Blepharoplasty
Cosmetic Eyelid Surgery | Eyelid Lift | Eye Bag Removal Surgery | Eye Bag Reduction Surgery
Before and After Upper and Lower Lid Blepharoplasty
- Blepharoplasty (pronounced BLE- FA- RO- PLA- STEE ) surgery, commonly known by various synonyms such as eyelid lift surgery, eye plastic surgery, cosmetic eye surgery literally means ‘refashioning of the eyelid’ and is an operation commonly performed to improve the appearance of the skin around the eye.
- In the UK, most blepharoplasty operations are performed to reverse the changes of ageing (often removing excess loose folds of skin from the upper eyelids or eyelid 'bags' from the lower eyelids) and are either performed for cosmetic improvement or for functional reasons.
- A smaller proportion of patients, undergo different types of blepharoplasty surgery for other reasons e.g. Asian blepharoplasty/ double eyelid surgery, thyroid eye disease blepharoplasty, congenital problems etc.
- Although there are many types of operations to improve the appearance of eyelids, in general, the vast majority of patients who seek cosmetic eye surgery are usually enquiring about cosmetic blepharoplasty to reverse the signs of ageing.
- Contrary to popular belief, not all patients need to undergo surgery and indeed excellent results can be often achieved by non-surgical methods.
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How Eyelids Age: Baggy Eyelids | Drooping Eyelids | Eyelid Bags | Heavy Eyelids | Eyelid Hooding
As we all get older, changes in the structural of the tissues of the face begin to occur. For example, tendons become lax, muscles lose their tone, fat starts to shrink and skin loses its elasticity.
Normal age related changes with the eyelids. Notice the bulging fat pads. These are commonly referred to as eyelid bags and patients commonly complain of baggy eyelids or heavy eyelids
- default_titleExcess skin develops leading to redundant droopy skin which can give rise to a melancholic appearance to the eyelid. Women often complain that they no longer have an eyelid on to which they can apply eye makeup. Patients remark that people comment on them looking angry, tired or frowning.
- default_titleWeakening of one of the middle layers of the eyelid allows for outward bulging of the fat of the eye socket leading to eyelid ‘bags’ known as steatoblepharon. Sometimes the fat behind the eyelid may start to descend leading to changing contour of the eyelid.
- default_titleAge related weakening of the main tendon involved in the lifting of the upper eyelid results in a skin crease that is less defined and sometimes a drooping upper eyelid (ptosis).
- default_titleSometimes the tendons which keep the eyebrows in position may start to weaken leading to descent of the eyebrow itself, usually starting with the tail of the eyebrow (outer end)
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In the lower eyelid, similar changes occur with age related stretching of the tendons of the eyelid:
- default_titleThe lower eyelid instead of having a youthful sharp contour starts to become more concave with greater exposure of the lower half of eye.
- default_titleWeakening of the middle layer of the eyelid results outward bulging of orbital fat and the appearance of eyelid bags or 'festoons'.
- default_titleThe skin loses its elasticity and the muscles weaken leading to excess skin and wrinkles. As the tissues start to descend and shrink around the junction between the lower eyelid and cheek, the tear 'trough' or hollow starts become increasingly obvious and often one of the first complaints is of both men and women is of deep shadows or hollowness under their eyes.
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What are the reasons for undergoing blepharoplasty?
- default_titleFunctional reasons: In some patients the hooding of their eyelids is so severe that their peripheral vision becomes very compromised or cause frequent blinking. These patients commonly have to exert their forehead muscles in an attempt to lift their eyelids out of the way in order to see properly. In such severe cases, upper eyelid blepharoplasty surgery may be funded by the NHS or patient's private medical insurance schemes since it is deemed that their surgery is not for cosmetic improvement but purely for functional reasons. Similarly but less commonly, patients undergoing lower eyelid blepharoplasty/ plastic surgery may have their surgery also funded by the NHS or via private medical insurance if it is deemed that their surgery is necessary for rehabilitative purposes e.g for thyroid eye disease.
- default_titleCosmetic reasons: The appearance of one's eyes are central to facial expression. As one ages, one's upper eyelids become more hooded and droopy, the lower eyelids often develop 'bags'; the fat within the eye socket may start to bulge forward and under eye hollows may start to develop. Unfortunately, many of these normal age related changes are misinterpreted by one's peers. Many patients who request blepharoplasty (cosmetic eyelid / eye plastic) surgery often do so because they are fed up of their peers commenting on them looking tired or angry. Cosmetic eyelid plastic surgery (cosmetic blepharoplasty) is therefore commonly performed to reverse these changes and is one of the most commonly performed cosmetic plastic surgery procedures worldwide. After blepharoplasty surgery, patients often remark that they look less tired, and even at times feel more energised in themselves. Although the majority of patients undergoing cosmetic eyelid surgery are women, increasingly men are also undergoing cosmetic eyelid surgery both for functional and cosmetic reasons. Indeed, cosmetic eyelid plastic surgery in men is one of the fastest growth sectors currently in the UK and this may be due to the perceived importance of appearance in the workplace.
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Patient 1: This lady's upper lids are so hooded that she could barely see. Her carers complained that she had difficulty navigating around. Her upper lid blepharoplasty surgery was therefore available on the NHS for functional reasons
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Patient 1: Following Upper Lid Blepharoplasty as funded by the NHS. She noticed a dramatic improvement in her visual field
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Patient 2: Before Surgery: Not only does this gentleman have severe upper eyelid hooding and complained of very heavy eyelids. In addition he also sufferes from eyelid ptosis itself (drooping eyelid). This patient underwent combined blepharoplasty surgery and ptosis correction. This is commonly referred to as eyelid lift surgery
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Patient 2: Before Surgery: Notice the low eyelid position (eyelid ptosis) even after the excess hooded skin (dermatochalasis) has been lifted out of the way. This patient needs both excess skin removal (blepharoplasty/ eyelid lift) and strengthening of the main tendon involved in lifting the eyelid itself (levator aponeurosis advancement)
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Patient 2: 3 weeks following combined blepharoplasty surgery (excess skin excision) and ptosis correction (strengthening the eyelid tendon). This patient had both procedures funded by the NHS for functional reasons.
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Patient 3: Cosmetic upper lid blepharoplasty: Pre Surgery: Prior to upper eyelid blepharoplasty (eyelid lift surgery). This lady complained of problems with eyelid make up. She was also fed up of being told she looked stern.
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Patient 3: Cosmetic upper lid blepharoplasty: Post Surgery: 2 months following upper eyelid blepharoplasty One can see why blepharoplasty surgery is sometimes referred to as eyelid reduction surgery.
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Before surgery pictures: This lady complained of bulging lower eyeids i.e. eyelid bags or baggy eyelids. This patient was fed up of being told she looked tired.
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3 months following lower eyelid blepharoplasty surgery (eye bag removal surgery) to both eyes Because most GPs consider this to be cosmetic eyelid surgery, most GPs will not refer patients to the NHS for eye bag removal surgery.
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Before blepharoplasty surgery pictures: This lady complained of both overhanging upper eyelid skin (i.e. very heavy eyelids), lower eyelid bags (baggy eyelids) with wrinkling of her eyelids
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6 weeks following cosmetic eyelid surgery to all 4 eyelids. This lady has undergone upper eyelid blepharoplasty surgery to remove the excess drooping skin and lower eyelid bag reduction surgery to remove the lower eyelid bags.
How is blepharoplasty/ cosmetic eyelid surgery performed?
- default_titlePrior to any surgery, the surgeon should discuss with you what you wish to achieve, what is safely achievable and the risks and benefits of surgery. At the end of the consultation, the surgeon should be able to develop a surgical plan for that particular patient. Each patient is an individual, and the surgical plan reflects this.
- default_titlePrior to any eyelid operation, it is highly recommended that every patient should ideally undergo a formal eye examination either by the surgeon who is going to be performing the procedure or an impartial ophthalmologist.
- default_titleBlepharoplasty/ eyelid cosmetic surgery is performed commonly as a day case procedure.
- default_titleMuch like the word ‘haircut’, the term blepharoplasty describes refashioning of the eyelid in general. The procedure itself will have slight variations depending on the patient. Because oculoplastic surgeons perform more eyelid operations than any other type of surgeon, they are more equipped to offer the full repertoire of techniques to address different variations in patient anatomy.
- default_titleLike all types of eyelid surgery, blepharoplasty surgery, either for cosmetic or functional reasons, can be performed under local anaesthesia, local anaesthesia with mild sedation, or general anaesthesia.
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Upper Eyelids
- default_titleFor upper eyelid blepharoplasty, the surgeons will draw some lines on the upper eyelid.
- default_title Surgery can be performed using either general anaesthetic or local anaesthetic. The vast majority of patients opt for local anaesthesia since its is quicker and very acceptable. Sometimes the anaesthetist may administer some sedation through a vein in the back of the hand to make relax the patient further.
- default_title Removal of the excess skin is then performed using either a scalpel, carbon dioxide laser, or radiofrequency cutting device. The incisions are situated within the normal skin crease of the eyelid so that afterwards, the incision scar is hidden and becomes invisible.
- default_titleFor those patients with bulging fat in the upper eyelid, the fat is then either sculpted away or repositioned.
- default_titleAn oculoplastic surgeon can then perform any additional procedures as necessary , for example, correcting a droopy eyelid with eyelid ptosis surgery, repositioning a prolapsed tear gland, debulking of any prolapsing orbital fat or lifting/ stabilising the eyebrow position.
- default_titleThe wound is then closed with sutures. Although their removal is required, non-dissolvable sutures are sometimes used, because of their more predictable cosmetic result.
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Before Surgery: This lady complained of upper eyelid hooding, lower lid lid wrinkiing and smudgy eye make up.
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2 weeks following surgery (Upper and Lower lid blepharoplasty)
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After Upper and Lower Blepharoplasty: The patient remarked how her friends were amazed with the subtle natural improvement
Lower Eyelids
- default_titleFor patients with excess skin causing wrinkles, a skin incision can be made just below the eyelash line allowing removal of the excess skin. The incision is so close to the eyelash line that it becomes invisible within a few weeks of surgery. If there are eye bags ( which is usually caused by the normal orbital fat prolapsing forwards) this can be addressed at the same time through the same incision.
- default_titleIn those patients where skin redundancy is not an issue and the only problem is eyelid bags due to bulging orbital fat, the incision can be made along the inside of the lower eyelid (transconjunctival approach) and the fat prolapse can be addressed resulting in sutureless scarless surgery. This results in a much quicker recovery time following surgery.
- default_titleThere are various ways of addressing prolapsing fat in the lower eyelid and a good cosmetic surgeon should be able to discuss with you the most appropriate options. These include simple fat removal (debulking) to repositioning. In patients with a tear trough deformity, a popular technique which has gained popularity recently is to drape this fat over the edge of the socket and use it to replace the fat which has started to disappear on the rim of the orbit itself. Therefore, instead of simply disposing of the orbital fat, the surgeon is utilising it as a filler.
- default_titleLower eyelid blepharoplasty is technically more challenging than upper eyelid blepharoplasty due to its slimmer margin for error and riskier potential complications. For this reason, many surgeons choose only concentrate on upper eyelid blepharoplasty.
- default_titleThe surgery performed will be individual to that patient. For example, eyelid tendons may need to be tightened, the bulging fat may be excised or redistributed, the midface/cheek may be lifted, some of the wrinkles may be removed, the hollows underneath the eyelids may be softened and filled. A good cosmetic surgeon should be able to discuss with the patient a personalised surgical plan: customised to the patient's anatomy, the patient's wishes and expectations.
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This lady complained that her lower lid eyebags made her look tired. These had been present even since she was young and ran in her family. She also wanted better symmetry of upper eyelids as she felt her left upper lid looked hooded. Note the lower lid orbital fat bulging due to weakness of the orbital septum.
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1 week following left upper eyelid blepharoplasty ( an exact amount of skin was removed to match the right upper lid) and bilateral lower lid transconjunctival blepharoplasty ( fat was removed from both lower lid via an incision through the back of the eyelid). The recovery time for this surgery is very quick.
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After Upper Eyelid and Lower Lid transconjunctival blepharoplasty: This patient remarked how amazed her friends and family were following surgery.
Frequently Asked Questions
It is often advisable to have someone accompany you on the day of surgery, particularly if the surgery is performed as a day case procedure. Rarely, the eyes may be covered with pressure dressings for an hour, to help reduce the build up of any postoperative swelling. As the anaesthetic wears off, your eyelids may feel tight and sore, but this wears off quickly and is usually easily treated with simple painkillers. If the postoperative pain is severe, this may indicate a serious problem and patients should get in touch with their surgeon immediately.
You will advised to sleep upright and apply regular cold compresses to the eyelids to reduce the postoperative swelling. It is especially important to keep your wounds clean and dry. Eye drops are commonly provided to help soothe the eyes which can feel slightly dry due to temporary impairment of the normal blink reflex following surgery.
-Swelling and minor bruising is normal and peaks about 24-48 hours after the procedure.
-However 90% of the swelling usually disappears by 10 days but minor swelling may still persist for 10-12 weeks depending on the complexity of the procedure. For example, most of Mr Cheung's patients who return to work after 10-14 days often comment that their work colleagues remark that they look fresher but often do not realise that any surgery has been performed.
-Most patients return back to work about 10-14 days after blepharoplasty surgery.
- The first clinic visit following surgery is usually scheduled for 1 - 2 weeks following surgery. Mr Cheung often personally removes any skin sutures with the aid of an examination microscope to ensure there is no retention of the fine skin stitches.
-Make up can be safely used usually from the 10th postoperative day.
- Most patients are usually discharged at 3-6 months following surgery.
As with any cosmetic procedure, the patient's part in expecting a realistic outcome and understanding the potential complications is probably more important than the skill of the surgeon. Any good surgeon will take the time to chat with the patient so that they have a good understanding of what to expect and what is realistically achievable. Patients with unrealistic expectations are likely to be disappointed no matter how skilled the surgeon or good the postoperative result.
Complications are extremely rare and the vast majority of patients are extremely satisfied following surgery. The complications of blepharoplasty surgery include:
- default_titleEyelid Asymmetry: where one side does not match the other
- default_titleUndercorrection where insufficient skin/ orbital fat has been removed. It is important to be realistic about how much skin can safely be removed.
- default_titleOvercorrection-If too much skin is removed during upper eyelid blepharoplasty, the eyelid may not be able to close properly (termed lagophthalmos), which can be sight threatening. Lagophthalmos can be temporary from eyelid swelling, or permanent if too much skin from the upper eyelid was removed. The cornea (clear window on the front of the eye) may start to dry out due to the incomplete closure of the eyelid. This may be sight threatening since the cornea may ulcerate as a result. For severe cases of lagophthalmos, a skin graft or flap to replace the upper eyelid skin shortage may be necessary to allow the eyelid to function normally again.
- default_titleTemporary dry eye commonly occurs following upper eyelid blepharoplasty surgery and is commonly due to temporary impairment of the muscles involved in eyelid closure. Ocular lubricant drops are commonly prescribed for a few weeks following surgery for symptomatic relief. Less commonly though, permanent dry eye may result particularly particularly following excessive skin removal (both in upper and lower eyelid blepharoplasty) and in patients who have pre-existing problems with dry eye, tear film problems, previous refractive surgery and ocular surface problems. It is for this reason that the Dept of Health recommends that all patients undergoing any type of blepharoplasty surgery undergo a formal assessment by an ophthalmologist including testing ocular motility, tear film production and quality assessment.
- default_titleIf too much lower eyelid skin is removed, the eyelid may look hollowed out, too concave or may cause the eyelid to turn outwards leading to ectropion formation. All oculoplastic surgeons are trained to avoid this by performing additional procedures if necessary e.g. eyelid tendon tightening such as lateral canthopexy.
- default_titleScarring can also occur post-operatively, leading to a poor cosmetic outcome. Scarring following lower eyelid blepharoplasty can result in the lower eyelid being pulled out and downwards, leading to an unnatural appearance and ectropion. Corrective surgery may be necessary to address this. It can usually be avoided by meticulous dissection in the correct surgical planes and is rare in the hands of oculoplastic surgeons.
- default_titleAcute glaucoma is an rare but potentially blinding complication that can occur with any type of eyelid surgery and occurs when the internal pressure of the eye starts to rise as a result of some of the side effects of some of the drugs and injections utilised during eyelid surgery. Oculoplastic surgeons are trained to recognise and manage this complication through their general ophthalmology training. It is recommended in the US, that a formal ophthalmological assessment be performed prior to eyelid surgery to look for the potential risk factors for this complication.
- default_titleBleeding into the skin, known as a skin haematoma, after the procedure is an uncommon complication and excessive bruising leading to a collection of blood within the tissue. It is critical to stop all tablets which may increase the risk of bleeding and your surgeon should advise you about this prior to surgery. In the first few days following surgery, you should avoid any vigourous activity such as lifting, bending, since this can worsen any bruising or swelling of the eyelids.
- default_titleCorneal abrasion is when the corneal surface is damaged either due to the inadvertent trauma. This complication is extremely rare in the hands of oculoplastic surgeons.
- default_titleEyelid ptosis- Uncommonly the main tendon (levator aponeurosis) within the eyelid may be damaged during cosmetic eyelid surgery causing the actual eyelid itself to descend and stay permanently low. This complication is extremely rare for oculoplastic surgeons since they routinely operate on this structure anyway and the most experienced in recognising the complex anatomy. Indeed, oculoplastic surgeons routinely perform ptosis surgery anyway and may recommend simultaneous ptosis correction/ repair in patients who already have a compromised eyelid tendon.
- default_titleSunken eye (enophthalmos) and hollow eyelids- The fat within the socket (orbital fat) normally starts to shrink with age leading the the eyeball looking sunken over time. However, an artificially sunken eye can occur following excessive orbital fat removal. Similarly if excessive fat is removed the eyelids can look artificially hollow (sometimes known as skeletonisation). This complication occurs less commonly now surgeons have learnt to avoid it by being very conservative with orbital fat removal and performing safer techniques e.g. orbital fat repositioning.
- default_titleBy far, the worst complication of blepharoplasty and thankfully the rarest, is an orbital haematoma. Uncontrolled bleeding, usually from a blood vessel from manipulation of some of the pockets of fat, results in compression on the optic nerve and its blood supply. If left untreated, permanent blindness can occur. Early diagnosis—recognised by severe eye pain or visual changes—is critical. Urgent reoperation may be necessary to stem the bleeding point and relieve the pressure on the optic nerve. It is for this reason, that eyelid plastic operations should ideally be performed by surgeons who are experienced in handling the fat of the eye socket to not only avoid this problem but also be able to manage it quickly and safely should it arise. Oculoplastic surgeons perform more operations within the orbit and around the eyelids than any other type of surgeon and are therefore best equipped to avoid and manage this rare but fearsome complication.
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It is for all these reasons that Mr Cheung tends to err on the side of caution i.e. towards conservative blepharoplasty surgery to reduce the risk of complications and also give a more harmonious balance appearance, to try and avoid a 'plastic' unnatural look. Most complications can be avoid with careful preoperative examination, surgical planning and meticulous operative technique.
Yes you can have blepharoplasty surgery for functional reasons on the NHS i.e. if your eyelid hooding is so severe that it interferes with your visual field or if is for rehabilitation purposes from some pathological process e.g. for thyroid eye disease.
However the NHS is unlikely to fund blepharoplasty surgery purely for cosmetic purposes for the sake of rejuvenation purposes e.g. severe thyroid eye disease, amyloidosis.
For quite some time now, most CCGs (clinical commissioning groups) have brought out their eligibility criteria which patients would have to meet prior their surgery being agreed to be funded by their local NHS.
Dudley Procedures of Limited Clinical Value/ Aesthetic Policy Document 2019
Sandwell and West Birmingham/ Birmingham and Solihull CCG Policy for Cosmetic Surgery - Eyelid Surgery 2019
Cosmetic Eyelid Surgery Gallery
Before and After Pictures of Cosmetic Eyelid Surgery | Eye bag Reduction Surgery | Eyelid Lift Surgery by Mr David Cheung, Eyelid Specialist Surgery, Birmingham UK
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This lady was always troubled by lower lid bags since her 20s. Note the bulging fat baggy bulges which are due to weakness of the middle layers of the eyelid allowing forward prolapse of the orbital fat pad. Note also the tear trough groove deformity.
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1 week following lower lid blepharoplasty: This consisted of fat pad debulking and draping, orbicularis muscle tightening, lateral canthal tendon ligament tightening, skin sliver removal.
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Note the minimal swelling on the ocular surface. The incision is barely visible below the eyelashes.
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3 months following surgery: Conventional anterior lower lid blepharoplasty: The fat pads have disappeared, the wrinkling has reduced, the tear trough deformity has gone.
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The incision has become imperceptible.
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This lady complained of upper lid hooding on both sides but with the right worse than the left. Note the asymmetrical upper lid hooding. Her right eyebrow is lower than her left.
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This lady complained of upper lid hooding on both sides but with the right worse than the left. Note the asymmetrical upper lid hooding. Her right eyebrow is lower than her left.
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1 week following surgery: Bilateral Upper blepharoplasty with endotine brow lifting
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All incisons are hidden with the normal skin creases.
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Perfect symmetry at 6 weeks following surgery
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The incisions slowly continue to disappear completely.
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BEFORE Bilateral Upper Lid Lift and Right Brow Lift Surgery Again
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AFTER Bilateral Upper Lid Lift and Right Brow Lift Surgery Again
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Lower lid blepharoplasty. This 34 year lady complained of lower eyelid bags. Note the extremely thin skin leading to fine skin wrinkling, weakness of the middle layers of the eyelid leading to bulging of the orbital fat pad pockets.
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1 week following lower lid blepharoplasty. The incision is hidden under the eyelashes. Her surgery also involved draping of the fat pad to fill up the tear trough deformity, tightening up of the middle muscle layers, tightening of the outer ligaments of the lower eyelids and removing a small strip of skin to tighten up the skin.
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10 weeks following surgery: The incision has become invisible, the skin is smoother, the fat bags have disappeared. The patient was very happy.
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Combined Upper and lower lid complex multiplanar blepharoplasty: This lady in her late 50's complained of looking tired. Unfortunately she had very thin skin with weakening of the middle layers of her eyelids.
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You can see that the upper lid skin crease on HER RIGHT upper eyelid has disinserted, leading to slippage of the skin downwards. You can also see marked bulging (herniation) of the orbital fat. She has a deep tear trough deformity. The deeper muscle layers of the lower lid are also quite loose. Bespoke surgery needs to address all of these anatomical problems.
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You can see that the upper lid skin crease on HER RIGHT upper eyelid has disinserted, leading to slippage of the skin downwards. You can also see marked bulging (herniation) of the orbital fat. She has a deep tear trough deformity. The deeper muscle layers of the lower lid are also quite loose. Bespoke surgery needs to address all of these anatomical problems.
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1 week following surgery. Upper and Lower lid blepharoplasty. As with this sort of multiple plane surgery the swelling can be very marked. This sort of intense swelling is typically maximal after 48-72 hours with gradual improvement then onwards. Most patients are back to work though at 10-14 days post surgery.
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Surgery involved addressing all anatomical problems including bilateral upper eyelid anchor blepharoplasty to reform the skin crease, bilateral lower lid anterior blepharoplasty with orbital fat debulking and redraping, tear trough deformity lysis, orbicularis muscle tightening, minimal skin excision and then lateral canthopexy.
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8 weeks following surgery. This lady was very very happy. All her scars have disappeared
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8 weeks following surgery. This lady was very very happy.
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BEFORE upper and lower blepharoplasty surgery again
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AFTER upper and lower blepharoplasty surgery again.
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This lady complained of lower eyelid bags. These were due to age related weakening of the middle layer of the eyelid (orbital septum) allowing the orbital fat behind it to bulge forwards. Her quality and muscle quality were good meaning that the if we could shrink the fat bulging and strengthen the orbital septum, she would likely be happy with the cosmetic result.
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Four weeks following lower eyelid transconjunctival blepharoplasty. A small amount of fat was removed from both lower lids through an incision in the back of the eyelid. This delicate minimally invasive surgical approach means that the recovery is usually very quick avoiding the need for an incision and potential scar of the skin. Notice the eye bags have now disappeared.
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Young patients are increasingly seeking cosmetic surgery nowadays. This lady in her 20s complained that she her lower lid bags made her look tired.
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Transconjunctival lower lid blepharoplasty allows reduction of the bulging fat pockets through a small incision in the back of the eyelid. This photo taken only 1 week following surgery shows how minimal the bruising can be.
