Blepharoplasty Explained — The Definitive Guide

Two operations

Upper blepharoplasty works between the lid margin and the brow, removing excess eyelid skin and setting the lid crease or tether point. It will also correct the lid margin level if this has dropped (ptosis). Lower blepharoplasty works below the lid margin, addressing the orbital fat that creates bags and the transition between lid and cheek. They are not a matched pair — it is common to need one and not the other.

Why the brow matters

It is a common misconception that heaviness around the upper eyelid is always caused by the eyelid itself. In many cases, the brow is contributing to the heaviness.

When the brow descends, it can carry eyelid tissue down into the upper eyelid area, creating the appearance of hooding. What you see in the mirror may look like excess eyelid skin, but the source can be higher up, as when the brow is positioned correctly, much of that excess can disappear.

To the patient, these can look very similar. Surgically, however, they are quite different, which is why identifying the cause of the heaviness is an important part of the assessment.

Lower lids and the cheek

As we age, the membrane that holds the fat within the eye socket (septum) can weaken, the eye can sink a little, and the muscle holding the cheek up and the fat back can stretch and become less effective, allowing the fat to push forward and create a bulge beneath the eyes. This fat should not be removed as a rule, as it is important for the appearance of the entire upper and lower lid complex. It is far better to put it back where it belongs, use it to disguise the transition between eyelid and cheek, or disguise it by lifting the cheek back to where it belongs.

Removing too much fat can leave the lower and upper eyelids looking hollow, which makes people look aged and may become more noticeable over time. The aim is to consider the relationship between the fullness and the hollow, rather than treating them as two separate problems.

The lower eyelids are also influenced by changes in the cheek. As the cheek loses volume and the midface descends, the lower eyelid can appear longer and the transition between the eyelid and cheek can become more pronounced. This also stretches the lower eyelid muscle making it less efficient.

For this reason, the lower eyelid is assessed as part of the surrounding cheek and midface, rather than as an isolated feature.

What can’t blepharoplasty address?

Blepharoplasty does not address every concern around the eyes. Dark circles caused by pigmentation or thin skin showing the structures beneath it are unlikely to change significantly with surgery. Surgery does help however when the darkness is caused by a shadow created by a lower eyelid bulge.

Crow’s feet are caused by muscle movement and are not treated by blepharoplasty. Folds of loose skin or swelling over the cheekbone (malar bags or mounds) may also sit outside the area addressed by eyelid surgery.This is why some patients may be advised that blepharoplasty is not the right procedure for their particular concern. In some cases of lower eyelid problems, the solution lies in lifting the cheek back to where it belongs. This is a facelift, and addresses many other disharmonies on the face.

Where are the incision lines for blepharoplasty?

For upper eyelid surgery, the incision is placed within the natural eyelid crease should be, where it is generally concealed when the eye is open.

Lower eyelid surgery is almost always performed from inside the eyelid, depending on the individual anatomy and surgical plan. The internal approach does not leave an external scar. Rarely do I make an external incision unless the skin is excessive. Even then, most of the work is done from inside the eyelid.

All surgery leaves a scar, but how visible an individual scar becomes varies from person to person. Incision placement and expected scar appearance are discussed during consultation.

Can blepharoplasty improve my vision?

In some patients, excess upper eyelid skin can progress to the point where it obstructs the field of vision. When eyelid surgery is performed for a functional reason and the relevant criteria are met, a Medicare rebate may apply under item 45617, with photographic evidence required.

Lower eyelid changes that are primarily related to ageing generally do not qualify for a Medicare rebate on the basis of visual impairment.

Frequently Asked Questions

One eye looks bigger than the other. Can that be corrected?

Some asymmetry is close to universal, and most people only notice once they start considering surgery. The causes differ: asymmetric brow height (very common, often a habit of raising one side), differing lid crease height, a lid margin sitting lower on one side, underlying bone asymmetry, or previous injury or thyroid eye disease. Asymmetry can usually be improved and can rarely be made identical. Photographs are taken before surgery for exactly this reason.

What if my eyelid itself is drooping, not just the skin?

That is a different condition and a different operation. If the lid margin sits low because the muscle lifting it has stretched or detached, that is eyelid ptosis, funded separately under Medicare. Removing skin from a ptotic lid will not open the eye. Occasionally the reverse happens and removing overhanging skin reveals a ptosis the skin had been camouflaging — either way it needs assessing beforehand.

Does Medicare cover it?

Only where there is a genuine functional indication and the documentation requirements are met — most commonly upper eyelid skin obstructing the visual field. Cosmetic eyelid surgery is not covered, and schedule fees are not the same as the surgeon’s fee or your out-of-pocket cost.

Am I too young for eyelid surgery?

Age is not the criterion — anatomy is. Some hereditary lower lid fat prolapse appears in patients in their twenties and thirties and is unrelated to ageing. Equally, some patients in their sixties are better served by addressing the brow or midface first.