What the research shows
Serious problems are uncommon. Across common cosmetic operations including eyelid surgery, hematoma and a return to the operating room each occurred in fewer than 1 patient in 100 (Sergesketter 2023).
Dry eye. In one surgeon's long series, about 1 patient in 4 reported dry eye symptoms afterward and about as many had swelling of the clear membrane over the eye. Both were more common when upper and lower lids were done together, when a skin-muscle flap was used, when the outer corner was tightened, and when the eyes did not fully close after surgery; patients with dry eye or loose lids before surgery were at higher risk (Prischmann 2013). For the upper lid, two randomized trials found that removing a strip of the closing muscle did not worsen dry eye, and symptoms fell after surgery with either method (Hollander 2022, Mian 2023). Most patients who had dry eye before a muscle-sparing operation were no worse afterward (Saadat 2004). Raising a drooping lid by shortening the Müller muscle did increase dry eye, while removing skin alone did not (Zloto 2020).
A pulled-down lower lid. Lower lid retraction is the most common complication of the skin approach to the lower lid; the approach from inside the lid avoided it, and its main shortfall was leaving too much fat (Baylis 1989). Every patient referred for retraction in one practice had had the skin approach, and weak lid muscle, short skin, hollowness and prominent eyes were more common than internal scar (Griffin 2014). Patients with prominent eyes may get a supporting graft at the first operation to prevent it (Bui 2023). When retraction happens, lifting the midface vertically and anchoring the outer corner improved it in nearly every patient (Pascali 2017).
Bleeding and blood thinners. Bleeding behind the eye is an emergency. In published cases, most after injuries, about half regained full vision and about 1 in 5 lost sight; fast surgical release of the pressure predicted recovery, and steroids did not (Christie 2018). For upper lid surgery, continuing low-dose aspirin did not increase bruising (Winkler 2020), and selected patients on blood thinners had no more complications and no major bleeding (Viscardi 2026).
A lower brow. After upper lid surgery, the brow sat lower in about 1 patient in 3 in one series, more often in men (Hassanpour 2016).
Filler and fat under the eye. Filler in the tear trough can cause swelling or lumps that appear months or years later (Trinh 2022). At five years, puffiness, a blue-gray tint and uneven contour persisted in some patients, nine in ten of them mild and needing no treatment (Mustak 2018). Moving or grafting fat into the tear trough during surgery had complications in about 1 patient in 9 and a second operation in about 1 in 40 (Xu 2024).
Where surgeons disagree
- Cutting the closing muscle. A large series tied skin-muscle flaps to dry eye (Prischmann 2013); randomized trials of upper lid surgery found no harm from removing muscle (Hollander 2022, Mian 2023).
- Supporting grafts. Some surgeons place a graft at the first lower lid operation in high-risk patients (Bui 2023); a review found no graft material clearly better than another and little strong evidence for any (Park 2017).
- Stopping aspirin. The aspirin trial recommends continuing low-dose aspirin before upper lid surgery but was too small to judge bleeding (Winkler 2020); the blood thinner study asks for larger prospective studies first (Viscardi 2026).
What is new
- Two randomized trials found that removing muscle in upper lid surgery does not cause dry eye (Hollander 2022, Mian 2023).
- One session of high-dose hyaluronidase dissolved problem filler around the eyes in every treated patient; many then chose lower lid surgery (Chen 2026).
- Patients using GLP-1 weight-loss drugs had more brow drooping and excess lid skin and more often had eyelid surgery (Saffari 2026).
What is still unknown
- Which lower lid patients need a supporting graft, and which material works best (Park 2017, Bui 2023).
- The true bleeding risk of staying on blood thinners, which needs larger studies (Viscardi 2026).
Key papers
- Baylis 1989: the inside approach to the lower lid avoided retraction.
- Prischmann 2013: how often dry eye follows eyelid surgery and who is at risk.
- Griffin 2014: what causes a pulled-down lower lid after the skin approach.
- Pascali 2017: a vertical midface lift repairs lower lid retraction.
- Christie 2018: speed of treatment saves sight after bleeding behind the eye.
- Hollander 2022: removing muscle in upper lid surgery did not cause dry eye.
- Winkler 2020: low-dose aspirin did not increase bruising.
- Xu 2024: the complication rate of fat work in the tear trough.