Upper blepharoplasty

What it treats

• Dermatochalasis is excess eyelid skin; it can occur with orbital fat prolapse, lacrimal gland prolapse and involutional ptosis; upper blepharoplasty is the third most common cosmetic operation in the United States (PMID 42236867).
• Castanares described blepharoplasty for herniated orbital fat on an anatomical basis in 1951 (PMID 14864073).
• Older technique removed skin, muscle and a large amount of fat and left some patients with a hollow orbit; current methods remove less tissue (PMID 15536308).
• Pretarsal show: of 316 patients, 59% of eyes had complete pretarsal show before surgery; this group improved less after conventional excision, and eyes with a midpupil pretarsal height over 4 mm scored 1.95 against 2.50 (PMID 33234951).
• Superior visual field: 18 eyelids in 9 patients, Goldmann perimetry, mean 4.99-fold gain in the superior field at 3 months; the preoperative field predicted the gain better than MRD1 (PMID 35086303).
• Visual quality: 146 eyelids in 74 patients, contrast sensitivity rose and mean astigmatism fell from -1.17 to -0.89 after surgery; visual acuity did not change (PMID 36788649).
• Visual field testing alone does not capture the whole burden of dermatochalasis; no validated dermatochalasis-specific symptom questionnaire exists (PMID 42693598).
• Hidden ptosis: a survey of 214 Aesthetic Society members concluded that mild to moderate ptosis and different upper lid aging patterns are underrecognized (PMID 33346340).

How it is done

Skin, muscle and fat

• Skin-only excision leaves the orbicularis oculi muscle in place; skin-muscle excision removes a strip of preseptal orbicularis with the skin (PMID 33538853).
• Fat can be removed from the central (preaponeurotic) and nasal pads (PMID 39856176), preserved, or moved: one technique anchors the nasal fat pad centrally to fill the upper lid, 11 patients (PMID 39421583).
• Volumetric upper blepharoplasty: fat grafting to the hollow upper lid (mean 0.4 cc deep, 2.8 cc superficial) combined with orbicularis imbrication in 26 of 32 women (PMID 28753160).
• Survey data: surgeons with 10 or more years in practice or 100 or more cases a year preserved volume more often; high-volume surgeons more often added fat grafting, brow lift and ptosis repair (PMID 33346340).

Skin excision shape and closure

• Laterally extended excision against a traditional ellipse, 28 matched patients: slightly more and more even pretarsal show; the ellipse group had 1.4-2.0 mm more lateral brow descent (PMID 36205656).
• Intradermal against continuous 6-0 nylon, 50 patients randomized by eyelid: equal scar quality at 6 months; 80% rated the result much or very much improved (PMID 42118953).
• Scar review 2026: scalpel, radiofrequency and CO2 laser incisions gave no difference in final scar; absorbable and nonabsorbable sutures healed alike (PMID 41193896).

Anesthesia

• Adding tranexamic acid to lidocaine with epinephrine, 15 patients randomized by side: intraoperative blood loss 4.86 ml against 2.53 ml without it; no difference in swelling or bruising at day 7 (PMID 38789809).

Results and evidence

Muscle excision or skin only

• Meta-analysis of 12 randomized trials, 450 patients: dry eye symptoms fell after surgery (OR 0.22); dry eye did not differ between skin-muscle and skin-only excision (OR 1.55); lagophthalmos was more frequent with muscle excision (OR 7.98); satisfaction did not differ (PMID 40152471).
• Systematic review, 6 comparative studies (407 patients in cohorts, 57 in trials): no long-term aesthetic difference; muscle excision gave more early edema, bruising, pain, dry eye and lagophthalmos, which resolved within weeks (PMID 33538853).
• Randomized left-right trial, 15 patients: the muscle-excised side had more symptoms and a worse appearance at day 7; no difference at days 30 and 90 (PMID 21224748).
• Randomized trial, 54 patients, FACE-Q at 12 months: skin-only and skin-muscle scored the same for upper lids, brows, face and satisfaction; the "eyes in general" score was higher after skin-only (PMID 35219565).
• Retrospective series, 386 patients: skin, muscle and fat excision (51) against skin only (335) gave complications of 7.8% against 2.4% (p=0.075) and satisfaction of 8.3 against 7.0 out of 10 (PMID 39856176).

Dry eye and function

• Randomized trial, 54 patients: subjective dry eye complaints fell by 12 months with either technique; objective tear measures did not change (PMID 34612583).
• Randomized trial, 63 patients: dry eye symptom scores (SPEED) fell at 1 month and 1 year with orbicularis-sparing and orbicularis-excising technique alike (PMID 37354267).
• American Academy of Ophthalmology review, 20 studies: 5 of 7 dry eye studies found no subjective worsening; benefits in visual function, headache and daily life were reported (PMID 40913605).
• Randomized trial, 54 patients: headache scores fell and brow height decreased after blepharoplasty, with no difference between techniques (PMID 36674313).

Satisfaction

• 316 patients, photographs scored by 4 reviewers: mean cosmetic score rose from 1.75 to 2.38 (PMID 33234951).
• 79 patients, FACE-Q: upper eyelid appraisal and satisfaction with eyes improved; preoperative severity did not predict satisfaction (PMID 39037480).
• Nasal fat preservation, 11 patients: FACE-Q upper eyelid score up 25 points, no fat necrosis, volume held at a mean 1 year (PMID 39421583).

Brow position

• Meta-analysis, 17 studies: brow height fell after upper eyelid surgery (mean difference 1.45 mm); after simple blepharoplasty the drop was 0.67 mm; skin excision itself did not affect brow height (PMID 36890345).

Risks and complications

• Orbital hemorrhage, survey of 269,433 cosmetic eyelid cases: 149 hemorrhages (0.055%, 1 in 2,000), 12 with permanent visual loss (0.0045%, 1 in 22,000); most began within 3 hours of surgery (PMID 15599241).
• Blindness review, about 60 cases: retrobulbar hemorrhage was a feature of most cases, and the final event was usually retinal or optic nerve ischemia (PMID 3516289).
• CosmetAssure, 6,126 aesthetic eye patients (2008-2013): major complications 0.4% after blepharoplasty; hematoma, the most common, 0.2% (PMID 29369102).
• Wound dehiscence, 2,376 eyelids: 1.4% at a mean 9 days; male sex and fast-absorbing gut suture were independent risk factors (PMID 32852369).
• Antithrombotic drugs, 392 patients: complications 6.0% on aspirin, warfarin or apixaban (100) against 3.5% not on them (292), p=0.380; no major bleeding (PMID 42236867).
• Revision: 3.8% after blepharoplasty alone against 9.2% when ptosis correction was added, 278 patients (PMID 38315110).
• New dry eye lasting 3 months or longer: 0.8% of 533 upper blepharoplasties, all resolved (PMID 38315110).
• Post-upper blepharoplasty syndrome (ptosis, hollow sulcus, high crease): in 48 eyelids the levator aponeurosis was disinserted and bound into septal scar left by fat removal (PMID 31802837).
• Complication timeline: corneal abrasion and retrobulbar hemorrhage in week 1; lid malposition, exposure and tearing in weeks 1-6; contour change, asymmetry and scarring later (PMID 20195127).

Recovery

• Bleeding risk is highest in the first 3 hours and falls after 24 hours, though hemorrhage can occur several days later (PMID 15599241).
• Ice packs, 38 patients randomized by eyelid: no effect on edema, erythema or hematoma; slightly less pain on day 1 (PMID 25626811).
• Arnica ointment 10%, 136 patients: no difference from placebo in swelling, bruising, pain or satisfaction (PMID 27348641).
• Oral bromelain 200 mg every 8 hours for 2 weeks, 46 patients: lower edema scores on days 3, 7 and 11; lower bruising on day 3 only (PMID 42728656).
• Return to work was shorter after skin-only surgery than after skin, muscle and fat excision in a 386-patient series (PMID 39856176).
• Scar review: silicone products reduced hypertrophic scarring; cold compresses, compressive dressings and over-the-counter scar products showed minimal benefit (PMID 41193896).

Combined procedures

• TOPS database, 13,346 facelift patients: blepharoplasty was the most common added procedure; combined procedures raised the odds of adverse events; overall adverse events 5.1% (PMID 32459769).
• CosmetAssure, 806 combined blepharoplasty and brow lift patients: major complications 0.4%, the same as blepharoplasty alone (PMID 29369102).
• Brow lift was added in 31.7% and ptosis correction in 20.5% of 533 upper blepharoplasties in one series (PMID 38315110).
• Brow lift and blepharoplasty overview, including upper lid blepharoplasty with supratarsal fixation (PMID 20595828).

Current questions

• Muscle excision: pooled randomized data show more lagophthalmos and no aesthetic gain (PMID 40152471); a 2025 retrospective series reported higher satisfaction when muscle and fat were removed (PMID 39856176).
• Volume preservation against fat excision: experienced surgeons preserve more volume (PMID 33346340); the nasal fat preservation series has 11 patients and a mean 1-year follow-up (PMID 39421583).
• Complete pretarsal show: the authors of a 316-patient study advise considering fat grafting or ptosis repair instead of skin excision alone (PMID 33234951).
• Continuing blood thinners through surgery: one 2026 cohort found no major bleeding (PMID 42236867).
• Functional criteria: a 2026 review proposes adding a symptom score to visual field testing for funding decisions (PMID 42693598).
• Recovery adjuncts: bromelain reduced swelling in a 2026 trial (PMID 42728656); tranexamic acid in the local anesthetic increased bleeding in a 2024 trial (PMID 38789809).

Terms

• Dermatochalasis: excess, lax eyelid skin (PMID 42236867).
• Orbicularis oculi: the muscle that closes the eyelids; a strip is sometimes removed with the skin (PMID 33538853).
• Preaponeurotic and nasal fat pads: the two fat compartments of the upper lid (PMID 39856176).
• Pretarsal show: the visible lid skin between lashes and crease (PMID 33234951).
• MRD1: distance from the corneal light reflex to the upper lid margin, a measure of lid height (PMID 35086303).
• Lagophthalmos: incomplete eyelid closure (PMID 40152471).
• Orbital (retrobulbar) hemorrhage: bleeding behind the eye that can compress the optic nerve (PMID 15599241).
• Levator aponeurosis: the tendon that lifts the upper lid (PMID 31802837).
• FACE-Q: a validated patient questionnaire for facial aesthetic outcomes (PMID 35219565).
• Volumetric blepharoplasty: eyelid surgery that adds or keeps volume, for example with fat grafting (PMID 28753160).

Papers