With age, gradual morphological changes occur around the eyes, within the eyelids themselves, and in the structural relationship between the eye socket (orbit) and the midface. These changes in position, structure, and contour result from a combination of gravity, skin laxity, structural tissue atrophy, and the continuous action of the orbicularis oculi muscle surrounding the orbit.
Upper Eyelid Changes: Aging causes eyebrows to descend compared to their youthful position, along with skin excess and bulging fat pads. This creates a tired, heavy appearance, narrows the field of vision, ages the face, and makes makeup application difficult.
Lower Eyelid Changes: Changes include elongation of the lower lid and orbicularis muscle, descent of the eyelid-cheek junction (lid-cheek junction), development of tear trough hollows, and progressive tissue laxity. These shifts lead to a hollow, elongated, and skeletal appearance around the eyes. Crow’s feet (smile lines) also form at the outer corners of the eyes.
Blepharoplasty removes excess skin and bulging fat pads. Lower eyelid laxity can be corrected by anchoring the eyelid structure to the lateral orbital rim. When tear troughs or the lower bony orbital rim are pronounced, fat can be repositioned rather than removed to fill depressions, restoring a smooth, youthful contour to the lower eyelid.
Upper eyelid surgery is typically performed under local anesthesia. The surgical incision is hidden within the natural upper eyelid crease—positioned approximately 9 mm above the lash line in women and 8 mm in men—extending laterally into a natural laughter crease. Excess skin is precisely marked and removed, along with a thin strip of muscle and the protruding medial fat pad near the inner corner of the eye.
In cases with hollow upper eyelids, fat pads are preserved and repositioned rather than excised to maintain a youthful volume. In many instances, a temporal brow lift via a short incision at the anterior temporal hairline is combined with upper blepharoplasty. This is essential because brow-supporting ligaments relax over time, causing the eyebrow to descend. A narrowed distance between the brow and lash line exacerbates upper lid heaviness. Occasionally, a high brow position represents a compensatory habit to clear the visual field; removing lid skin alone without addressing the brow can cause the brow to drop postoperatively once compensation is no longer needed.
The surgical approach is determined during the preoperative evaluation by assessing skin quality, skin excess, and the presence of fat herniation.
Transconjunctival (Internal): The incision is placed inside the lower lid along the conjunctiva. This approach is ideal for patients with fat herniation without skin laxity or excess skin.
Subciliary (External): The incision is hidden just beneath the lower lash line. Fat compartments are exposed and bulging fat pads (the lower lid contains three compartments) are addressed.
Fat Repositioning & Blending: When the tear trough deformity is prominent along the inner lid extending toward the cheek, or when the lower bony rim is exposed, fat is redistributed and secured over the bony rim to smooth hollows.
Laxity Correction (Canthopexy/Canthoplasty): Lower lid laxity is addressed by securing the lid margin to the lateral orbital rim, preventing lower lid droop (ectropion) and restoring an almond-shaped eye contour.
Midface Elevation: When lower lid elongation and a dropped lid-cheek junction are present due to midface sagging, a midface lift can be performed through the subciliary incision. The orbicularis muscle is mobilized and anchored higher toward the temporal fascia, restoring a youthful, convex volume to the cheek and lower lid.
Recovery typically takes approximately one week. Minor bruising gradually fades. During the first 48 hours, cold compresses and sleeping with the head elevated are recommended. Lubricating eye drops during the day and an ophthalmic gel at night are used to protect the cornea and prevent dryness while early swelling resolves. Sutures are removed on day 6. Incision scars are well-concealed and become virtually unnoticeable within a month.
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