image of silk fabric and dry skin

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.

Key Words:
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.


Upper Eyelid
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.laser. 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 coldsteel 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

Lower Eyelid

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 pads. 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 transfer techniques.

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.

Pre- and post-operative images of patient with lower eyelid pseudoherniated fat pads and 3 months following transconjunctival blepharoplasty and erbium
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 increase hooding.

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. However, the 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. Consequently, 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. There 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 literature. 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 patients.

Counseling Patients

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 condition. 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 required. Patients should expect to appear less tired after these procedures, and should be counseled as to the complications and the postoperative recovery of blepharoplasty.


  1. Baylis HI, Goldberg RA, Kerivan KM, Jacobs JL. Blepharoplasty and periorbital surgery. Dermatol Clin 15(4):635-47 (1997 Oct).
  2. Rohrich RJ, Coberly DM, Fagien S, Stuzin JM. Current concepts in aesthetic upper blepharoplasty. Plast Reconstr Surg 113(3):32e-42e (2004 Mar).
  3. 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).
  4. 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).
  5. 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).
  6. 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).
  7. 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).
  8. 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).
  9. 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).
  10. Sklar JA, White SM. Radiance FN: a new soft tissue filler. Dermatol Surg 30(5):764-8 (2004 May).
  11. Dailey RA, Saulny SM. Current treatments for brow ptosis. Curr Opin Ophthalmol 14(5):260-6 (2003 Oct).
  12. Niechajev I. Transpalpebral browpexy. Plast Reconstr Surg 113(7):2172-80 (2004 Jun).
  13. 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).
  14. 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).