What Is A Blepharoplasty?

The ideal appearance of the lower eyelid involves smooth skin that gently transitions to the cheek without significant hollowing or bulging. This area, known as the lid-cheek junction, should have a subtle, continuous curve that blends seamlessly into the midface, creating a youthful and rested appearance. Under-eye rejuvenation reduces puffiness and under-eye bags which can give a tired or prematurely aged appearance.    

There are two common surgical approaches to rejuvenating the lower eyelid: transcutaneous and transconjunctival blepharoplasty.  

• Transcutaneous lower blepharoplasty – Traditionally the primary approach, this procedure involves an incision just below the eyelashes and allows for the removal of excess skin and fat. This technique carries a higher risk of visible scarring and potential lower lid malposition.  

• Transconjunctival lower blepharoplasty – Dr Azizzadeh’s preferred approach for patients without significant skin laxity, is performed through an incision inside the lower eyelid, minimizing the risk of visible scarring and complications related to malpositioning of the lower lids (ectropion) while focusing on fat removal. Advanced fat repositioning or redistribution techniques can also be employed in a transconjunctival approach to smooth the transition between the lower eyelid and cheek, reducing the appearance of hollowing. This approach yields excellent long term results and significantly reduces the risk of complications or altering the eye’s shape. 

While the goals of lower blepharoplasty are generally similar across different ethnicities, upper eyelid blepharoplasty differs significantly for individuals of Asian descent. Asian “double eyelid” blepharoplasty is a specialized procedure designed to create or enhance the upper eyelid crease, which is naturally absent in about 50% of East Asians. Culturally, double eyelids have long been viewed as attractive in many Asian societies, even before Western influence. This difference arises from unique anatomical features, such as the upper eyelid muscle being attached closer to the lashes, thicker skin, and more fullness in the fat compartments. These characteristics contribute to the “monolid” appearance, which is a natural and beautiful variation of eyelid anatomy. 

While not all individuals of Asian descent seek double eyelid surgery, for those who do, Asian blepharoplasty is designed to enhance the eyelid fold while respecting the individual’s ethnic identity and maintaining facial harmony. This procedure can be performed on younger individuals to create a double eyelid or on older patients to address hooding and reposition the fold affected by aging. Aesthetically, it can make the eyes appear larger, and functionally, it may reduce the heaviness of the upper eyelid, potentially improving the field of vision. Importantly, the goal of this surgery is not to ‘Westernize’ the appearance but to achieve a natural result that complements the individual’s unique facial structure. 

Dr. Azizzadeh’s approach to Asian blepharoplasty focuses on creating a subtle, low crease that enhances your unique facial features while preserving your ethnic identity. He emphasizes the importance of retaining fat and muscle to avoid hollowing or ‘skeletonization’ around the eyes, ensuring natural results that harmonize with the rest of the face. His technique avoids an overly ‘Westernized’ or artificial appearance, prioritizing a balanced and authentic outcome. The surgical approach typically involves making a precise hidden incision along the planned eyelid crease, conservatively modifying excess fat and tissue, and anchoring the skin to the underlying muscle or tarsal plate to create a dynamic fold when the eye opens.  

For those with thinner eyelid skin, non-incisional suture techniques are also an option. Regardless of the method, the goal is to create a natural-looking double eyelid that enhances your appearance and ethnic identity. 

Revision blepharoplasty (Revision eyelid surgery) is a highly complex procedure that presents greater challenges than primary blepharoplasty due to factors such as altered anatomy, scar tissue, and potential complications from the original surgery. It requires meticulous planning and precision. Patients may seek revision for various reasons, including the natural aging process many years after an initially successful surgery, or dissatisfaction with suboptimal outcomes from the initial procedure. 

Upper eyelid revisions often focus on correcting persistent or new skin hooding, asymmetry, adjusting crease height, addressing ptosis, or refining the overall contour. Lower eyelid revisions typically address concerns such as worsening hollowness in the tear trough, ectropion (outward turning of the eyelid), entropion (inward turning), or persistent puffiness and fat pockets. In both cases, Dr. Azizzadeh conducts a thorough evaluation of the existing tissue and considers previous surgical alterations to achieve the desired outcome while preserving proper eyelid function. 

For patients who had a successful blepharoplasty years ago, revision may be relatively uncomplicated, involving careful removal of excess skin and contouring of underlying muscles and fat. Extreme care is taken to avoid removing too much skin or fat, which could lead to complications like incomplete eye closure (lagophthalmos), dry eyes, or an unnaturally hollow appearance that paradoxically ages the eyes. In some cases, non-surgical or minimally invasive treatments like fillers, fat grafting, or laser resurfacing may be sufficient to address volume loss and skin texture concerns. 

For those experiencing complications from an initial blepharoplasty, more complex surgical solutions may be necessary, such as soft tissue grafts (hard palate or skin grafts), repositioning of eyelid ligaments (canthoplasty, canthopexy, MIOS), or adjunctive procedures like a deep plane facelift or brow lift. Ultimately, successful revision requires a delicate balance between functional restoration and aesthetic improvement. 

The ideal aesthetics of the lower eyelid should feature a smooth, well-positioned contour that provides gentle support to the eye, contributing to a youthful, balanced facial appearance. Proper eyelid positioning is essential not only for protecting the eye but also for enhancing natural beauty. When the lower eyelid is malpositioned, it disrupts both aesthetics and function, leading to irritation and altered eye shape, which can affect facial harmony and expression.  

Surgical procedures such as MIOS, canthopexy and canthoplasty can reinforce and enhance the support of the lower eyelids, particularly for patients with significant eyelid laxity. These procedures can be performed either preventively or to correct lower eyelid malposition, where the lower lid droops or becomes misaligned. Canthoplasty involves reconstructing the canthus (the outer corner of the eyelid) to provide stronger, long-term support, while canthopexy is a less invasive technique that tightens and stabilizes the existing structures without requiring full reconstruction. Both techniques aim to improve eyelid function and aesthetics, especially for patients at risk of complications like ectropion (rounding or outward turning of the lower eyelid).  In recent years, newer treatments such as Minimally Invasive Orbicularis-Sparing (MIOS) lower eyelid recession have gained popularity and are favored when appropriate, as they provide excellent outcomes with quicker recovery times and reduced risks compared to more traditional approaches. 

Dr. Azizzadeh employs canthopexy and canthoplasty selectively in conjunction with lower blepharoplasty, understanding that while these procedures offer benefits, they also carry potential risks such as scarring, asymmetry, and changes to the natural shape of the eyes. To minimize the need for these procedures, he generally avoids lash line incisions typically used in “transcutaneous lower blepharoplasty”, which can increase the likelihood of requiring additional interventions to prevent lower eyelid malposition. Instead, he prefers transconjunctival lower blepharoplasty, which reduces scarring by incision inside the eyelid. To further enhance results, he often combines this approach with laser treatments and fat grafting to achieve skin rejuvenation and volume harmony for a natural appearance with fewer complications. However, in cases of significant eyelid laxity or high risk of ectropion, lower lid tightening surgeries such as canthopexy, MIOS, and canthoplasty may be performed with precision to preserve both functional integrity and aesthetic balance. 

Eyelid ptosis, or drooping of the upper eyelid, can be caused by temporary factors such as trauma, inflammation, or Botox injections, which typically resolve with time. Permanent causes include age-related weakening of the eyelid muscles, congenital defects, or nerve damage.  Ptosis can be corrected through surgery as a permanent solution or eyedrops for a temporizing measure.  Upneeq® (oxymetazoline hydrochloride ophthalmic solution, 0.1%) is an FDA-approved prescription eye drop specifically designed to temporarily improve mild to moderate eyelid ptosis. It works by stimulating the Müller’s muscle, a small muscle in the upper eyelid, causing it to contract and thereby lifting the eyelid. The effects typically begin within a few minutes and can last for several hours, offering a non-surgical option to enhance eyelid elevation and improve the field of vision. This is an ideal option if your eyelid ptosis occurred after botulinum toxin cosmetic injections like Botox®, Dysport®, or Daxxify™.  

Mullerectomy and open ptosis eyelid repair are two primary approaches to surgically address eyelid ptosis.  Mullerectomy is a less invasive procedure that targets the Müller’s muscle, a small muscle in the upper eyelid, by removing a portion of it to achieve a moderate lift. It is typically used for patients with mild to moderate ptosis and good levator muscle function, often performed under local anesthesia with quicker recovery and minimal scarring. In contrast, open ptosis repair involves a more extensive surgery where the levator muscle, the primary muscle responsible for eyelid elevation, is tightened or reattached to provide a more substantial lift. This method is generally reserved for patients who are simultaneously undergoing cosmetic upper blepharoplasty or have more severe cases of ptosis or when there is poor levator function. While it offers a more pronounced correction, it may involve a longer recovery period and a higher potential for scarring. An upper blepharoplasty for cosmetic purposes can be combined with either approach to enhance overall eyelid aesthetics. Additionally, patients with ptosis may subconsciously elevate their brow to compensate for the drooping eyelid, which can contribute to forehead wrinkles and tension. 

Volume loss involving fat and bone is a significant contributor to the aging process around the eyes, leading to hollowing, tear trough deformity, and a sunken appearance. Traditional blepharoplasty techniques may not fully address these changes, making volume restoration with fat grafting or fillers essential for a more comprehensive rejuvenation. Dr. Azizzadeh utilizes a technique called “multilevel fat grafting” as his preferred method to transfer fat to effectively augment lost volume and enhance contouring. Volume loss in the temples and eyebrows can also contribute to upper facial aging, and volume augmentation in these areas further improves overall facial harmony. Recent advancements in fat transfer have improved survival rates and reduced risks of irregularities, making it a more reliable option for facial rejuvenation. Fat grafting, which involves harvesting fat from areas such as the abdomen or thighs and transferring it to the face, offers a safe and effective solution with lasting results as the grafted fat integrates into the new site. However, because the procedure requires precision, especially in delicate areas like the lower eyelids, it is essential to have it performed by a skilled plastic surgeon to minimize risks such as lumps or contour irregularities and achieve optimal outcomes. 

The brows and eyelids share a close anatomical relationship, and proper evaluation of both is crucial in blepharoplasty to ensure balanced, natural results that maintain harmony between the upper face and the eyes. A well-positioned brow that sits in the correct position rim helps frame the eyes and contributes to an overall refreshed and youthful look, preventing a tired or heavy-lidded appearance. Aesthetic differences between men and women regarding the eyebrow-eye area primarily involve brow shape and position; women typically have higher, more arched brows that create an open, lifted appearance, while men often have straighter, lower-set brows that contribute to a more defined and masculine look. These distinctions are important in eyelid and brow rejuvenation to preserve gender-specific facial harmony. A brow lift is sometimes essential to perform alongside or instead of upper blepharoplasty, especially when brow drooping is a significant contributor to the heaviness of the upper eyelids. Dr. Azizzadeh focuses on resetting the brow to its natural position rather than simply lifting it, which helps avoid the unnatural “snoopy” or surprised look that can be a telltale sign of poorly performed surgery. His approach ensures a more harmonious and subtle rejuvenation of the eye area. Often utilizing minimally invasive techniques, including small incisions and endoscopic tools, Dr. Azizzadeh achieves natural results with quicker recovery times and minimal visible scarring, offering patients a smoother, more discreet experience. 

Adjunctive procedures like laser skin resurfacing are often combined with blepharoplasty to enhance facial rejuvenation by addressing multiple aspects of periorbital aging. Dr. Azizzadeh prefers using a fractionated CO2 laser, which offers a high level of safety compared to traditional lasers and allows for a quicker recovery time of 7-14 days. This technique improves skin texture, reduces fine lines, and addresses pigmentation issues, complementing blepharoplasty for more dramatic, harmonious results and a youthful, refreshed appearance. Importantly, Dr. Azizzadeh’s approach often avoids the need for skin removal from the lower eyelids, which reduces the risk of complications like ectropion (outward turning of the eyelid). A proper preoperative skincare regimen tailored to your skin type, along with strict sun avoidance, is crucial to minimize complications and ensure optimal healing. Skin type also plays a significant role in treatment planning, as darker skin types are more prone to pigmentation changes and require extra precautions to ensure the best possible outcomes.