Cosmetic Eyelid Surgery/ Blepharoplasty Surgery for the Young

Am I too young to have cosmetic eyelid surgery/ blepharoplasty?

Contrary to common belief not all cosmetic eyelid surgery is performed in patients who are 40 years old plus i.e. for rejuvenation purposes.

Around 30% of the cosmetic eyelid surgery performed by Mr Cheung is for patients aged 18-35 ( Mr Cheung does not offer cosmetic surgery to patients under 18 years old).

As with all blepharoplasty surgery, success is often often dependent on careful surgical consultation, planning and meticulous surgery e.g. to create a skin crease which is harmonious with the patient’s facial features, ethnicity and cosmetic wishes.

Although Mr Cheung is happy to consider cosmetic blepharoplasty in patients from the age of 18 years old onwards; as with any cosmetic type procedure, it is vital that the patient is mature enough to consider the potential psychological/ emotional implications as well as the potential risks of any planned surgery.

For this reason, Mr Cheung would therefore normally recommend that patients only consider cosmetic surgery from the age of 25 onwards.

There are various reasons for young patients attending Mr Cheung’s cosmetic clinics but the most common reasons include:
• Young patients wanting greater exposure of their upper eyelids often to enable them to wear eye makeup or to make their upper eyelids look more symmetrical.
• Young patients unhappy with their lower eyelids looking fatty and bulging.
• Young patients feeling that their lower eyelids look tired and hollow.

This sort of cosmetic surgery is therefore designed to alter features which the patient was born with.

Upper Eyelid Anchor Blepharoplasty | Upper Cosmetic Eyelid Surgery in the Young

This sort of surgery is usually only performed by oculoplastic surgeons and involves creating newer, often higher, skin creases to increase the upper lid show (ULS) a.k.a. pretarsal lid show.
• This may involve surgery to both upper eyelids to increase the upper lid show on both sides.
• Whilst for other patients this involves performing surgery to one upper eyelid only to try to improve its symmetry with the eyelid on the other side.

Western Eyelid anatomy

The normal skin crease is formed due to the presence of an attachment between the skin and the fibres of the levator aponeurosis (main tendon responsible for elevating the upper eyelid). An anchor blepharoplasty is a specialised type of blepharoplasty which involves creating a new higher skin crease by making a incision where you want the new skin crease to be, carefully exposing the levator aponeurosis and then creating a new attachment between the skin and the levator aponeurosis by suturing the skin to the levator aponeurosis with so called anchor sutures (hence name).

Unlike older patients, young patients often do not have much excess skin to remove within the eyelid fold as one would normally do for a conventional upper eyelid blepharoplasty. Therefore to increase upper lid show safely, one cannot simply just remove skin as doing so would cause closure problems of the eyelid leading potentially to a dry eye syndrome.

By elevating the skin crease however, one can therefore increase the upper lid show safely. This sort of surgery evolved Mr Cheung’s work from incisional Oriental blepharoplasty where that sort of surgery in essence is all to do ablation of unwanted skin creases and then formation of new skin creases to the patient’s request.

Lower Cosmetic Eyelid Surgery in the Young

For most young patients attending Mr Cheung's clinics for their lower lids, their main complaint is typically of them looking either too bulging (lower lid fat bags) or slightly too hollow (tear trough deformity).

Before and One Week After Pictures of a Young Patient After Lower Transconjunctival Lower Lid Blepharoplasty

  • As the skin and muscle quality is usually excellent in young patients, these do not require treatment. Mr Cheung has therefore performed a transconjunctival lower lid blepharoplasty where the access incision is made on the back surface of the lower eyelids, thus avoiding the the need for a skin incision or risk getting a scar.
  • This young lady complained of bulging of the lower lid before surgery.
  • Surgery is typically performed under sedation and a small amount of fat is removed from the fat pockets to make them look less apparent. Recovery time is very quick and most patients are back to work after 2 weeks.


Tear trough filler treatment in the young to correct lower eyelid hollows/ dark circles

For most young patients though with hollow looking lower eyelids, surgery is NOT required. Instead these patients often do very well without surgery using tear trough filler injections of restylane

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    Tear trough deformity in a 30 year old lady. She complained that she looked tired.

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    Notice that she has some hollowing under her eyes (tear trough deformity) and a mild bulging of a fat bag

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    She complained that she had looked tired even in her teens and that this had worsened as she got older.

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    Immediately following injection of Restylane. Only a tiny volume was necessary on each side

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    Notice the single injection points when using a microcannula technique

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    There was minimal bruising and the patient can return to work the following day

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    Two weeks Restylane injection for tear trough deformity.

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    All the bruising has disappeared. The Restylane filler not only fills up the under eye hollowing but also helps disguise the mild bulging from the small fat bag

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    Before treatment again

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    After treatment again

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.
Most cosmetic eyelid surgery can performed quite safely as a day case procedure so that most patients go home the same day. It is advisable that someone you know can take you home and stay with you at least overnight just to be on the safe side. For some patients attending from outside the Midlands, particularly those undergoing complex surgery, Mr Cheung may advise staying overnight in the hospital or in a nearby hotel.

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. About 50% of Mr Cheung's cosmetic patients are from outside the West Midlands region and undergo this surgery quite safely as a day case procedure. Most travel between home and hospital for their consultations and surgery to reduce accommodation costs.
Yes (and No).

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

..Now I understand why there’s a waiting time to see you and for surgery! You were so worth the wait though. I bit more expensive than my local plastic surgeon but so much more thorough. The plastic surgeon I saw before I saw you didn’t do half the tests that you did. I had total confidence in your care. Now to save up for my lowers! Thanks so much David!
Miss MB (Bristol). Surgery performed: Bilateral upper eyelid blepharoplasty with ptosis correction under local anaesthetic at the BMI Edgbaston Hospital, Birmingham