“I’m so glad I went to Dr. Armstrong for an upper and lower blepharoplasty! I had the procedure under local anesthesia and was amazed at how quick and painless it was. Every time I look in the mirror I’m so happy I went to Dr. Armstrong.”
– Katherine Bevington
Dark circles and sagging eyelids are one of the first signs of aging — often beginning in the late 30s. These changes may be due to aging, family traits, allergies or other causes, but they can make you look tired, or older than you are. It is no surprise that eyelid surgery (blepharoplasty) is one of the 3 most common cosmetic surgeries performed by facial plastic surgeons. For many patients, the solution is as simple as removing a pinch of excess skin under local anesthesia in the office.
Blepharoplasty is plastic surgery performed on the eyelids to improve cosmetic appearance or to improve vision loss or tearing caused by aging or sagging eyelids. When the primary problem is excess skin in the upper eyelids, the surgeon removes a sliver of skin and sews it back together such that the scar is well hidden within the natural crease of the upper eyelid. Often a portion of muscle and sometimes fat is removed along with the skin for patients who have unusually heavy upper eyelids. The wound heals quickly and stitches are removed within 5 days.
Lower eyelid surgery is more variable, depending on your specific needs. Bulging fat can be removed through a small incision that is completely hidden inside the eyelid. Excess skin is usually removed through an incision hidden just below the eyelashes. The lower eyelid incision is often used for access to perform a cheek lift.
Frequently Asked Questions
The first step is to consult a well-qualified Plastic, Oculoplastic, or Facial Plastic Surgeon. Ask about training and credentialing by the appropriate specialty boards. The surgeon should take an interest in your concerns before jumping to a recommendation or decision. Before the appointment, take a good look in a mirror at various times a day and in different lighting, and write down the concerns that bother you the most. Discuss any concerns that you may have regarding your eyes with your surgeon, including vision problems, contact lenses, dry eyes, or allergies. After a thorough examination and in consideration of your concerns, the surgeon will make specific recommendations and discuss the alternatives, risks and costs of the procedure.
Eyelid surgery is most commonly performed by plastic surgeons and by eye, ear, nose or throat surgeons with additional training and experience in cosmetic surgery of the face. Experienced surgeons will often be certified by the American Board of Facial Plastic and Reconstructive Surgery , or by the American Board of Plastic Surgery .
Board-certified facial plastic surgeons have generally completed at least 6 years of surgical training specializing in diseases of the ears nose and throat as well as surgery of the face, head and neck. They have demonstrated at least 2 years of professional experience in facial plastic surgery outside of residency and their work has been thoroughly evaluated through chart review and written and oral examinations. Facial plastic surgeons specialize in cosmetic and reconstructive procedures above the shoulders, including eyelids, facelifts, nasal surgery, ear surgery, cleft lip and palate, and skin cancer.
Board-certified general plastic surgeons have completed a residency in Otolaryngology (ears nose and throat), Orthopedics (bones), or general surgery, followed by a two-year residency in plastic surgery. Plastic surgeons are trained to care for a broad diversity of cosmetic and reconstructive problems that may include facial surgery, breast reconstruction, body contouring, hand surgery and skin cancer.
Oculoplastic surgeons are eyelid specialists who have been certified by the American Board of Ophthalmology. Following initial training in medicine and surgery of the eye, these surgeons have specialized in surgery of the eyelid and surrounding structures, including the eye socket and the tear ducts.
Cosmetic facial plastic surgery is performed for your pleasure. Advance preparation can help to keep you comfortable and make this a relaxing experience. At least a week before surgery, discontinue smoking and all medications and herbal supplements that may increase the risk of bleeding. Fill your prescriptions, shop for groceries, and try to anticipate any other needs that may arise in the first week after surgery. Arrange a ride, even if you are having office surgery, as you will not be allowed to drive until we are comfortable that eyelid swelling will not impair your vision. Although some patients return to work as early as 3-5 days after blepharoplasty, it would be ideal if you have no responsibilities or obligations for the first week. You may wear make-up after a week, but it will take at least 3 weeks for bruises to completely resolve.
Take care of all financial arrangements with our surgical coordinator. If your procedure is scheduled at the Medarva Stony Point Surgery Center , be sure to take care of operating room and estimated anesthesia fees with them as well. Payment is generally expected one week before cosmetic surgery, after which time the fee is non-refundable except in extreme circumstances.
On the morning of surgery, shampoo your hair twice, wash your face thoroughly, and apply no lotions or makeup. Wear a washable undershirt or camisole covered by a button-down or zip up shirt or jacket. Avoid tight fitting pullovers, such as a crew neck or turtleneck shirt. You should have a comfortably light meal and adequate fluids before any office procedure. If you are scheduled for sedation or anesthesia at the surgery center, then do not eat for 6 hours before arrival.
It is our goal to ensure your utmost comfort during surgery. If you choose to have your blepharoplasty performed in the adjacent, fully accredited Medarva Stony Point Surgery Center , you will be comfortably sedated under the direction of our board-certified anesthesiologist. Do not eat for 6 hours before your scheduled surgery. You may have black coffee, tea or water no more than 2 hours before surgery. You should arrive at the surgery center about 1 hour early. Expect a reminder call from the nurse the afternoon before surgery. She will provide you with an updated time to arrive.
After you register at the surgery center, the nurse will invite you back to a preoperative staging area. She will review your history, obtain vital signs, and start an IV in your arm. The anesthesiologist will then examine you and discuss the anesthesia plan. With minor procedures, you will most likely be briefly sedated while the surgeon injects local anesthesia. You may be allowed to awaken during surgery, as long as you are resting comfortably following the local anesthetic. For larger procedures, you may be more deeply asleep, with a breathing tube in the airway. You will most likely awaken in the recovery room feeling that very little time has passed.
If you are the type of person who can comfortably sit still for a dental procedure, then most likely you could sit still for a blepharoplasty in the office under local anesthesia. Facility fees are reduced and there is no anesthesia fee. You will feel a momentary pinch and burn when the local anesthetic is first injected. After that you may listen to music, doze off, or chat quietly with the surgeon. The skin of your face will be disinfected and covered with sterile towels. You will feel hands working about your face, but it should be no more uncomfortable than having your teeth cleaned or your hair done.
The most common complication of cosmetic surgery is disappointment. Surgery cannot correct every visible imperfection or asymmetry, and it is most important that you discuss your concerns with the surgeon preoperatively. It is equally important to ask questions and listen to your surgeon, so that you have realistic postoperative expectations. In most cases, asymmetries and imperfections can be improved with a minor touchup in the office under local anesthesia. Severe pain, infection, and bleeding are very rare after blepharoplasty alone. Swelling of the eye surface (chemosis) and a perception of dry eyes does commonly occur after blepharoplasty. Be sure to discuss all eyedrop medications that you are taking and any symptoms of dry eyes that you may have prior to surgery. The risk of a serious injury that might leave permanent vision loss or double vision is exceedingly rare, but is always present with surgery on or near the eyes.
Medicare and most commercial insurance plans will cover blepharoplasty if medically necessary to restore vision. If you have so much eyelid skin that you cannot see above the horizon without struggling to hold your eyes open, then insurance is likely to pay for your surgery. In addition to a consultation with a facial plastic surgeon, you should also schedule an appointment with your ophthalmologist, who will measure your peripheral vision. This is called a visual field test. By examining the visual field test and by carefully examining your eyes, the ophthalmologist will determine whether the obstructed vision is due to sagging eyelids or due to a disease within the eye, such as glaucoma.
If the margin of the upper eyelid covers a portion of the pupil, then the eyelid may partially block your vision. This is known as eyelid ptosis or blepharoptosis. Occasionally, this is simply due to excessive skin weighting down the lid, and can be improved with a routine blepharoplasty and/or eyebrow lift. If lifting the excess skin does not correct the ptosis, then the cause is most likely weakness of the muscle or ligament that lifts the eyelid (levator muscle and levator aponeurosis). Muscle weakness may be caused by age, congenital anomalies, or by treatable medical conditions such as myasthenia gravis. Proper diagnosis requires a thorough examination by your ophthalmologist. Surgical treatment usually requires tightening or reattaching the ligament to the cartilage of the eyelid (tarsal plate).
Blepharoplasty is usually performed to improve your appearance rather than for treatment of a medical disease, and it is usually not covered by insurance. Performed in our office, a simple upper or lower blepharoplasty costs $2750. A combination of upper and lower blepharoplasties on the same day is approximately 2/3 more. These procedures are about one third more expensive if performed under anesthesia at the surgery center. In some cases, the eyelid is sagging such that it impairs vision or causes excessive tearing. Repair of the eyelids may be covered by insurance or Medicare if your ophthalmologist documents that it is medically necessary.
People with Asian heritage commonly request a more defined eyelid crease. Asian eyelids characteristically are fuller and have an “epicanthic fold” that covers the inside corner of the eye (medial canthus). The fold of skin often rests at the lash line, even in young women. Frequently referred to as a “double eyelid surgery,” a blepharoplasty designed to make the eyelids look more western creates a new crease distinguishing the upper half of the lid from the mobile lower half. The surgeon makes a cut at the level of the desired crease and sutures the skin to the eyelid ligament (levator aponeurosis) so that the lid folds precisely at the upper border of the eyelid cartilage (tarsal plate) when the eye is open. This leaves the lower portion of the eyelid visible, for application of mascara and eye shadow.
It is important to discuss your cosmetic goals with the surgeon. Are you trying to restore your previous youthful appearance, or do you wish to change your appearance to look less Asian?
For younger individuals, the eyelids can be temporarily improved with Botox, fillers and skin care. A more permanent improvement in the eyebrows can be achieved with a brow lift. If you have a deep horizontal forehead wrinkles, then you may have descent (ptosis) of the eyebrows. Use the palm of your hand to lift the forehead and see the effect that this has on your eyelids. Botox may temporarily relax the muscles that pull your eyebrows down, allowing them to drift upward, improving the appearance of your eyelids. This is sometimes referred to as a chemical brow lift. For a more permanent improvement in the eyebrows, including improvement in the forehead wrinkles, your doctor may recommend a forehead or brow lift. It is important for your surgeon to recognize eyebrow ptosis, because your forehead muscles may relax after upper eyelid surgery, giving you the disappointing impression that too little skin was removed. Removal of additional eyelid skin will not fix the eyebrow problem, and may make it difficult to close your eyes.
The lower eyelids are far more complex. Historically, the focus was upon removing excess skin and bulging fat. However, the removal of eyelid fat often left patients with hollowed eye sockets that did not particularly look better than before surgery. In recent years, we have come to recognize the importance of mid-face sagging and volume loss on the appearance of the lower eyelids. Rather than removing the fat, surgeons more commonly camouflage it by injecting fat or fillers into the shadows underneath the eyelid. This can often be done on the first office visit with immediate return to work or other activity. If you have thin, skin with crepe paper wrinkles in the lower lid, resurfacing with a chemical peel or laser may improve your appearance without surgery. When lower eyelid lengthening is associated with sagging of the cheeks, nasolabial folds, or jowls, the procedure can be combined with a midface lift for dramatic rejuvenation.
Eyelid surgery (blepharoplasty) is one of the quickest, least invasive procedures to improve your appearance. However, there are other options to consider, such as Botox, fillers, browlifts and cheeklifts. Blepharoplasty is most effective if you have excess skin in your upper eyelid, but otherwise youthful features. This may be a family trait that you have noticed as young as 30 years old. With natural aging, the upper eyelid skin loses elasticity and begins to droop over itself, sometimes resting directly on or below the eyelashes.
To determine if you might be a candidate for upper eyelid blepharoplasty, look in the mirror and use a small Q-tip or cuticle stick to roll the excess skin of your eyelids into the crease. If this appears to fix the problem, your blepharoplasty may be a simple as trimming the excess fold of skin in the office under local anesthesia.
If heaviness of the eyebrows is a problem, lift your forehead straight up with the palm of your hand while looking in the mirror. If this improves the appearance of your eyelids, your surgeon may also recommend a forehead lift or endoscopic brow lift.
If your upper eyelids are so heavy that they obstruct your vision, you may have a medical condition known as ptosis of the eyelids. Look in the mirror. Does your eyelid cover any portion of your pupil (the dark hole in the center of your iris)? Do you see better if you hold your eyelids out of the way with your fingers? If so, Medicare or your insurance company may be willing to pay for repair of the eyelids.
Although many patients complain of bulging fat in the lower eyelids, cosmetic surgeons have come to learn that in most cases there is not excess fat in the lower lids, but a loss of volume in the cheeks. The fat loss begins in the 20s and usually becomes apparent in the early 30’s. Take a look at old photographs from your high school and college years. Most likely, you had small shadows under each lower eyelid. With aging, these shadows are not necessarily darker, but they have sagged lower.
Smile while looking in the mirror. As the cheeks bulge upward into a smile, does this improve the appearance of your lower eyelids? Press upward with your fingers under the cheek bone to hold the cheek in place while you relax your smile. If any of these maneuvers improve your lower eyelid, you may wish to consider a filler such as Sculptra, Radiesse, Belatero or Juvéderm. Fillers can often be injected in a few minutes, with immediate improvement.
Lastly, pull down on your cheek with your fingers. Does the lower eyelid easily pull away from the eyeball? Does the eyelid snap back readily when you let go? Do your eyes frequently water or become red and irritated? If so, you may have developed a loose tarsal ligament in the lower eyelid. It will be very important to discuss this symptom with your surgeon. In some cases, repair of the ligament is medically necessary.
Medical conditions can increase the risk of eyelid surgery. Be sure to discuss your complete medical history with your surgeon, including potential problems such as glaucoma, dry eyes, thyroid disease, diabetes, hypertension, and the use of any blood thinners including Coumadin, Plavix, aspirin, vitamin E, and large doses of herbal supplements such as garlic and ginko biloba.