Upper blepharoplasty: surgery for sagging upper eyelids

What is upper blepharoplasty?

Upper blepharoplasty corrects the typical changes that develop around the eyes with age, and its results affect not only appearance but also function ^[1]. The traditional approach removes loose upper eyelid skin and muscle, along with fat when needed ^[4].

An evidence-based review summarized the core of upper eyelid surgery as removing loose skin and placing the eyelid crease (supratarsal crease) in an attractive position, adding that a deeply hollow upper eyelid can be filled with injections when needed ^[2]. Upper eyelid surgery is described as usually not requiring fat removal, working in shallower layers than lower eyelid surgery, and generally being performed through an incision on the skin side ^[2].

The review also notes that it is a relatively short procedure that can be done under IV sedation or local anesthesia alone ^[2]. The type of anesthesia and the extent of surgery may vary depending on the condition of your eyelids and any procedures done at the same time.

What to consider with older eyelids

Upper blepharoplasty in older adults is described as needing to achieve a more youthful look and harmony with the rest of the face at the same time ^[3]. The most important goal is to correct sagging upper eyelid skin, and a double eyelid may or may not be created in the process ^[3].

In older adults, the skin and the muscle around the eye (orbicularis oculi) are thin, and the fat under the skin and behind that muscle has also decreased, so in most cases removing skin alone is said to be enough ^[3]. Removing a lot of soft tissue can lengthen recovery, and pulling the lower skin too tight can make the face look harsh and severe, so some fine wrinkles are sometimes left in place for a more natural look ^[3].

Brow position matters too. Many patients keep their brows raised to compensate for drooping eyelids, and once the droop is corrected the brows may come down, a condition called brow ptosis ^[3]. For this reason, it is stressed that these changes should be anticipated before surgery and the amount of skin to remove should be estimated precisely ^[3].

East Asian eyelids and whether to create a double eyelid

As the anatomical differences between East Asian and Western eyelids have become better understood, upper blepharoplasty for East Asian patients has developed into modified techniques ^[6]. Its goal is described as creating an attractive, long-lasting upper eyelid crease ^[6].

Whether to create a double eyelid in an older eyelid should be decided after fully discussing the pros and cons. One author said he prefers to create a double eyelid unless the patient does not want one, explaining that it is an efficient way to correct sagging skin and keep it from sagging again ^[3]. Because this is an opinion based on one expert's experience, it is best to consider your own features and preferences as well.

Additional techniques that refine results

One review notes that a broader understanding of the anatomy behind aging around the eyes has led to more successful and reproducible results, and it places particular emphasis on planning before surgery ^[5].

Recent studies of the shape and tissue structure of the area around the eyes have prompted a fresh look at long-held ideas about how it ages, and a number of modified and additional techniques aimed at improving results have emerged from this work ^[4]. The examples described in one review are listed below, and the review also covered the complications and aftercare for each technique ^[4].

• Repositioning fat on the nasal (inner) side of the upper eyelid
• Preserving the orbicularis oculi muscle
• Adding volume to the outer part of the eyelid
• Resecuring the tear gland
• Lifting the brow from the inside through the eyelid incision (internal brow elevation)
• Removing the muscles between the brows

Effects on eye function and complications

Many studies have reported that upper blepharoplasty affects the cornea, eye pressure, dry eye, and quality of vision ^[1]. A 2023 systematic review examined 20 studies and performed a meta-analysis on 9 of them, comparing eye pressure, corneal thickness, corneal astigmatism, vision, tear production tests, and tear film breakup time by type of surgery ^[1].

The meta-analysis did not find significant results ^[1]. The authors also noted that several individual studies had reported effects from surgery, and concluded that few complications were reported and that patients were satisfied with the cosmetic results ^[1]. The level of evidence for this review is III, which limits how firmly its conclusions can be drawn ^[1].

An evidence-based review explained that complications from upper eyelid surgery are uncommon with current techniques ^[2]. Uncommon does not mean they never happen, so if you have dry eye symptoms or an eye condition, it is best to mention it in advance and have it checked.

What to ask during your consultation

The results of upper eyelid surgery depend on how much the skin sags, where the brow sits, the thickness of the skin and muscle, and the look you want ^[3]. Several reviews stress that planning before surgery is important to the outcome ^{[2, 5]}, so we recommend going over the following points during your consultation.

• How much loose skin there is and how much will be removed
• Whether you habitually raise your brows, and how your brow position might change after surgery
• Whether to create a double eyelid, and the pros and cons
• Any existing eye conditions, such as dry eye
• The type of anesthesia, recovery time, and expected complications