Eyelid surgery (known as blepharoplasty) is a corrective procedure that can remove excess wrinkles, and provide a more youthful appearance to the eyes. One of the first things noticed about a person is their eyes. During the aging process, wrinkles, lines, and puffiness contribute to a tired or aged appearance. The blepharoplasty surgery is often performed in conjunction with other facial procedures such as a face lift or rhinoplasty (nose surgery).
Reasons for Considering Eyelid Surgery:
General Procedure
The surgical procedure includes incisions made in the natural contours around the eyes which should leave hardly any visible scarring in most cases. The surgeon will usually work on the upper eyelids to remove excess tissue and tighten loose skin. Upper eyelid surgery can be completed under just local anesthesia, and the risks are quite low.
Lower eyelids are operated to improve contour. There are more issues and risks with lower eyelid surgery. General anesthesia may be necessary when lower eyelid surgery is performed from inside the lower eyelid.
Recovery Process
Normally, post-operative instructions call for rest and limited movement in order to speed up the healing process and reduce the recovery time. Patients report minor pain associated with surgery which can be treated with oral medication. While complications are not usual, patients can minimize the risk for potential problems by carefully following the post-operative directions given after the surgery. The benefits are long-lasting. Patients will have a more rested and youthful appearance.
For more details, please see the following informational article that was published for other types of doctors.
BLEPHAROPLASTY, A CLOSER LOOK AT THE EYES
Signs of aging often appear first in the periocular area, and people are attentive to the appearance of these “windows to the soul”. Cosmetic eyelid surgery is the most common aesthetic procedure performed plastic surgeons.
Factors which can adversely affect the appearance of one’s eyelids include sun exposure, habits (squinting, smoking), age, heredity, recurrent bouts of swelling (related to the menstrual cycle, systemic disease, etc.), unusual or asymmetrical eyeball size, and forehead/eyebrow sagging,.
Blepharoplasty improves dermatochalasis, which is what people often call “baggy eyelids”. Excess skin in the upper eyelids can be removed, which makes this area appear more youthful. A lesser amount of skin can be removed in the lower eyelids, which results in some smoothing of the skin adjacent to the lower lid margin. As we age, fat which used to be inside the bony cavity surrounding the eyeball moves forward out of the eye socket. This produces bulging “bags” above and below the eyelids. And this can also be improved by blepharoplasty. Blepharoplasty can make a person look and feel more awake and enthusiastic.
Blepharoplasty alone does not necessarily improve wrinkled or baggy skin much below the level of the bony rim of the orbit. Eyelid surgery does not have major effects on ”crowsfeet”, nor does it alter skin characteristics. Eyelid surgery cannot compensate for asymmetry in eyeball size or position. Nor does it alter the bony contour of the orbit. When eyelid-related “bags” fluctuate in size, this is not improved, and may be worsened by, blepharoplasty. Interestingly, when a person’s eyebrow position is low, that person’s forehead (frontalis) muscle tone is often habitually increased, in order to prevent further lowering of skin and tissue onto the upper eyelid area. Then when excess upper eyelid skin is surgically removed (with blepharoplasty), the person’s frontalis muscle tone decreases. The brow often then descends, resulting in an upper eyelid appearance which is not very different from the preoperative condition in these individuals.
Relative and absolute contraindications to blepharoplasty include significant ptosis (drooping) of the eyebrows (see above), eyes which are prominent in relation to the lower and/or lateral bony orbital rim, lower lid laxity, systemic conditions such as excessive bleeding, and symptoms of “dry eyes”.
There is a moist “tear film” over the eyeball, which has three layers. An inner layer of mucous (layer 1) adheres to the eyeball itself, and this mucous attracts and holds an overlying thin layer of the water-like tear liquid (layer 2). (This water-like liquid is the component of tears that can run down the face when crying.) The outer layer is composed of oil (layer 3), which slows evaporation of the tear film. A deficiency of any one of these layers results in “dry eye” symptoms. When the eye is irritated or dry, the large lacrimal glands reflexively secrete large amounts of the (layer 2) water-like liquid, which can paradoxically result in excessive tears, even when the person’s eyeballs do not have a uniform protective three layer tear film.
Important points to cover in the preoperative work-up include findings related to the above issues, family history of eyelid abnormalities, thyroid disease, tobacco use, and prior eyelid surgery. Visual acuity and eye movement is assessed. The surgeon looks for upper eyelid ptosis, symmetry of eyebrows and lids, and the position of the lacrimal glands and tear drainage puncta. Frequent blinking can be a sign of inadequate tears. Lower eyelid tone/elasticity is carefully assessed by pulling each lower lid forward and watching the speed of lid recoil: this is repeated after pulling each lower lid downward. Bulges of hypertrophic orbicularis muscle are noted, as these will be excised during the surgery. “Festoons” of muscle which droop toward the malar/maxillary areas are also noted, as they can be improved via plication and contouring.
The most common procedure that I perform is upper blepharoplasty with removal of excess skin and some excess orbicularis muscle. This can be accomplished in an appropriate treatment area under local anesthesia only. If the doctor is patient, 
knowledgeable and methodical, the anesthetic causes very little discomfort. The amount and shape of the skin to be removed is very carefully drawn on the eyelid skin. The corner of the eye that is toward the temple is called the lateral canthus. The lateral end of the skin removal pattern usually extends one to 2.5 centimeters beyond the lateral canthus (but not as far if a forehead lift is also performed or planned). Patients are usually surprised at how much skin can be removed. If there is not a large amount of excess fat (bulging) in the upper eyelid, this may be left alone, because there will be some fat loss with additional aging, and risks and recovery are affected by the removal of such fat. Good results usually last for many years, as shown on the left. (Procedure not performed on the lower eyelid in this case.)
The lower eyelid presents a unique challenge, because if the lid were to be pulled downward by the surgery, a “staring” appearance can result. This usually means that less skin can be safely removed than the patient may desire, and even fat bag removal can cause subsequent scarring, which can also pull the eyelid inferiorly. Thus, lower eyelid fat bag removal or repositioning is often performed via an incision in the conjunctiva. This fat can be removed, repositioned back into the orbit, or brought down over the orbital rim to fill the depression beneath the “bag”. Also, it is not uncommon to tighten the lower eyelid (“canthoplasty”) at the same time as blepharoplasty. Several methods of canthoplasty are used. I most often use a technique of suturing the lateral canthal tendon upward and laterally to the periosteum of the lateral orbital rim at about the level of the upper edge of the pupil. Despite appropriate care, some patients develop a sagging of the lower eyelid after lower blepharoplasty. This usually resolves spontaneously, but there are a number of surgical options to surgically improve this condition, if it should become necessary to do so. After the above issues are addressed, there is usually still visibly wrinkled lower eyelid skin; this can be improved using a “resurfacing” technique, but not without all of the recovery and side-effect issues that resurfacing entails. Because of the above issues, lower blepharoplasty very often is performed under general anesthesia, which requires the use of an accredited operating room, and the addition of these prerequisites influences the recovery and dramatically increases the cost.
If the patient and doctor agree that the potential benefits outweigh the risks, a surgical plan is formulated. The goal is to provide maximal improvement while minimizing the risks. Sometimes, raising the eyebrows via a forehead lift (without blepharoplasty) is most appropriate. A forehead lift can be performed at the same time as blepharoplasty, or at a later date. The recovery after blepharoplasty varies quite a bit between patients even when similar procedures were used. Sutures are removed within a week. The portions of scars that extend lateral to the lateral canthus are barely visible at first, becoming more red over the first six to eight weeks, and they usually eventually fade to nearly invisible. Makeup can be applied after sutures are removed. Few patients have enough pain to warrant more than about two doses of pain medication. Some patients are not quite able to completely close their eyes for the first few days, and special eye care is necessary to prevent corneal drying in these cases. I prepare patients for the “worst case scenario”, which means that swelling can interfere with visual fields, and bruising can last up to three weeks.
In addition to the possible complications alluded to above, in rare cases, a bruised appearance can last for a few months. In the very rare cases where blindness has occurred, it has apparently been due to bleeding which tracked posteriorly, interfering with optic nerve function. Infection is also rare, as is corneal injury. Ptosis (eyelid droop) can occur due to separation of the levator palpebrae aponeurosis (a sheet of fascia which connects the muscle which raises the eyelid to the rim of the eyelid). This is rare, but can occur in an elderly patient with pre-existing weakness of this structure, for example. If ptosis is present preoperatively, it is difficult to obtain perfect symmetry; thus several techniques for postoperative adjustment are described in the literature. Very often, blepharoplasty improves upon a patient’s pre-existing asymmetry, however, if some asymmetry persists for several months, a second “touch-up” procedure is easily done. Skin conditions, such as vascular telangiectasias can be worsened by blepharoplasty.
This article highlights that the procedure of blepharoplasty itself is not extremely complex, but patient evaluation and the judicious use of adjunctive procedures requires some sophistication. You are now well on the way to a good understanding of the benefits and enigmas of aesthetic eyelid surgery.