ADVANCES IN DERMATOLOGIC SURGERY -
Editors: Jeffrey S. Dover, MD and Murad Alam, MD
Blepharoplasty: Indications, Outcomes, and Patient Counseling
H.B. Gladstone, MD
Division of Dermatologic Surgery, Stanford University School of Medicine, Stanford, CA, USA
A telltale sign of the aging face is upper eyelid skin redundancy and lower eyelid bags. These changes can contribute to
a “tired” appearance. Upper and lower blepharoplasty procedures can correct these processes. By removing skin and
muscle, an upper eyelid blepharoplasty can give the eye a larger appearance. A lower blepharoplasty can remove pseudoherniated
fat, or transpose it to provide a smooth infraorbital contour. It appears that a transconjunctival approach for the
lower blepharoplasty will lead to a lower incidence of eyelid malposition. An adjunctive procedure such as laser resurfacing
may be appropriate. Patients should be counseled on all potential complications, including visual loss from muscle
injury or hematoma, as well as the extent of postoperative recuperation.
blepharoplasty, dermatochalasis, transconjunctival
While cosmetic evaluation needs to address the face
as a harmonious whole, it can be divided into the
lower, middle, and upper face. Recently, the upper
third, consisting of the eyes, brows, and forehead has
drawn increased attention from esthetic surgeons. This
renewed interest may reflect the perception that an
individual’s face begins with the eyes, underscoring the
notion that the “eyes are the windows of the soul.”
The hallmarks of upper third facial aging are:
lowered brows; lines of expression on the forehead
glabellar and periorbital regions; and lateral hooding,
dermatochalasis, and fat pseudoherniation in the
medial aspect of the upper eyelids. In the lower eyelids,
there may be a tear drop deformity, pseudoherniation
of the three fat compartments, and rhytides. These
changes in the lower eyelid, combined with malar
hollowing, leads to the so-called “double bubble”
irregularity, a telltale sign of the aging face.
The majority of patients who end up requiring an
upper or lower blepharoplasty or both will give the
chief complaint of “looking tired or not alert” even
when they are rested and alert. Some will state that
their eyes appear much smaller. Many women will also
relate that they have no upper eyelid platform upon
which to place make-up. Some patients who have
significant upper hooding will have reduced lateral
visual acuity. Lower eyelid bags will accentuate the
tired look and may appear as unsightly dark circles.
Essentially, the goals of blepharoplasty should be
to restore a rested appearance to the eyes with a
wider palpebral aperture and greater smoothness
and symmetry.1,2 When there is visual compromise, the aim is increased temporal vision. Depending on
the patient, resection of skin, muscle, and fat will
achieve these objectives. However, in recent years,
most cosmetic surgeons have reduced the amount
of skin and fat removed from both the upper and
lower eyelids. Too aggressive an approach may
lead to hollowing of the eyelids and a “cadaveric”
appearance. In some patients, particularly those with
a nasojugal depression, a fat pedicle or filler may
be necessary. Some practitioners have advocated
fat transfer to both the upper and lower eyelids,
which may tighten the skin, decrease hollowing, and
provide a more youthful appearance.
The basic decisions involved in upper eyelid
blepharoplasty include whether to extend the incision
laterally and superiorly if there is lateral hooding,
and whether to remove fat in addition to the skinmuscle
excision. Some surgeons warn against lateral
extension of the blepharoplasty incision since it
may invite visible scarring. In most cases, however,
this scar can be hidden in the periorbital crow’s
feet. While there has been a trend toward removal
of skin rather than fat, if there is pseudoherniation,
particularly in the medial fat pad, not removing fat
will produce an unsatisfactory result.
When performing a four-lid blepharoplasty, there
are no hard and fast rules for the order. Many
surgeons will perform the upper blepharoplasty first,
particularly if there has been a browlift.
The author performs blepharoplasties under local anesthesia with
oral sedation, and finds it preferable to perform the
upper and then lower lids because the patient may be
more attentive initially in keeping his/her eyes closed.
Another basic issue in performing upper and lower
blepharoplasties is determining which cutting device
to use: cold steel vs. cautery vs. radiofrequency vs.
Again, there is no correct answer. Laser may
result in better hemostasis and less collateral damage,
but many surgeons prefer the tactile feel of scalpel or
electrocautery/radiofrequency. The author uses cold
steel for the upper blepharoplasty and a Colorado
needle for the lower transconjunctival blepharoplasty.
It has been reported that radiofrequency may result
in less collateral damage and less risk of injury to
orbital structures.3 The diamond scalpel has also
been used successfully for blepharoplasties.4
Similar to the upper eyelid, the lower eyelid should
have a smooth contour. This contour may be disrupted
by pseudoherniated fat, a reduction in volume in the
nasojugal groove, static rhytides in the periorbital
region, and crow’s feet. The overall aging process
creates an unevenness of the lower eyelid and an
undulation between the periorbital cosmetic unit and
the malar region of the cheek. Therefore, the goal of
rejuvenating the lower eyelid should be to create a
uniform contour and surface.
If the patient has crow’s feet and static periorbital
rhytides with only mild bulging, the best option
would be to combine laser resurfacing with
botulinum toxin A (BOTOX®, Allergan). If
fat is to be removed, then a transcutaneous or
transconjunctival approach can be chosen. Though
technically more demanding, the latter technique
reduces the likelihood of postoperative lower lid
malposition.5,6 There is also no visible scar. While fat
will generally need to be removed from each of the
three fat pockets, the philosophy again is to remove
less rather than more. Experimentally, injections of
phosphatidylcholine have been used to reduce a small
amount of fat.7
If there is a tear drop deformity, then
a fat pedicle will have to be raised and mobilized in
the subperiosteal space. A bulge in a portion of
the lower lid, particularly in men, is usually due to
orbicularis oculi hypertrophy, and a partial resection
will need to be considered. The disadvantage of
the transconjunctival approach is that it will not
remove excess skin. Therefore, on practically all of
the author’s patients, periorbital laser resurfacing
is performed; however, if a patient has festooning,
this procedure will not be adequate and some skin
resection will be necessary. A small group of patients
has undergone radiofrequency treatment of the lower
eyelid for redundant periorbital skin with reasonable
results and minimal downtime.8
If laser resurfacing is to be performed on a more
mature patient who has pre-existing lid laxity, then
it would be prudent to incorporate a canthopexy
procedure.9 This procedure can also be used to
produce a slightly more “almond” shaped eye as well
as increasing the canthal tilt. Both of these anatomic
characteristics communicate youthfulness and are
accentuated in the female eye.
While the decisions in blepharoplasty focus on
the removal of tissue, there is a school of thought
that emphasizes replacement of tissue since facial
aging does indeed cause volume loss. This loss
can be replaced by fat transfer. The lateral brow
can be elevated by injecting fat just inferior to the
brow. Injecting fat into the upper eyelid sulcus
will create fullness, while making the redundant
upper eyelid skin taut. In the lower eyelid, fat
injections can diminish hollowing, or potentially,
even out the valleys between the pseudoherniated fat
This fat contouring will eliminate the “double
bubble” and create a more youthful appearance. The
disadvantages of fat transfer are that it is temporary
and that it requires multiple treatments. It should be
reserved for the subset of patients who have only
mild dermatochalasis, and where hollowing of the
lower lids predominates over fat pad protuberance.
In addition, this technique should be performed only
by those who have a great deal of experience in fat
Recently, other fillers such as hyaluronic acid, calcium
hydroxyapatite10 and l-polylactic acid have been used
in these areas, particularly in the tear trough. These
injections offer ease of use and less downtime than
fat transfer. However, there has not been long-term
follow-up for these techniques, and they may provide
only a short-term effect. Importantly, injections of
these substances in this cosmetic unit are considered
an off-label use.
Figure 1A, B: Pre- and post-operative images
of patient with lower eyelid pseudoherniated fat
pads and 3 months following transconjunctival
blepharoplasty and erbium: YAG laser resurfacing
of the infraorbital region.
Long-term outcome studies for upper eyelid
blepharoplasty have not been performed. Yet, with
natural senescence, the positive effects of an upper
blepharoplasty should last at least a decade. If fat is
appropriately removed, it is unlikely that there will
be additional pseudoherniated fat for a substantial
number of years.
As mentioned, the opposite effect,
that of hollowing, will be the major challenge in the
ensuing years. An important factor determining the
longevity of an upper lid blepharoplasty is the descent of the eyebrows. This phenomenon will create a
pseudoredundancy of upper eyelid skin and will
This descent is genetic-, expressionand
photodamage-related. Because of this natural
descent, a minimally invasive transblepharoplasty
browpexy may be indicated.11,12
Transcutaneous vs. Transconjunctival Approaches
An unpublished review of the literature since 1970
compared 4,460 transcutaneous blepharoplasties with
3,438 patients who underwent the transconjunctival
approach.13 In terms of complications, lid malposition
was the most frequent in patients who received a
transcutaneous blepharoplasty, occurring in 1.4% vs.
0.7% in the transconjunctival patients.
latter had significantly more edema, i.e., 18.4% vs. 0.2%
for the transcutaneous blepharoplasties. Hematoma
and inferior oblique injury were also more common in
the transconjunctival approach, as were inadequate fat
removal and overcorrection. Both of the latter occurred
in 1.2% of the patients. Wrinkling of the lower eyelid
remained in a far greater number of those undergoing
the transconjunctival blepharoplasty, i.e., 11.4% vs.
2.4% in the transcutaneous group.
adjunctive procedures such as chemical peels and
laser resurfacing were much more common, i.e., 32%
vs. 1.5% with the transconjunctival approach. Yet, a
large majority of the patients, 90.4%, were ultimately
satisfied with the transconjunctival approach.
was minimal data in this outcome for those undergoing
the transcutaneous blepharoplasty. Despite the higher
rate of potential complications, the transconjunctival
approach and an adjunctive resurfacing procedure
was preferred by most practitioners in this review of
The approach’s steeper learning curve
may account for some its complications. Because the
transconjunctival approach dramatically reduces the
potential for ectropion (lid malposition was probably
under-reported for the transcutaneous approach), it
is a more versatile technique, particularly for elderly
As with any procedure, appropriate patient
expectations is one of the keys to a satisfactory
outcome. The patient should understand that
a blepharoplasty will not elevate the brows, or
reduce rhytides or lines of expression. An upper
blepharoplasty will make the eyes appear larger
and more prominent in the upper third of the face.
The patient will appear more alert, and, if female,
have a larger platform on which to apply make-up.
This aspect will provide a rejuvenating effect, but
middle-aged patients should not expect to appear
as they did in their third decade. Similarly, a lower blepharoplasty will produce a smoother infraorbital
contour and make the patient appear well rested. It
will not affect a sagging malar eminence directly
below this cosmetic subunit. A mid facelift would
be needed to elevate the malar area and diminish a
“double bubble” effect.
During the preoperative appointment, all
complications, from conjunctival irritation and
bruising to muscle injury and retrobulbar hematoma,
should be explained.14 The possible visual
consequences should also be discussed. There is
an art to explaining these potential complications
without having the patient forego the surgery. These
explanations should be outlined in the informed
consent. Postoperative care and length of recuperation
also need to be discussed and reiterated. Optimally,
a handout should be given to the patient that
details what to expect following the surgery. While
bandaging is minimal for blepharoplasty, the upper
lid incision will be highly visible for at least 1 week.
Swelling in both upper and lower eyelids may take
months to resolve. Antibiotic ointment may cause a
contact dermatitis, and the patient should be educated
about this possibility.
For a lower lid blepharoplasty,
there may be conjunctival irritation and dry eyes.
Artificial tears may be needed for several weeks,
particularly if the patient has a history of this
If laser resurfacing is to be performed,
then the patient needs to be educated about prolonged
erythema and wound care. Most importantly, because
of possible swelling, the final results of the surgery
may not be fully apparent for 3 months.
Blepharoplasty is indicated for patients who have
pseudoherniated fat pads in the upper and lower
eyelids as well as those with redundant skin and
hooding in the upper eyelids. While the outcomes
of the device used—cold steel vs. laser—aren’t
definitive, it does appear that in the lower lid, the
transconjunctival approach is preferred. However, an
adjunctive procedure such as laser resurfacing may be
Patients should expect to appear less tired
after these procedures, and should be counseled as to
the complications and the postoperative recovery of
- Baylis HI, Goldberg RA, Kerivan KM, Jacobs JL. Blepharoplasty and periorbital surgery. Dermatol Clin 15(4):635-47 (1997 Oct).
- Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg 113(3):32e-42e (2004 Mar).
- Eremia S, Newman N. Use of an insulated ultrafine point electrocautery for transconjunctival blepharoplasty of the lower eyelids. Dermatol Surg 27(12):1052-54 (2001 Dec).
- Baker SS, Hunnewell JM, Muenzler WS, Hunter GJ. Laser blepharoplasty: diamond laser scalpel compared to the free beam CO2 laser. Dermatol Surg 28(2):127-31 (2002 Feb).
- Rizk SS, Matarasso A. Lower eyelid blepharoplasty: analysis of indications and the treatment of 100 patients. Plast Reconstr Surg 111(3):1299-306 (2003 Mar).
- Kim SW, Kim WS, Cho MK, Whang KU. Transconjunctival laser blepharoplasty of lower eyelids: Asian experience with 1,340 cases. Dermatol Surg 29(1):74-9 (2003 Jan).
- Ablon G, Rotunda AM. Treatment of lower eyelid fat pads using phosphatidylcholine: a clinical trial and review. Dermatol Surg 30(3):422-7 (2004 Mar).
- Ruiz-Esparza J. Noninvasive lower eyelid blepharoplasty: a new technique using nonablative radiofrequency on periorbital skin. Dermatol Surg 30(2 Pt 1):125-9 (2004 Feb).
- Gladstone HB, Moy RL. Canthopexy as an adjunct to blepharoplasty. Presented at: the Combined American Society for Dermatologic Surgery – American College of Mohs Micrographic Surgery and Cutaneous Oncology Annual Meeting. Dallas, TX (2002).
- Sklar JA, White SM. Radiance FN: a new soft tissue filler. Dermatol Surg 30(5):764-8 (2004 May).
- Dailey RA, Saulny SM. Current treatments for brow ptosis. Curr Opin Ophthalmol 14(5):260-6 (2003 Oct).
- Niechajev I. Transpalpebral browpexy. Plast Reconstr Surg 113(7):2172-80 (2004 Jun).
- Gladstone HB. A comparison between the transconjunctival lower blepharoplasty and the transcutaneous approach. Presented at: the Combined American Society for Dermatologic Surgery – American College of Mohs Micrographic Surgery and Cutaneous Oncology Annual Meeting. San Diego, CA (2005).
- Hass AN, Penne RB, Stefanyszyn MA, Flanagan JC. Incidence of postblepharoplasty orbital hemorrhage and associated visual loss. Ophthal Plast Reconstr Surg 20(6):426-32 (2004 Nov).
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