bag’s volume. Different fat compartments within the same lower eyelid may require different amounts of adjustment.

Repositioning lower eyelid fat changes the distribution of existing tissue in the adjacent area. Fat transfer, by contrast, places fat taken from another part of the body into the target area. If moving fat is discussed during your consultation, you can ask whether existing eyelid fat will be used or whether fat will be taken from elsewhere.

Prominent lower eyelid fat may be concentrated near the nose, in the middle, or at the outer side. The eyelid-cheek transition beneath each area may differ in depth. Fat markings therefore include both the surface distribution of the bags and the hollow areas beneath them. Marking the area of excess skin as well makes it possible to see the separate boundaries of the planned fat and skin procedures.

Canthopexy and the outer corner of the eye

With canthopexy, a procedure that supports the outer corner of the eye, we adjust the angle of the eye opening. Where excess skin and muscle need to be addressed, we remove these tissues as well and close the incision with fine sutures. We can discuss the shape of the lower eyelid and the change you are considering at the outer corner in the same consultation.

The outer corner of the eyelids connects to supporting tissues at the outer rim of the eye socket. Canthopexy adjusts this supporting relationship with sutures. Lower eyelid tension and contact with the eye surface are considered when deciding whether to add corner support to the surgical plan.

The outer end of the brow and the outer corner of the eye are neighboring but separate anatomical structures. A brow lift targets tissues supporting the brow, while canthopexy targets the support structure of the eyelid corner. When defining the desired change in lower eyelid surgery, brow height, the angle of the eye opening, and contact of the eyelid margin are recorded separately.

Anesthesia and accompanying procedures

We can perform upper eyelid surgery under local anesthesia. For lower eyelid surgery, we prefer general anesthesia. The procedures planned for the upper and lower eyelids and any brow or facial procedures included in the same plan are explained during the anesthesia consultation.

Local anesthesia in eyelid surgery may be accompanied by sedation. Local anesthesia numbs the treatment area, while sedation is a method of calming administered by the anesthesia team. Anesthesia options relate to the extent of the eyelid procedure and the person’s general health.

Depending on the transition between the lower eyelid and cheek, we can add a midface procedure to the operation. A brow lift and eyelid surgery can also be included in the same plan. If you are considering a change in brow position as well as your upper eyelids, you can share this during the consultation.

If lower eyelid bags are accompanied by downward displacement of the cheeks and sagging along the jawline, eyelid surgery and a facelift may be part of the same surgical plan. The boundary where the lower eyelid meets the cheek determines the relationship between the tissues reached in the two procedures. Separate anatomical targets are defined for eyelid skin and fat adjustment and for cheek repositioning.

Fat transfer may be added to the plan if there is insufficient volume in the cheek area adjacent to the eyes. The area where fat will be placed is selected according to the lower eyelid bag’s boundary and the junction of the tear trough and cheek. If repositioning existing eyelid fat is being considered, the location of any additional fat is determined in relation to this tissue distribution.