Blepharoplasty
The eyes are the first thing to convey tiredness, and the first to reveal age. But "I have bags" or "my eyelids droop" are not diagnoses: they are symptoms that can arise from four different structures, each treated differently. A significant part of my work in consultation is precisely telling which is the real cause, because operating on the wrong structure does not improve the look — sometimes it makes it worse.
When is it recommended?
- Excess upper-eyelid skin that weighs on the gaze or even reduces the visual field.
- Lower-eyelid bags that protrude beyond the contour of the cheek.
- A permanently tired appearance despite resting well.
- A marked groove between the lower eyelid and the cheekbone.
My approach
On the lower eyelid I am deliberately conservative, and that decision has a reason. For years eyelid surgery meant removing: removing skin, removing muscle, removing fat. The medium-term result of that philosophy is recognisable from across a room — the hollow, skeletonised eye that ages a face more than the bags it set out to correct. Today the criterion is the opposite: remove only what is necessary, and in many cases reposition the fat to fill the groove rather than excise it. The goal is not an empty eyelid, it is an eyelid that looks rested.
Four structures, four different treatments
When I assess a lower eyelid I analyse skin, muscle, fat and cheek support separately. Excess skin is checked by gently pinching with the gaze directed upward, and its amount decides whether an external incision is needed or whether operating from inside the eyelid is enough. Orbicularis muscle hypertrophy shows when squeezing the eyes shut or smiling broadly. Fat requires distinguishing a true herniation — the bag protrudes beyond the plane of the cheek — from a false one, where the bag only looks large because the cheekbone has lost projection. And cheek support conditions the outcome of everything above. The surgical plan comes from that analysis, not from the initial complaint.
Not every dark circle needs surgery
This is probably the complaint that most often ends in a recommendation not to operate. The word "dark circles" covers very different things. When colour predominates — a violet or brown tone from pigmentation or from vascular show through thin skin — surgery adds nothing, because there is no volume to correct; the approach is dermatological. When the groove predominates but the fat is not truly herniated, the problem usually lies in a lack of cheekbone projection, and is better treated by adding volume than by removing it. And when morning puffiness or fine wrinkles predominate, medical causes must be ruled out first and surface treatments considered. Only when the bag is a true herniation does surgery make sense.
Droopy eyelid: is it the lid or the brow?
This is the most common confusion on the upper eyelid, and getting it wrong has consequences. When it is the brow that has descended, operating on the eyelid and removing skin does not fix the problem: it can even lower the brow further and accentuate the heavy-lidded look. There is also a third possibility that should always be ruled out, true eyelid ptosis, where the lid covers part of the pupil because the levator muscle has weakened; that case requires a different surgical manoeuvre, not a simple skin excision. That is why in consultation I always assess brow position, actual eye opening and symmetry between sides before proposing anything.
Recovery
It is one of the fastest-recovering facial operations. Upper-eyelid sutures come out around day five to seven, and most patients resume social life between 7 and 10 days, helped by sunglasses in the first days. Swelling and bruising peak at around 48 hours and then subside quickly. When only the inside of the lower eyelid is operated on, with no external incision, recovery tends to be even more discreet. A sensation of dry eye or mild tightness for a few weeks is normal and temporary.
Frequently Asked Questions
Are the scars visible?
On the upper eyelid the incision hides in the natural crease and is concealed when the eye is open. On the lower lid, when the issue is only the bags, it can often be operated from inside the eyelid with no external scar; if there is also excess skin, the incision sits just beneath the lashes and likewise ends up very discreet. The eyelids are one of the areas of the body where skin heals best.
How long does a blepharoplasty result last?
It is among the longest-lasting facial operations. On the upper eyelid the result typically holds for 10 to 15 years, and many patients never need a second procedure. On the lower lid, the fat that was removed does not build up again. What does continue is general ageing: skin keeps losing elasticity and the brow may keep descending, so years later some heaviness can reappear, though almost never to the previous degree.
Can it be combined with other procedures?
Yes, and often it is the most sensible option. The most common combination is with a brow-tail lift, when brow descent contributes to the problem. Fat grafting into the tear trough or cheekbone is also frequently associated, precisely to avoid leaving the eyes hollowed. And in patients who also consult about the midface or neck, blepharoplasty integrates naturally into a facelift, taking advantage of a single anaesthetic and a single recovery.