A Series of Articles on Eyelid Surgery (Blepharoplasty)

Lower Eyelid Surgery – Blepharoplasty

What is lower lid blepharoplasty?

One of the first areas of cosmetic concern for many patients is the lower eyelid. As we age, the fat that is around the eyes can start to move forward in the lower lid, creating the “bags” that create a shadow and make us look like we have dark circles around the eyes. Depending on your anatomy, this can occur at a very young age, but is certainly more common as we get older.
There are only a couple of ways to help with the dark circles and fat pads. A great non-surgical option is to fill in the tear trough, just below the fat pad, with a hyaluronic acid filler. This adds volume to the tear trough and smooths out the transition from the cheek into the lid. This additional volume makes the dark circle less pronounced, and helps to mask the fat pad.
The other option is a lower lid blepharoplasty. In a traditional lower lid blepharoplasty, fat and excess skin (dermatochalasis) are removed. While results can be good with this technique, the removal of fat can lead to hollowing of the lower lid and a worsening of the dark circle. For this reason I prefer to do a fat repositioning blepharoplasty. With this technique the fat is not removed, but moved down into the tear trough. This maintains the volume of the lower lid, and filling in the tear trough will decrease the appearance of the dark circles.
Dr. Martin is one of the only surgeons in the South Florida area who does the fat repositioning surgery. In addition he performs the surgery with a laser to decrease the swelling and bruising.


Many of the patients seen in the office come in because of the puffiness of the fat pads in the lower lid. If someone is young, or does not have a lot of fat prolapse, fillers are usually the best option. A hyaluronic acid such as Restylane is used, and will usually last about 1-2 years here.
If someone has more significant amounts of fat and some loose, wrinkled skin, then surgery should be considered. A fat transposition blepharoplasty would be discussed, and this is done from a trans-conjunctival approach, which is on the inside of the eyelid. If there is excess skin, a strip of skin can be removed from just below the lashes in the lower eyelid crease. Laser resurfacing can also be done to tighten the skin and improve the skin texture.

The Surgery:

To do a trans-conjunctival fat repositioning, the lid is pulled down so that inside of the lid is visible. Using a laser, an incision is made in the eyelid. The skin and muscle are elevated, and the fat pads are located. The fat is then moved down into the tear trough and sutured into position. The lid is then returned to its’ normal position. If the lid is very lax and loose, the tendon is tightened at the outer corner of the lid. A pinch of excess skin is then excised, and the skin is sutured closed. Laser resurfacing is then done to improve the skin texture in patients with lighter skin tones.


Lower eyelid blepharoplasty is done with local sedation anesthesia. Performing the surgery with only local anesthesia is not easy for the patient as the manipulation of the fat is uncomfortable. The patient will therefore have an IV placed to receive sedation. After surgery the patient will be in the recovery room for about one hour before going home.
General anesthesia is not necessary for this surgery.


After a lower eyelid blepharoplasty all patients will be bruised and swollen. This will last for at least 10 days and will vary from eyelid to eyelid and patient to patient. Ice compresses are used for the first 3 days, followed by warm compresses. An eye ointment is used 3x a day for a week. The sutures are removed in about 7-10 days. There is minimal discomfort for most patients post-op, and is usually controlled with Tylenol. The swelling can last for many weeks in some patients. If laser resurfacing has been performed, there may also be redness of the skin for several weeks.


The most troubling complication of lower eyelid surgery is ectropion. This is when the eyelid pulls down away from the eye, exposing the white sclera. This can cause redness, dryness and chronic irritation of the eye. If severe, a revision surgery will have to be performed. This usually occurs from excision of too much skin, or from not tightening a lax lid during the surgery. Other complications include chemosis which is a swelling of the conjunctiva, tearing, and dry eye. Prolonged swelling, especially of the malar fat pad can also occur.


A lower lid blepharoplasty can be combined with other cosmetic surgeries such as browlift, upper lid blepharoplasty, and face/neck lift. If a patient has a very hollow tear trough and does not have much fat in the lower lid, additional fat can be transferred from elsewhere on the body to the eyelid.




Upper Eyelid Surgery – Blepharoplasty

What is an upper eyelid blepharoplasty:
An upper eyelid blepharoplasty is the 3rd most common cosmetic surgery performed in the United States. It is a surgical procedure done to remove excess skin and fat, a condition known as dermatochalasis, from the upper eyelid. The eyelid skin is the thinnest skin on the body, so this is the area that shows the signs of aging first. Even in our 30s some people may begin to notice drooping skin on the upper eyelids. And there is certainly a genetic component to this.
As an oculoplastic surgeon Dr. Martin is uniquely qualified to perform a blepharoplasty. He did a fellowship in eyelid surgery at the renowned Bascom Palmer Eye Institute. He lectures around the world on the latest techniques for blepharoplasty, including using a laser to perform the procedure.

The Consultation:
When a patient comes to the office complaining of a droopy lid there are several things that need to be examined. First is the level of the eyebrow. Many patients have a low eyebrow. When the brow is low, the skin on the lid can will look heavy and redundant. So for many people a browlift is actually what is needed to improve the appearance of the upper lids. The browlift can be done by itself, or in combination with the upper lid blepharoplasty.
It is also important to evaluate the actual lid height to check for ptosis. Ptosis is a condition where the lid margin is low due to a weak or stretched levator muscle. If someone has ptosis and this is not corrected at the time of the blepharoplasty surgery, the eyelid will still appear droopy post-op.
The amount of excess skin and fat are evaluated during the consultation. A discussion is done to determine how much skin and fat will be removed. Excision of a lot of fat can hollow out the upper eyelid and change the appearance of the eye. We now try to preserve more fat in the upper eyelid to create a softer appearance post-op.

The surgery:
For an upper eyelid blepharoplasty, a line is marked for the lid crease, usually at about 8mm above the eyelid margin. A special instrument is then used to determine the amount of excess that can be removed. Local anesthesia is injected into the eyelid to numb up the area and also decrease bleeding. The outlined ellipse of skin is then excised with either scissors or a laser. Excess fat is also removed. If a patient has a deep sulcus (hollow upper lid) the nasal fat pad can be moved laterally to add volume to the lid and make it appear less hollow. The skin is then closed with sutures. (can add picture here of the marking on the eyelid)
Dr. Martin is one of the only surgeons in south Florida who uses the CO2 laser when performing blepharoplasty. Using the laser results in less swelling and bruising and a faster recovery.

This surgery can be done with either straight local anesthesia or local sedation. With straight local, the patient is given a pill for anxiety, but is awake and will feel the injections of local anesthesia which will burn. After that there should be minimal to no discomfort. For patients who are very anxious or sensitive to pain, IV sedation can be administered. General anesthesia is not needed for this surgery.

For the first 3 days we have patients use ice compresses over the lids to decrease bruising, swelling and pain. After 3 days warm towels can be used. An ointment is applied to the incision 3 times a day. There is very little pain with this surgery. Sutures are dissolvable, but can be removed in 7-10 days if they haven’t dissolved on their own.

Most patients will have some bruising and swelling for about 10 days, but minimal discomfort. The vision may be a little blurry, and many patients experience some dryness in their eyes. We have everyone use some artificial tears for the first couple of weeks to help with the dryness.
Full healing can take up to 6 months. Some patients will have some intermittent edema or redness of the lids during this period, but it will resolve.

The main complications with an upper eyelid blepharoplasty are under or over correction. Many patients may have difficulty closing the eye completely for the first few days post-op due to the swelling. If too much skin has been excised, closure may be impaired for a longer period of time and a dry eye can develop.
If under corrected, there will be some redundant skin present after the surgery. It is important to once again evaluate the brow height. If the brow has fallen after the surgery, there will appear to be excess skin. In those cases a browlift is needed. If the brow looks okay, and there is just some extra skin in the eyelid, this can be removed at 6 months post-op.
Other complications include dry eye, blurred vision, suture reactions, and slow healing. These will all resolve with time and appropriate intervention.

An upper eyelid blepharoplasty can be done by itself or combined with any other cosmetic facial surgeries a patient may want, such as browlift, lower lid blepharoplasty, and face/neck lift.


Upper eyelid surgery (blepharoplasty) among most common cosmetic surgeries performed

Upper eyelid surgery, called a blepharoplasty, is the #3 most common cosmetic surgery performed. As we age many people get laxity of the upper eyelid skin, and it can begin to droop down over the lid crease, creating an aged, tired appearance. The only way to correct this is with a surgical excision of the excess skin.

A blepharoplasty is done in an outpatient setting often with just local anesthesia. A blepharoplasty can be performed with a laser which decreases bruising and swelling. Most patients have about a week of downtime, and there is minimal discomfort post-operatively.

When performed correctly, an upper eyelid blepharoplasty will make you look more refreshed and less tired. For women it will also restore the upper eyelid platform for makeup.


Dr. John Martin Article Published in JAMA Facial Plastic Surgery Journal on Upper Eyelid Blepharoplasty

In a busy cosmetic surgery practice, upper eyelid blepharoplasty will be one of the most frequently performed surgical procedures performed. Often, the patient will also have a ptosis of the upper eyelid, and this must be addressed at the same time. An upper eyelid is considered to have functional ptosis when the upper eyelid margin rests 2.5 mm or less from the center of the pupil.1,2 The most common form of ptosis is involutional, in which an attenuated aponeurosis results in a drooping of the upper eyelid.3 This type of ptosis is characterized by good levator function (≥12 mm), a high eyelid crease (>10 mm), and thinning of the eyelid tissue so that the iris color can occasionally be seen through the eyelid.4


Upper Eyelid Surgeries – Blepharoplasty and Ptosis Repair

There are two types of upper eyelid surgery that are routinely performed, blepharoplasty and ptosis repair. In a blepharoplasty, excess upper eyelid skin is removed. However, many patients will also have an actual drooping of the eyelid due to a weak muscle which is called a ptosis. In these people a ptosis repair should also be performed. With a ptosis repair, the weak muscle is tightened which will elevate the eyelid and make the eye appear more open. Excess skin can also be removed at the same time to give a nicer cosmetic appearance to the eye area.


Eyelid Blepharoplasty Surgery Details

As an ophthalmic cosmetic plastic surgeon, one of the most popular procedures I perform is upper eyelid blepharoplasty. In this surgery the excess skin and fat are removed to make the eye look younger and more open. I have been doing this surgery for 20 years, and have probably performed about 5000 of these surgeries. I do the surgery with the CO2 laser, which will help to decrease swelling and bruising so that you will heal faster. The surgery is done here in our accredited surgical facility using either local or local sedation anesthesia. The patient will go home about one hour after the surgery, and post-op discomfort is minimal. The eyes are a bit swollen, and there are no patches placed over the eyes. I use dissolvable sutures, and most people can return to full activity within about a week.


Upper Eyelid Blepharoplasty

Upper eyelid blepharoplasty is the #3 cosmetic surgical procedure in the US, after breast augmentation and liposucstion. The skin of the lids is the thinnest on the body, and because of this will start to show the signs of aging at an earlier age. For patients with extra skin on the upper lids, an upper lid blepharoplasty will help to improve their appearance. Using local anesthesia , the excess skin is removed, and sometimes some of the underlying fat as well. Sutures are used to close the skin, and the scar is placed within the eyelid crease so it will not be visible post-op. There is often some swelling and bruising, but this will resolve quickly.



Eyelid skin is the thinnest skin on the body, and it is here that most of us will show the signs of aging first. The lower lids can be especially problematic, because the skin not only becomes thin and wrinkled, but the fat around the eyes can move downward into the lid to produce the swollen “bags”. These fat pads will create a dark shadow on the lid, and people will complain of the dark “circles.” This dark shadow is also called the tear trough.

In a traditional lower lid blepharoplasty, excess skin and fat are removed. While this initially produces a smooth contour to the lid, with time, most people will start to look hollow from the lack of fat, and the lid can start to look very hollow and dark again. In a newer technique called fat repositioning, instead of removing that fat, we reposition the fat over the cheek bone, to fill in the tear trough, smooth out the contour of the lid and decrease the appearance of the dark circles. It is much more rejuvenating to preserve the fat here than to remove it.

In our office operating suite, we have a CO2 laser which we use for this procedure. Using the laser helps to decrease bleeding and subsequent bruising and swelling. This surgery is usually done with IV sedation and local anesthesia. We make a small incision inside the lid to allow direct access to the fat pads, which can then be moved down into the tear trough. Once the fat has been repositioned, any loose skin is addressed. If there is a lot of excess skin, some of this can be excised with an incision that is directly under the lashes, and extending out in one of the wrinkle lines on the side of the eye. Laser resurfacing can also be done on the lids to help tighten and improve the texture of the skin. This is done with one of several lasers, depending on the degree of tightening needed, and the color of the skin.

There is little or no pain post-operatively, but the lower lids have a lot of blood vessels, so most patients will have bruising and swelling after a blepharoplasty. You will use ice packs over the eyes for the first 2-3 days, and then warm compresses. After a fat repositioning blepharoplasty you can expect a fuller, more youthful under-eye appearance.


Lower Eyelid Blepharoplasty with Fat Repositioning

At the recent Vegas Cosmetic Surgery meeting in June, there were several presentations about lower eyelid cosmetic surgery. Almost all of the speakers agreed that the best way to rejuvenate the appearance of aging lids is to add volume. In patients with large fat pockets, this is done by moving the prominent fat further down into the eyelid and placing it into what is called the tear trough. The tear trough runs from the inner corner of the lower eyelid down toward the cheek. It can often appear hollow, and is frequently darker than the surrounding skin.

In a traditional lower eyelid blepharoplasty the fat is removed from the lid. While this may look good initially, with time the lid and eye will often appear hollow with very dark circles. A much better approach is to move the fat down into the tear trough. By preserving the fat, the tear trough gets filled in and the dark circles will dramatically decrease. This can be done on the inside of the eyelid so that there is no external scar.

If a patient does not have much fat in the lower eyelid, fat can be transferred to the lid from another area on the body. Liposuction is done in the abdomen or hips, the fat is processed, and then injected into the lower lid. This fat will fill in the tear trough, and help to plump up the skin so it will appear less wrinkled.


Lower Eyelid “Bags” – What to do

One of the most common complaints from patients, even at a young age, is puffiness in the lower lids. This is due to the fat pads in the lower lid, which in some people can become chronically puffy. This is due both to the anatomy of their lower lid, and to genetics. The swollen fat can cast a shadow on the lower lid and make the tear trough area appear dark and hollow.

There are two ways to help with this cosmetically. One is to fill in the tear trough below the fat with an HA filler such as Restylane. This will make the area appear smoother and lighter and the filler should last at least a year. The other option is surgery. I prefer to do a fat repositioning blepharoplasty.

In this surgery the fat is moved down into the tear trough from an incision on the inside of the eyelid. If there is extra skin it can be removed from an incision just below the lashes, or tightened with laser. So there are 2 excellent options available to help with the fat bags in the lower lids.


One of the most exciting procedures that has become popular over the last decade is fat transfer. This is a technique where fat is taken from somewhere on the body and placed into the face. For women, the fat is usually harvested from the abdomen or hips, and in men, from the love handles.

A fat transfer can be done with just local anesthesia. The donor area is anesthetized, and after about 30 minutes, the fat is harvested with a gentle form of liposuction. The fat is gently cleaned and processed in a centrifuge, and then injected into any area of the face that could use some filling such as: the temples, lower lids, cheeks, nasolabial folds, lips, and jawline. After injection, any extra fat is stored in the freezer for future use. We expect about 40-50% of the transplanted fat to be absorbed back into the body, while the rest should remain in the face indefinitely. And if touch ups are needed, the fat in the freezer can be used for up to a year.

Fat transfers are a great way to plump up a face that has lost fat with aging. If you think of a balloon, as the balloon loses air, it becomes wrinkled. In the same way, our face deflates, becomes loose and wrinkled when we lose fat as we age. Most other fillers available are temporary, and cannot produce the degree of filling that can be achieved with fat. Fat is also a great way to help fill in any irregularities in the skin, such as old acne or other scars.

Recent studies have shown that there are stem cells in the harvested fat. Once transferred into the face, these stem cells should migrate toward the surface to help improve the texture of the skin.

Fat transfers can be done as an isolated procedure or in conjunction with other rejuvenation surgeries such as a facelift, blepharoplasty, or laser resurfacing.

Female Eyelid Lift Brow Lift

As early as in our thirties, our eyes, foreheads, and brows may begin to look heavy and tired. Wrinkles, loose skin, sagging muscles, and excess or fallen fat are all signs that sun, the environment, gravity, and time have taken their toll. Procedures that give a more refreshed, youthful look to the eye area make a big difference in overall appearance for both men and women. Upper and lower eyelid lifts (blepharoplasty) give the eye an alert, open look. Excess skin is easily removed, and fat is removed or repositioned to restore a more youthful contour. Incisions are concealed in the natural creases of the eye. The minimally invasive laser eyelid lift allows for smaller incisions, precision fat contouring, reduced bleeding and swelling, and more rapid recovery.


Forehead/ Brow Lifts can greatly reduce the heavy horizontal and vertical lines of the forehead and between the eyes. A brow lift is sometimes needed when the eyes appear heavy. It is important to know when an eyelid lift is the right choice, when just the brow and forehead need to be lifted, or when a combination of the two procedures is best. With a specialization in ophthalmic plastic surgery, Dr. Martin will help you understand exactly which procedure will give you the best result. New laser-assisted endoscopic forehead/brow lifts offer smaller incisions, reduced recovery time, and natural results. If in addition to these lifting procedures, you would like to tighten or smooth out the skin and fine lines around the eyes, laser resurfacing may be performed at the same time, for more economical, single-recovery period experience.

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