History of blepharoplasty

Origins of the term, 1818-1907

• Karl Ferdinand von Graefe, a Berlin surgeon, introduced "Blepharoplastik" into the medical literature in 1818, for a case of eyelid reconstruction he had performed in 1809 (non-PubMed; corroborating: non-PubMed).
• Sichel published the first detailed description of herniated orbital fat in 1844; it did not lead to a wave of surgery because surgery at that time was performed only for functional reasons, and Sichel credited the earlier work of Dupuytren (non-PubMed).
• Charles Conrad Miller published the first photograph showing resection of excess lower-eyelid skin in the early 1900s, in an approach similar to techniques used today; in 1907 he produced the first published book on cosmetic surgery, "Cosmetic Surgery: The Correction of Featural Imperfections" (PMID 21319687; non-PubMed).
• In Japan, M. Mikamo reported the first cases of a double-eyelid operation for aesthetic purposes in 1896, at a time of social transition and early Westernization; a first English translation of his original article was published in 1997 (PMID 9047184).

Technique milestones, 1924-2004

• Julien Bourguet of France first described a transconjunctival approach to resecting herniated periorbital fat in 1924 (PMID 21319687; non-PubMed).
• Salvador Castañares codified "subtractive" blepharoplasty, skin, muscle and fat excision on an anatomical basis, in 1951, after describing the fat compartments of the upper and lower orbit (PMID 14864073; PMID 21319687; non-PubMed).
• Fasanella and Servat published "levator resection for minimal ptosis" in 1961, a simplified tarsoconjunctival-Müller muscle resection for small amounts of ptosis, still performed as the Fasanella-Servat procedure (PMID 13698293).
• Jones, Quickert and Wobig described aponeurotic repair for involutional ptosis in 1975: 57 eyelids in 34 patients with 8 mm or more of levator excursion, operated through a skin incision, with excellent results and minimal trauma (PMID 1156224).
• In the same 1975 issue of Archives of Ophthalmology, Putterman and Urist described Müller muscle-conjunctiva resection (MMCR), a posterior-approach technique selected by a positive response to 10% phenylephrine, with satisfactory results in 27 of 28 eyelids (PMID 1156223).
• Loeb described fat-pad "sliding" in 1981: mobilizing vascularized medial and central lower-lid fat through a subciliary incision to fill the tear trough, rather than excising it (PMID 7338007; technique described in PMID 21319687).
• Hamra modified Loeb's technique in 1995 with arcus marginalis release, advancing lower-lid fat over the orbital rim under the repositioned orbicularis muscle in 152 cases over 3 years; he revised this to the "septal reset" technique in 2004 (PMID 7624408, PMID 15253208).
• Goldberg described fat repositioning through a transconjunctival approach in 1998, then a subperiosteal-pocket version of it in 2000, followed in 24 patients for 6 to 30 months with good graft viability and patient acceptance; a related paper on maintaining infraorbital rim contour followed in 1999 (PMID 9787211, PMID 10697189, PMID 11816085).

Results and evidence: how the published record has grown

• Of the 100 most-cited periorbital-rejuvenation articles published from January 1989 to April 2020, 53 came out in the 1989-1999 decade, more than any later decade; mean citations per article were 75 (SD 42); 82 originated in the USA and 81 appeared in plastic surgery journals; plastic surgeons wrote 71 and oculoplastic surgeons 22; of 69 clinical studies, 45 (79%) provided only level IV evidence (PMID 36837432).
• Of the top 100 cosmetic upper-facial articles over 50 years, average citations were 55.1 (SD 38.7); surgical methods were the largest single study area at 30%, followed by botulinum toxin (29%) and complication management (15%); invasive procedures made up 55% of the set, and the late 1990s and 2000s were the period of fastest growth (PMID 39867419).
• A 20-year Web of Science analysis of blepharoplasty publications (2002-2021) found 1,125 papers, with output rising every year; Aesthetic Plastic Surgery carried the most papers and Plastic and Reconstructive Surgery was cited most; Massry GG was the most prolific author and Hamra ST the most co-cited author, and Rohrich RJ had the highest citations per publication (PMID 36203097); a letter responding to this analysis followed in 2024 (PMID 37798496).
• Among the top 50 cited blepharoplasty papers from 2015-2022, citation counts ranged from 9 to 37 and altmetric attention scores from 0 to 54; output and citations both peaked in 2021, and the most productive institution was the University of California System (PMID 37153349).
• Across five decades (1970s-2010s) of the top 50 cited articles per decade, plastic surgeons held the largest first-authorship share in blepharoplasty at every time point, while ophthalmology's contribution to the blepharoplasty literature grew over that period (PMID 26994394).

Risks and complications: how the safety record changed

• The older skin-muscle-fat technique removed enough tissue to leave some patients with a hollow orbit and a visibly operated look; current methods remove less tissue for that reason (PMID 15536308).
• A 1986 review of roughly 60 published blindness cases after cosmetic blepharoplasty found retrobulbar hemorrhage in most, with the final injury usually retinal or optic-nerve ischemia; this review is still cited as the baseline case series for blepharoplasty-related vision loss (PMID 3516289).
• "Post-upper blepharoplasty syndrome," ptosis, a hollow sulcus and a high crease from an earlier generation of aggressive fat removal, was traced in 48 eyelids to levator aponeurosis disinsertion bound into septal scar; recognizing this pattern shaped how surgeons now handle the septum during fat removal (PMID 31802837).
• Full current complication rates and their evidence appear in upper blepharoplasty and lower blepharoplasty.

Recovery

• The literature carries no direct historical comparison of recovery time across eras of blepharoplasty technique.
• Holds's own current lower-lid technique, combining septal reset with a transconjunctival incision, is described as an in-office procedure using a CO2 laser, a shift from the hospital-based skin-incision surgery of the mid-twentieth century (PMID 21319687).
• Current recovery evidence, including trials of ice, arnica and bromelain, is in upper blepharoplasty.

Combined procedures

• Ramirez described raising the forehead and brow through the upper-blepharoplasty incision itself in 1996, dissecting to the orbital rim and beyond with endoscopic assistance in 12 of 14 patients, avoiding a separate brow-lift incision (PMID 8988768).
• Codner's 2010 overview of blepharoplasty and brow lift describes upper-lid blepharoplasty combined with supratarsal fixation as a standard pairing (PMID 20595828).
• In the Tracking Operations and Outcomes for Plastic Surgeons database of 13,346 facelift patients, blepharoplasty was the most common procedure added to a facelift (PMID 32459769).
• Current combined-procedure complication data are in upper blepharoplasty, browpexy and direct brow lift, and temporal and lateral brow lift.

Current questions

• Which posterior ptosis technique should be first-line: a 2011 review traced a swing in preference back toward Putterman's 1975 Müller muscle-conjunctiva resection, driven by differing views of what causes involutional ptosis, the predictability of MMCR, and its speed compared with Jones's external levator advancement (PMID 21730839).
• Who is publishing this history now: bibliometric analyses through 2025 disagree about the most-cited and most-prolific authors and institutions in the field, and at least one of these analyses has drawn a published rebuttal (PMID 36203097, PMID 37798496, PMID 39867419).
• How the double-eyelid lineage that began with Mikamo in 1896 is now written: since 1989, the epicanthal-fold surgery literature has been authored predominantly by surgeons of East Asian descent (PMID 38281686).
• Whether quality-of-life outcomes justify techniques descended from the 1975 ptosis papers: a 2025 American Academy of Ophthalmology report reviewed health-related quality-of-life evidence for upper blepharoplasty and blepharoptosis surgery (PMID 40913605).
• Whether mild ptosis, the condition Fasanella and Servat operated on in 1961, is still being missed: a 2021 survey of 214 Aesthetic Society members concluded mild to moderate ptosis remains underrecognized among blepharoplasty patients (PMID 33346340).
• Whether von Graefe's original functional framing of eyelid surgery still fits: a 2026 review argues that visual field testing alone, the standard functional test descended from that framing, misses the full burden of dermatochalasis (PMID 42693598).

Terms

• Blepharoplastik: the 1818 German term for eyelid reconstruction, source of the modern word blepharoplasty (non-PubMed).
• Subtractive blepharoplasty: skin, muscle and fat excision, the technique Castañares codified in 1951 (PMID 21319687).
• Transconjunctival approach: an incision on the inner eyelid surface, avoiding a skin incision, first described by Bourguet in 1924 for fat removal and by Goldberg in 1998 for fat repositioning (PMID 21319687, PMID 9787211).
• Fat repositioning: moving orbital fat over the orbital rim instead of removing it, developed by Loeb, Hamra and Goldberg between 1981 and 2000 (PMID 7338007, PMID 10697189).
• Arcus marginalis: the ligament at the orbital rim that Hamra released in 1995 to advance lower-lid fat (PMID 7624408).
• Aponeurotic ptosis repair: Jones's 1975 technique of re-suturing a dehisced or disinserted levator aponeurosis (PMID 1156224).
• Müller muscle-conjunctiva resection (MMCR): Putterman's 1975 posterior-approach ptosis operation (PMID 1156223).
• Fasanella-Servat procedure: the 1961 tarsoconjunctival-Müller muscle resection for minimal ptosis (PMID 13698293).
• Double-eyelid operation: surgery to create a supratarsal crease in an eyelid without one, first reported for aesthetic purposes by Mikamo in 1896 (PMID 9047184).
• Post-upper blepharoplasty syndrome: ptosis, sulcus hollowing and a high crease from aggressive fat and tissue removal, traced to levator disinsertion in septal scar (PMID 31802837).

Papers

Non-PubMed sources:

• The History of Cosmetic Oculoplastic Surgery — textbook-chapter excerpt naming von Graefe (1818), Sichel (1844), Miller (1907), Bourguet (1924) and Castañares (1951) with their original dates.
• The Fascinating History of Eyelid Surgery — oculoplastic-surgeon practice page, corroborates von Graefe coining "blepharoplasty" in 1818.