Upper blepharoplasty

What it is

Loose upper lid skin (dermatochalasis) is common with age and often comes with bulging fat, a dropped tear gland or a slightly low lid (ptosis) (PMID 42236867). Upper blepharoplasty is one of the most common cosmetic operations in the United States (PMID 42236867).

The thinking behind the operation has changed. Older surgery removed skin, muscle and a lot of fat, and some patients were left with a hollow, operated look that aged them; current surgery removes less tissue and aims to keep the fullness of a youthful upper lid (PMID 15536308). Results depend on matching the operation to the cause of the heaviness: skin, fat, a low brow or a low lid (PMID 33346340, PMID 33234951).

Surgery also helps the eye work. After removing skin, the upper field of vision widened several-fold in a small study, and the field measured before surgery predicted the gain better than lid height (PMID 35086303). Contrast sensitivity improved and astigmatism lessened, while sharpness of vision did not change (PMID 36788649).

Where it came from

• In 1951 Castanares described the anatomy of bulging eyelid fat and an operation built on it (PMID 14864073).
• By 2004, Rohrich and colleagues described the shift from aggressive fat removal to conservative surgery that keeps volume (PMID 15536308).
• In 2004 a survey of American oculoplastic surgeons measured how often bleeding behind the eye follows eyelid surgery and how rarely it causes lasting vision loss (PMID 15599241).
• In 2020 Alghoul and colleagues showed that people who already have a full view of the lid skin below the crease gain less from skin removal alone (PMID 33234951).
• From 2011, randomized trials compared removing skin alone with removing skin and muscle; pooled, they show the muscle can usually stay (PMID 21224748, PMID 40152471).

Who it suits

• Heavy, hooded upper lids from loose skin, with or without bulging fat (PMID 42236867, PMID 39856176).
• Lids that block vision. The visual field test shows the gain; symptom scores capture what the field test misses (PMID 35086303, PMID 42693598).
• A hollow upper lid. Keeping or moving fat, or grafting it, fits better than removing it (PMID 39421583, PMID 28753160).
• A lid that is already open. People whose lid skin below the crease is already fully visible improved less with skin removal alone; the authors advise considering fat grafting or ptosis repair instead (PMID 33234951).
• Hidden ptosis or a low brow. Mild to moderate ptosis and brow descent are often missed; experienced surgeons more often add a brow lift or ptosis repair (PMID 33346340).

How it is done

• Skin only, or skin and muscle. The surgeon removes an ellipse of skin, and may remove a strip of the orbicularis muscle with it (PMID 33538853). Fat can be removed from the central and inner pads (PMID 39856176), kept, or moved to fill the lid (PMID 39421583).
• Adding volume. Volumetric blepharoplasty grafts fat into a hollow upper lid and tightens the muscle (PMID 28753160).
• The shape of the cut. Extending the excision to the side gave a slightly larger and more even visible lid and less drop of the outer brow than a standard ellipse (PMID 36205656).
• Closing the skin. Buried and running stitches gave equal scars (PMID 42118953); the tool used to cut (scalpel, radiofrequency or CO2 laser) and the stitch material did not change the final scar (PMID 41193896).
• Numbing. Adding tranexamic acid to the local anesthetic increased bleeding during surgery in a randomized trial and did not reduce swelling or bruising (PMID 38789809).

Results and how long they last

• Removing the muscle adds little. In pooled randomized trials, satisfaction was the same with or without muscle removal, while incomplete eyelid closure was more frequent with it (PMID 40152471). Removing the muscle caused more early swelling, bruising, pain and dry eye, which resolved within weeks, with no long-term difference in appearance (PMID 33538853, PMID 21224748). A year after surgery, skin-only and skin-muscle lids scored the same on patient questionnaires (PMID 35219565). One retrospective series found higher satisfaction when muscle and fat were removed (PMID 39856176).
• Dry eye usually improves. Dry eye symptoms fell after surgery in pooled trials (PMID 40152471), at 1 month and 1 year with either technique (PMID 37354267), and most quality-of-life studies found no worsening (PMID 40913605). Tear measurements did not change (PMID 34612583).
• Headaches ease. Headache scores fell after surgery with either technique (PMID 36674313).
• Patients are satisfied. Blinded reviewers scored appearance higher after surgery (PMID 33234951), and patient-reported eyelid scores rose; how severe the lids looked beforehand did not predict satisfaction (PMID 39037480). Kept fat held its volume at a year (PMID 39421583).
• The brow drops a little. After a simple blepharoplasty the brow sat a little under 1 mm lower on average; skin removal itself did not lower it (PMID 36890345).
• How long it lasts. The trials follow patients for about a year (PMID 35219565, PMID 37354267); a revision for leftover skin is the most common reason to operate again (PMID 38315110).

Risks and how surgeons lower them

• Bleeding behind the eye. The most serious risk: about 1 in 2,000 eyelid operations, with permanent vision loss in about 1 in 22,000 (PMID 15599241). Most cases start within 3 hours of surgery, and high blood pressure, aspirin, vomiting and exertion were common in those affected (PMID 15599241). Blindness after eyelid surgery follows bleeding behind the eye that cuts off blood to the optic nerve (PMID 3516289).
• Major complications are rare. About 1 in 250 aesthetic eyelid patients had one in an insurance registry, most often a hematoma (PMID 29369102).
• Wound opening. About 1 in 70 eyelids, more often in men and with fast-dissolving gut stitches (PMID 32852369).
• Blood thinners. Patients taking aspirin, warfarin or apixaban had no major bleeding and no significant rise in complications in one study (PMID 42236867).
• Revision. About 1 in 25 after blepharoplasty alone, and about 1 in 11 when ptosis repair was added, mostly for leftover skin, scar or asymmetry (PMID 38315110).
• Lasting dry eye. New dry eye lasting 3 months or more followed about 1 in 125 operations and resolved in all (PMID 38315110).
• Hollow, droopy lid after fat removal. In the post-blepharoplasty syndrome, the lid-lifting tendon is torn loose and caught in scar left by fat removal (PMID 31802837); conservative fat removal avoids it (PMID 15536308).
• When problems appear. Corneal scratches and bleeding behind the eye in the first week; lid malposition, exposure and tearing in weeks 1 to 6; contour change, asymmetry and scarring later (PMID 20195127).

Recovery

• Bleeding risk is highest in the first 3 hours and falls after 24 hours, though bleeding can still occur days later (PMID 15599241).
• Ice packs did not reduce swelling or bruising, and eased pain only slightly on the first day (PMID 25626811). Arnica ointment did no better than placebo (PMID 27348641). Bromelain tablets for 2 weeks reduced swelling in a randomized trial (PMID 42728656).
• Return to work came sooner after skin-only surgery than after skin, muscle and fat removal (PMID 39856176).
• Silicone gel or sheets reduced raised scars; cold compresses, pressure dressings and over-the-counter scar creams did little (PMID 41193896).

With a facelift

• Blepharoplasty is the procedure most often added to a facelift, and combining procedures raised the odds of complications in a national database (PMID 32459769).
• A brow lift added to blepharoplasty did not raise the rate of major complications (PMID 29369102).
• In one practice, a brow lift was added to about 1 in 3 upper blepharoplasties and ptosis repair to about 1 in 5 (PMID 38315110).
• Brow lift and blepharoplasty are planned together because brow position and lid fold are linked (PMID 20595828).

Questions to ask a surgeon

• Is my heaviness from skin, fat, a low brow or a low lid? (PMID 33346340)
• Will you remove muscle or fat, or keep them? (PMID 40152471)
• My lid already shows a lot of skin below the crease: will skin removal alone help me? (PMID 33234951)
• Should I stop aspirin or a blood thinner, and for how long? (PMID 42236867)
• What should I watch for in the first hours after surgery, and whom do I call? (PMID 15599241)
• How often do your patients need a revision? (PMID 38315110)

Open questions

• Muscle removal: pooled randomized data show more incomplete eyelid closure and no gain in appearance (PMID 40152471), while a retrospective series reported higher satisfaction when muscle and fat were removed (PMID 39856176).
• Keeping volume: experienced surgeons keep more (PMID 33346340), and the fat-preservation series is small with a year of follow-up (PMID 39421583).
• A fully visible lid below the crease: fat grafting or ptosis repair may serve better than skin removal (PMID 33234951).
• Blood thinners: one cohort of patients taking them found no major bleeding (PMID 42236867).
• Insurance criteria: a review proposes adding a symptom score to visual field testing (PMID 42693598).
• Recovery aids: bromelain reduced swelling (PMID 42728656), and tranexamic acid in the local anesthetic increased bleeding (PMID 38789809).

Terms

• Dermatochalasis: excess, lax eyelid skin (PMID 42236867).
• Orbicularis oculi: the muscle that closes the eyelids; a strip is sometimes removed with the skin (PMID 33538853).
• Preaponeurotic and nasal fat pads: the two fat compartments of the upper lid (PMID 39856176).
• Pretarsal show: the visible lid skin between lashes and crease (PMID 33234951).
• MRD1: distance from the corneal light reflex to the upper lid margin, a measure of lid height (PMID 35086303).
• Lagophthalmos: incomplete eyelid closure (PMID 40152471).
• Orbital (retrobulbar) hemorrhage: bleeding behind the eye that can compress the optic nerve (PMID 15599241).
• Levator aponeurosis: the tendon that lifts the upper lid (PMID 31802837).
• FACE-Q: a validated patient questionnaire for facial aesthetic outcomes (PMID 35219565).
• Volumetric blepharoplasty: eyelid surgery that adds or keeps volume, for example with fat grafting (PMID 28753160).

Papers