Patients over 40 usually have more skin laxity. In these patients, laser treatment alone may not produce enough skin tightening to adequately take up the slack. An external, transcutaneous approach with skin resection works better (See Illustration).


Eyelids—Early Signs of Aging

Often in their 40s, but sometimes much earlier, many men and women complain that they “always look tired.” This is frequently an inherited condition. They recognize the same problem in their mother or father. The sign of facial aging usually start with the eyelids. The skin relaxes, the fat bulges forward, wrinkles develop, and a crease forms along the orbital rim, defining it and demarcating it from the cheek. The curved depression that runs from the inner corner of the eye down onto the cheek, just where a tear would travel, is aptly named the tear trough. The demarcation between the lower lid and cheek, called the “lid-cheek junction” is not to be found on models. In youth, the lower lid blends imperceptibly into the cheek.

Eyelid Rejuvenation: Cosmetic and Functional

Patients usually come in with cosmetic concerns—looking tired—and are pleased to learn that there may be functional benefits too. Extra skin may weight down the upper lid, causing an uncomfortable feeling of heaviness. This skin fold can interfere with makeup application. Older patients may find that the extra skin fold of the upper lid is starting to restrict their vision. They find themselves subconsciously lifting their eyebrows not only to see, but to appear to be awake! They don’t want to give the impression that they are not alert, which is obviously socially undesirable. Some of my patients have told me that looking tired all the time seems to make them feel tired too.

Fortunately, this condition is very treatable, and surgery can produce dramatic results. In fact, eyelid surgery is one of the most gratifying procedures for both the patient and the surgeon. The upper lids may be treated alone or in combination with the lower lids. The lower lids may be treated alone, but usually all four eyelids are treated at the same time.

Wrinkle Treatment

Laser resurfacing may be used simultaneously to treat wrinkles around the eyes, crow’s feet, and over the bridge of the nose. Eyelid surgery on its own does not treat crow’s feet because these lines extend off to the side, beyond the end of the eyelid incisions, which are used to tighten the skin. Often Botox injections are used to soften crow’s feet by relaxing the underlying muscles that compress the skin and form the wrinkles in the first place.

Saggy Eyebrows Require a Brow Lift

Epicanthal Fold Correction
L.G., Age 28
Procedure: Upper and lower transconjunctival blepharoplasties with release of epicanthal folds.

Before, 3½ months after


S.S., Age 29
Procedure: Upper and lower blepharoplasties.

Before, 6 months after


Dark Circles

R.M., Age 30
Procedure: Lower blepharoplasties, fat injection of the tear troughs (5 cc), and periorbital (around the eyes) CO2 laser resurfacing.

Before, 4 months after


DI 33.
Procedure: Lower transconjunctival blepharoplasties, facial fat injection, periorbital laser resurfacing, and excision on nasal skin lesion.

6 weeks


L.M., Age 35
Procedure: Upper and lower blepharoplasties

Before, 2 months after

L.M., 3½ years after (with makeup)


Inherited Baggy Eyelids
J.H., Age 37
Procedure: Upper and lower transconjunctival blepharoplasties, and periorbital CO2 laser resurfacing.

Before, 1 month after



Transconjunctival Approach
L.K., Age 37
Procedure: Lower transconjunctival blepharoplasties and periorbital CO2 laser resurfacing.

Before, 10 days after



S.S., Age 38
Procedure: Upper and lower transconjunctival blepharoplasties, release of epicanthal folds, erbium laser resurfacing, excision of skin lesions of right upper eyelid and right infraorbital rim.

Before, 5 months after

7½ months after (with makeup)


D.T., Age 40
Procedure: Upper and lower blepharoplasties.

Before, 1 month after


Tear Trough Correction
C.M., Age 40
Procedure: Upper and lower blepharoplasties and facial fat injection (26 cc). Second procedure, 6 weeks later: CO2 and erbium laser resurfacing.

Before, 10 months after



T.A., Age 42
Procedure: Lower blepharoplasties, facial fat injection (27 cc), and periorbital CO2 laser resurfacing

Before, 1 year after



Correction of a “Tired” Look
D.S., Age 44
Procedure: Upper and lower transconjunctival blepharoplasties and periorbital CO2 laser skin resurfacing

Before, 7 weeks after

7 weeks after



J.L., Age 46
Procedure: First Procedure: Fat injection of lower face (13 cc) and perioral (around the mouth) CO2 laser resurfacing. Second procedure, 15 months later: upper and lower blepharoplasties, facial fat injection (41 cc), excision of forehead skin lesion, full face CO2 laser resurfacing, Botox Cosmetic injection of forehead and crow’s feet.

Before, 3 months after 2nd procedure.



S.Y., Age 49
Procedure: Upper and lower blepharoplasties, Botox injection of forehead and crow’s feet.

Before, 2 months after

S.Y., 4 days after


K.H., Age 50
Procedure: Upper and lower blepharoplasties, excision of facial skin lesions, fat injection (24 cc), endoscopic forehead lift, and erbium laser resurfacing.

Before, 14 months after

Full Facial Rejuvenation
D.B., Age 51
Procedure: Upper and lower blepharoplasties, facelift, submental lipectomy, fat injection (18 cc), tip rhinoplasty, endoscopic forehead lift, and CO2 laser resurfacing

Before, 1½ years after

Y.M., Age 52
Procedure: Upper and lower blepharoplasties, excision of skin lesions. Second procedure, 8 months later: periorbital CO2 laser resurfacing.

Before, 9 months after (1 month after 2nd procedure).

Dark Circle Correction
D.S., Age 77
Procedure: Upper and lower blepharoplasties, facial fat injection (32 cc), excision of skin lesion of right cheek, and full face erbium laser resurfacing.

Before, 6 months after


K.O, Age 39
Procedure: Upper and lower blepharoplasties, submental lipectomy, erbium laser treatment of brown spot on right cheek.

Before, 6 months after

E.I., Age 42
Procedure: Upper blepharoplasties and septorhinoplasty.

Before, 3 months afterJ.C., Age 45

Procedure: Upper and lower blepharoplasties

Before, 2 months after

RM. 60


Avoiding Overtreatment

Traditionally, both skin and fat have been removed from the eyelids, prompting one surgeon to deride older techniques as “blepharectomies.” Today, we recognize the problems with such procedures. They can produce hollowed-out eyelids, which are not at all youthful. Many older women treated with these techniques have this unfortunate appearance. Men worry that they will have an overly alert or “deer in the headlights” appearance. Some older male actors and celebrities have overly rounded eyes, which look effeminate. In male models, the lower lid is almost horizontal. This looks masculine. In both men and women, it is essential for the surgeon to avoid changing the shape of the eyes.

Tissue Preservation

Today the emphasis is on preservation of tissues and avoidance of over-resection of skin or fat. I no longer trim any muscle from the upper lids, which I was trained to do routinely in residency. Any fat removal from the upper lids is conservative. I remove just what is “poking out” and nothing more.

Fat Injection for Tear Troughs

Although some surgeons have advocated transposing the fat pads of the lower lids into the tear trough areas, I have found that this is inadequate. I prefer to trim the fat pads where they cause bags, and transfer fat into the tear trough using fat harvested from another source (usually the tummy). I can introduce a greater volume of fat this way, bringing a net increase to the face.

Tightening of the Lower Lid 

One area of controversy in plastic surgery is whether the lower lid should be “tightened” or “anchored” at the time of the lower blepharoplasty. There are some old reconstructive techniques that shorten the lower lid horizontally, reducing its width. Some surgeons advocate doing this almost routinely on older patients to avoid or treat any tendency for the lower lid to sag. The problem is that any shortening of the lower lid makes the eye look smaller, the “beady-eyed” look, which is impossible to correct. Larger eyes are attractive and any surgery in the corner of the eye can leave a noticeable malalignment. Consequently, I avoid routine shortening of the lower lid (canthoplasty).


The surgery may be performed with the patient either awake or asleep. If just the upper lids are treated, this is usually done awake, under local anesthesia alone. The patient just has to tolerate a few needles and then there is no pain at all. The procedure takes 30 minutes or less and is easier than a trip to the dentist because you don’t have to hold your mouth open. The lower lids are usually treated under intravenous sedation because the fat pads are typically treated and there can be a little discomfort caused by pulling on the fat pads.

Laser Treatment of Wrinkles 

I am cautious in using the laser around the eyes. Usually I perform just one pass with the CO2 laser. Because the skin is so thin, too many passes with the laser may cause the skin of the lower lid to tighten too much, causing unsightly traction on the lower eyelid. Some lines and creases persist, and others will appear over time. One of the advantages of laser treatment is that it may be repeated. I tell my patients that they will likely return for “maintenance” laser treatments and fat injections. It is better to be cautious and accept some persistent lines than to risk complications from an overly aggressive treatment. Almost all bad outcomes from laser resurfacing have been caused by overtreatment.

Commonly, patients elect to have full face laser resurfacing (not just around the eyelids) to treat signs of aging on other facial areas. Usually these patients are in their 30s and 40s who have developed early skin wrinkling and blemishes from sun exposure in addition to bagginess of the eyelids. They figure that if they are going to be off work for a week or so, they may as well take advantage of this time off to rejuvenate their facial skin.


The incision for the upper lid is placed within the crease above the eyelid. The incision is inconspicuous in this location. Fortunately, eyelid skin heals exceptionally well. Even patients whose scars heal poorly on other parts of the body find that their eyelid incisions heal nicely.

Of course, the amount of skin removed depends on the amount of excess tissue, which may be more than most patients realize. In the past, surgeons often placed the upper lid incision too high, leaving a scar where it was visible. The scar tends to be very well-hidden if it is placed lower, in the lowest crease of the upper lid. This level is typically less than a centimeter from the lid margin (See Illustration).

The incision for the lower lid may be placed either just below the eyelashes, which is the traditional transcutaneous approach, or on the inside of the eyelid—the transconjunctival approach—where it is completely hidden. A surgical error is to make the transcutaneous incision too low; it should hug the eyelashes where it will be almost invisible when healed.

The incision for both the upper and lower eyelid (when the external incision is used) extends laterally about a centimeter beyond the outside corner of the eye (lateral canthus). This extension of the incision is necessary to sufficiently remove excess skin.

Selection of Internal vs. External Incision

What determines the approach—transcutaneous or transconjunctival? One factor is whether or not laser resurfacing is to be performed simultaneously. Laser resurfacing causes the skin to tighten a little, so that it may not be necessary to cut out extra skin. An external incision that trims extra skin may be avoided. I prefer to use the “scarless” transconjunctival incision (inside the lower lid) when treating young patients (under 40) with baggy lower lids but minimal skin laxity. This incision is placed well on the inside of the eyelid so it is completely invisible. Through this incision, the extra fat is trimmed, removing the bags. The incision is closed with an absorbable suture.

Dark Circles

The label “dark circles” is a refreshingly easy term to understand, referring to the semicircular areas of dark discoloration of the lower eyelids that extend to the orbital rims (the lower border is the tear trough).

Dark circles are thought to be caused by hyperpigmentation of the skin and translucency, such that the dark color of the muscle under the thin skin shows through. In the past, dark circles have been notoriously difficult to treat. Fortunately, we now have more to offer.

Laser resurfacing and fat injection have helped to make dark circles a treatable condition. The three techniques—lower blepharoplasties, laser resurfacing, and fat injection—can be used in combination to provide maximum improvement, as demonstrated by some of the patient photos in the next section.

Laser Resurfacing Adds to Recovery 

Patients who have eyelid surgery alone (without laser resurfacing) typically experience a very tolerable and relatively comfortable recovery. If laser resurfacing is performed, the recovery issues relate to the laser resurfacing treatment. Laser treatment adds oozing of the skin and swelling to the recovery process. Usually there is minimal pain, but because of the redness and swelling, patients look like they must be in a lot of pain. Fortunately, the benefits tend to justify this added nuisance to the recovery.

Recovery from blepharoplasties entails a variable amount of swelling and bruising (See Patient S.Y., Patient Photographs). Occasionally, the eyes are swollen shut on the morning after surgery, but this is unlikely with proper elevation and the use of ice packs during the first 24 hours.

When laser resurfacing is performed, there is increased swelling and oozing of the treated skin. Postoperative care is the almost the same as for laser resurfacing without blepharoplasty (except for corneal lubrication). The face is cleansed with soap and water at least 3 times daily. Vaseline ointment is applied to keep the skin from drying. As the new skin cells resurface the area, the oozing lessens and stops 5 to 7 days after surgery. The skin is now healed and is usually pink, indicating the presence of new skin cells (See photo).

Patient C.M. 8 days after laser resurfacing (See Before and After patient photographs for additional photos)

Lubricating the Eyes During Recovery

Patients may not be able to close their eyes fully for several days. During this time it is imperative that the eyes be kept well lubricated with drops during the day and ointment at night. The drops are used during the day because they do not blur the vision as much as the ointment, which lasts longer and is therefore used at night. If the eyes are swollen shut, it is unnecessary to pry the eyelids open, because the eyes are already protected from drying by the closed eyelid. Ice packs are used to reduce swelling on the day and evening after surgery. Head elevation by sleeping in a recliner or using pillows to prop up the upper body is helpful. Some patients have used foam wedges to elevate the upper body about 30 degrees in bed.

There may be a temporary space between the lower eyelid and the surface of the eyeball, especially in the outer corner of the eye. Air can circulate in this space, evaporating the tear film layer, and drying the surface of the eye. The lacrimal gland produces more tears to compensate for this evaporative loss, and the overproduction may cause tearing as the tears go over the edge of the lower eyelid. Extra tearing is normal in this situation and lessens as the swelling goes down, the lower lid starts to hug the eyeball again, and the tearing function returns to normal. Oozing from the incisions during the first couple of days is normal. In fact, this escape of fluid helps the swelling go down.

Healing after Eyelid Surgery

At first, the skin is gathered along the incision lines, causing little bumps. These irregularities smooth out after the sutures come out and the skin starts to relax.

The patient is seen in the office between 3 and 5 days after surgery. At this time, the skin is almost healed, but there may still be a crust present on the lower lids. The upper eyelid sutures are removed, which is momentarily uncomfortable as the suture slides out. When a traditional lower transcutaneous blepharoplasty is performed, the lower lid suture is pulled out at the same time. The eyelid skin relaxes and the eyelids feel more comfortable after suture removal.

Sometimes patients who have had transconjunctival (incision inside the eyelid) blepharoplasties notice the sensation of the dissolving suture in the lower eyelid for a few weeks but the feeling goes away as the suture dissolves.

Patients may notice a small bump at either end of the upper eyelid or external lower lid incision. Plastic surgeons call these bumps “dog ears.” Skin removal causes bunching of the skin at the end of the incision which can produce these areas of (usually) temporary puckering. Gradually, the bump goes down as the tension on the surrounding skin is relieved. Occasionally, I have touched-up this area with the laser or by removing a tiny area of persistent skin puckering under a local anesthetic—this is called “revision of a dog ear.” The only way to avoid dog ears is by making the incision longer, which would increase the length of the scar. Plastic surgeons try to strike the right balance between minimizing the length of the incision and avoiding dog ears. In my experience, it is better to avoid longer scars and treat the little dog ears if necessary. The majority smooth out on their own with time.

It is important to recognize that a drop in the position of the eyebrow may contribute to hooding of the skin of the upper eyelid. Some degree of hooding may persist after eyelid surgery in patients with droopy eyebrows. Eyelid surgery will not correct saggy eyebrows.

For patients wishing to correct droopy eyebrows, an endoscopic forehead lift is often done at the same time to help correct both sources of redundant tissue, trimming skin from the upper eyelid and also elevating the fallen eyebrow (see R.M.’s photographs). Over-resection of eyelid skin can make it impossible for the patient to fully close the eyes, which can lead to dry eyes. Experienced surgeons avoid this problem by being conservative in their skin removal and recognizing the importance of brow position.

Sometimes, older patients will return to me and show me that there is still some “crepey” loose skin on their upper lids. They may be unaware that when they close their eyes, this loose slack is completely taken up. Any additional removal of eyelid skin would restrict eyelid closure, particularly at night when eyelid closure is involuntary and therefore not as tight. They understand that dry eyes pose a significant problem and incomplete eyelid closure is best avoided. Some patients may be candidates for an endoscopic forehead lift. If the skin laxity is corrected by pulling up on the skin above the eyebrow, it is clear that eyebrow elevation is the appropriate treatment, not more skin removal from the upper lid


At first, the incision lines feel thickened (called induration) and there is soft swelling of the upper lids. This swelling takes a few months to settle down. There also may be swelling along the orbital rims below the lower lids. This is called malar edema, which means swelling of the upper cheeks. A characteristic of swelling is that it waxes and wanes. It may be better one day and worse the next, which always concerns patients because they think that swelling should gradually do down and an increase makes them nervous.  Swelling may be worse in the morning than at night because during the day the head is usually up and gravity helps reduce the swelling.

Swelling can be aggravated by vigorous physical activity, increased blood pressure, or even a high-salt diet. Head elevation at night, using several pillows, a recliner, or foam wedge, is useful during the first several days after surgery. Then elevation becomes less important and patients need to be able to sleep comfortably.

Patients are often concerned when they observe that one eyelid is more swollen or bruised than the other. However, this is normal and quite common. One side always seems to heal a little faster than the other. This observation is true for just about any bilateral plastic surgical procedure.

Swelling of the transparent lining of the eye (“conjunctiva”) may also occur and is called chemosis (See photo). A bubble develops over the white part of the eye. It may feel like there is something in the eye, called a foreign body sensation. This is due to swelling under the transparent lining of the eye. Some redness caused by blood that has tracked under this transparent lining (“subconjunctival hematoma”) is expected and not caused by trauma to the eye during surgery (See photo). Although it can look a little scary, this redness of the white part of the eye is normal, temporary, and not a cause for concern.

Normal Temporary Findings after Eyelid Surgery:

• Redness of the sclera (white part of the eye).

• Swelling of the conjunctiva or (chemosis).

• Small bumps at the end of the scars (dog ears).

• Thickening and bumpiness along the incisions.

• Temporary oozing from the incisions.

• Blurring of eyesight, due to swelling of the conjunctiva, and by the use of the lubricating ointment.

• Inclusion cysts. Little cysts occasionally develop along the suture lines. These little cysts may be easily removed under local anesthetic in the office.

P.C., Age 49, Subconjunctival hematomas

Procedure Description: Upper and lower blepharoplasties, fat injection, and CO2 laser resurfacing

Comments: Note the redness of the left eye in this 49-year-old woman 10 days after surgery. A week later, it has cleared. Although we call this a hematoma, it is really a thin layer of blood, not a significant collection of blood, and differs from hematomas elsewhere in that it does not require surgical evacuation. In fact, “hematoma” is probably a misnomer in this setting.

Before, 10 days after, and 17 days after

A.B., Age 47, Chemosis

Procedure: Upper and lower blepharoplasties, fat injection, and periorbital erbium laser resurfacing

Comments: The left lower lid demonstrates the yellowish bubble, called “chemosis” in this 47-year-old woman 4 days after surgery. Six days later, it has resolved. In this case, the conjunctival swelling resolved quickly. However, in some patients it can take several weeks to resolve. Her eyelid incisions are already inconspicuous 4 days after surgery.



Q:  Is the surgery painful?

A: Eyelid surgery is typically not painful. Patients are uncomfortable because of the swelling and blurry vision, caused by the ointment and temporary swelling of the conjunctiva.

Q:  How long do I need to be off work? 

A: Time off work largely depends on the importance of your appearance at work. It can take several days for your vision to return to normal because of swelling that affects the transparent eye lining (conjunctiva). Bruising and swelling typically take about 10 days to subside. For most patients, 10 days off work is reasonable, but it is certainly possible to return sooner if swelling and some degree of bruising are tolerable in the workplace. Eyeglasses can help camouflage the area. Most patients are out running errands wearing dark wraparound sunglasses to conceal swelling and bruising as early as a few days after surgery.

Q:  How long do the results last?

 A: It usually takes decades for the skin to relax enough to need to be trimmed again. It is not unusual for a patient to need a forehead lift rather than a repeat upper blepharoplasty. A repeat upper blepharoplasty has to be done very cautiously to avoid over-resection and the possibility of incomplete eyelid closure (lagophthalmos).

Fat bulges of the lower lids are caused by weakness of the orbital septum, which is a sort of retaining wall that holds the fat back under the eyeball. These bulges take a long time to recur. It is unusual for me to have to redo fat resection and it is important not to remove too much fat, because this can give a hollowed-out look, which is not youthful.

Q:  Will this surgery take away the dark circles under my eyes?

A: Dark circles are notoriously resistant to treatment. Makeup helps conceal the dark discoloration. Lower blepharoplasties to remove extra fat under the eyes can help to de-emphasize the circles, making them less noticeable. I often recommend simultaneous laser resurfacing and fat injection. The fat is placed in the tear troughs to reduce the demarcation of the lower lids. Laser resurfacing can provide some lightening. Youthful lids blend into the cheek without a noticeable trough or border. These treatments work together to soften and smooth the lid-cheek transition, a hallmark of aging.

Q: Can this surgery be done if I’m having Lasik surgery for my vision?

A: Yes. We usually allow a few weeks between procedures for healing and resolution of swelling.

Q:  How bruised and swollen will I be? How long does this last?

A: Swelling and bruising vary greatly from patient to patient. Bruising goes away before the swelling fully resolves. In most patients, the bruising clears in about 10 days. Almost everyone is back to work at this time and some return much sooner. It takes a few months for the eyelid swelling to completely subside.

Q:  Will I be able to see properly after surgery?

A: Your vision may be blurry at first because of the swelling that also affects the cornea, making it difficult to read after surgery. The eye lubricant also makes your vision blurry.

Q:  Will my eyes appear “bloodshot” after the surgery?

A: There is often some redness of the white part of the eye (subconjunctival hematoma) that can look scary, but is not dangerous and goes away on its own. It is simply blood that has tracked across the eye from the eyelids and is absorbed.

Q:  I once heard of someone who couldn’t close her eyes after this surgery. Could that happen to me?

A: Yes, but this is likely to be temporary. Most patients cannot completely close their eyes after surgery for at least a few days and sometimes a week or more. It is essential that they use lubricant during this time. It is possible that this problem might persist, although eventually the swelling tends to go down and the tissues loosen to allow eyelid closure. Experienced surgeons are cautious not to remove too much skin.

Q:  I know I can’t wear my contacts for 2 weeks after surgery. What about my glasses?

A: Glasses are fine. They will also help to disguise bruises and swelling when you go out. You can wear contacts when the swelling goes down enough so that you can easily manipulate your eyelids. Some patients can do this a week after surgery.

Q:  I have to return to work right away. How can I cover the bruises?

A: If you do not have laser resurfacing, you can apply makeup a few days after surgery. There is really no point trying to apply makeup before that time because you are not going to look good anyway. If you have laser resurfacing, you need to wait until the skin has healed, which can take a week or so. Mineral-based makeup works well to hide redness after laser resurfacing, and may also help with UV protection.

Q:  Is it okay if I am in the sun. 

A: Sun exposure or UV exposure in a tanning bed is not advisable on any healing wound because it can cause hyperpigmentation. This principle is especially true after laser skin resurfacing. You can be outside, but be sure to take precautions: Wear a hat and sunglasses. Always use sunblock after the skin treated by the laser has healed. Before you can use sunblock you simply have to avoid the sun, even when in a car.