From cringing and smizing to widening in surprise—you need only scan the emoji roster on your phone to grasp the range of emotions the eyes can express. Not pictured in that lineup, however, are their less-intentional communications—exposing worry and fatigue, or betraying age.
Thin-skinned and highly mobile (think: 20 blinks per minute), the eye area is typically the first to show signs of aging. As the delicate skin of the lids turns crepey and lax, underlying muscles and tendons weaken and drop, allowing fat pads to push forward and bulge out into bags, which are often magnified by the sharp contrast of adjacent hollows in the tear troughs.
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Whether doctors are treating under-eye bags, loose skin, hooding or shadows, blepharoplasty, often referred to as an eyelift, is a safe, long-term solution that can restore volume and smooth contours to natural effect. Hallmarks of the modern-day eye job include minimally invasive techniques, near-invisible scars and a forward-thinking focus on preserving precious fat rather than removing it altogether. But, if you’re not quite ready to commit to surgery, injectables and energy-based devices can offer a subtle short-term rejuvenation. Here’s a closer look at all of your options.
What to Expect
A Thorough Consultation
Even before measurements and markings, “we start by asking the patient about their desires and concerns,” says Boca Raton, FL oculoplastic surgeon Steven Fagien, MD. With women, for instance: Do they want more area to put makeup on? Are they fearful we’re going to raise the crease? Ethnic and cultural considerations are also important: Is the patient Asian and wanting to keep certain aspects of their ethnicity? The answers to these questions will ultimately shape each individual’s treatment plan. An accurate aesthetic assessment follows.
A Dry-Eye Evaluation
Those prone to dry eye may not be candidates for blepharoplasty because “the procedure can worsen the condition, most certainly in the short-term and perhaps in the long-term, as well,” says Beverly Hills, CA facial plastic surgeon Sarmela Sunder, MD, explaining that the physiology of the eye is upset for a period of time during healing, compromising lubrication. In some people, “removing muscle can also affect eye closure, which can contribute to dryness,” she adds. Patients who have undergone LASIK procedures to improve eyesight are typically prone to dry eyes afterward, because the nerve supply to the cornea is disrupted, and tear production suffers, says Eugene, OR plastic surgeon Mark Jewell, MD.
Most blepharoplasties are performed in one to three hours under local anesthesia with intravenous sedation to minimize complications and recovery time. General anesthesia may be used if the surgeon prefers it or the patient requires it for medical reasons.
Nearly Invisible Scars
Incisions are made in the natural crease of the upper eyelid, or in the lower lash line. They blend in well with the skin once healed.
Seven to 14 days, depending on the extent of the surgery; no strenuous activity for two to three weeks. “Lower blepharoplasties are generally more complex,” says Dr. Fagien, “and at times, it can take up to four or six weeks for swelling to fully resolve.”
This Bleph's for You: Top, Bottom or Both?
This procedure targets upper eyelid hooding—“the excess tissue that protrudes over the eyelid’s crease,” says Atlanta plastic surgeon Mark Codner, MD. Depending on one’s anatomy, ethnicity and extent of aging, the surgery may also address surplus fat at the inner corners of the lids near the nose, as well as slack skin and possibly muscle. Techniques vary: Some surgeons preserve muscle and central lid fat “to maintain or enhance volume in the upper lid,” says Dr. Fagien. Others choose to remove equal amounts of skin and muscle. Average Treatment Cost $1,750–$5,000
Lower eyelifts remove distended fat (bags), resuspend sagging muscle and pare loose, crepey skin. In patients with firmer skin, the procedure is quite simple: Through an incision hidden inside the eyelid, surgeons can obliterate the fat bulge and the shadow it casts. For those in their late 40s and 50s, the operation generally becomes more involved, necessitating an incision along the lower lashes. “With the subciliary approach, we not only remove extra skin and tighten the lower lid skin, but also tighten the muscle underneath,” explains New York plastic surgeon Mokhtar Asaadi, MD. Average Treatment Cost $2,500–$5,000
To better match her eyes to her true age, Palo Alto, CA facial plastic surgeon Jill L. Hessler, MD performed a lower blepharoplasty with fractional laser resurfacing on this 29-year-old patient.
Upper and lower blepharoplasty together addresses the top and bottom lids to varying degrees for an overall refresh. The procedure may also incorporate an endoscopic browlift (more on that ahead) and/or autologous fat sculpting—”free microfat grafts directly placed with forceps below the orbital rim to blend the lid-cheek junction for a smooth, natural result,” says New York plastic surgeon Glenn W. Jelks, MD. The fat is the patient’s own, typically the excess taken from the lids or, when necessary, a modicum harvested from the abdomen.
This 69-year-old patient was bothered by her droopy eyelids, so she sought Short Hills, NJ oculoplastic surgeon, Baljeet K. Purewal, MD for an upper and lower blepharoplasty and ptosis repair.
Rules of the Modern-Day Eyelift
“Everyone develops heavier upper eyelids with age as the skin loses elasticity,” says Dr. Jelks. But many folks, in a move to delay surgery, will “use compensation methods to try to raise that excess skin off their lids so they can see better, thereby causing secondary problems— horizontal forehead lines, deep furrows between the brows and high brows.”
Less Is More
“Back 20 or 30 years ago, we basically took everything ‘excessive’ out of the lids— skin, muscle, fat—and created a big change. At the time, some believed it was amazing. But really, we debulked the lids and left people with a hollow look,” recalls Dr. Fagien. “Eyelifts of today should fix the problem without removing anything that doesn’t need to be.”
“We can now take fat that’s been removed from the lids, mince it into a paste-like substance and use it to smooth the area between the lower lid and cheek,” says Dr. Codner.
Should I Get a Browlift Too?
While the heft of a fallen brow can weigh on the top lids, plastic surgeons are split on the usefulness of a surgical browlift. Here, all sides of the issue.
NO Some have all but abandoned the browlift, citing unacceptable side effects (hair loss, numbness, scarring) and the procedure’s relative impermanence (“brows notoriously do not stay where you put them,” Dr. Jelks laments). According to Dr. Fagien, browlifts of the past were often misguided and overprescribed: “Many patients are absolutely fine with upper blepharoplasty alone.” However, he concedes, certain low-browed women may still need a lift to notice a real change in their upper lids. Minor improvement of the brows can be achieved by elevating them through an upper blepharoplasty incision, but La Jolla, CA plastic surgeon Robert Singer, MD notes this is not as longstanding or reliable as a limited temporal lift (to elevate the lateral aspect of the brow) or an endoscopic lift.
YES Dr. Codner, who pairs browlifts with upper blepharoplasty in 20 percent of his eye cases, says he considers brow position and stability during every eyelid consult. “If the brow is low and loose, it exacerbates redundant skin and muscle on the upper lids,” he explains. “If you do a blepharoplasty without first lifting and stabilizing the brow, you can make the problem worse.” He performs all brow lifts endoscopically, creating three quarter-inch incisions behind the hairline, and says, “I’ve had results last well over 10 years, and am absolutely convinced that an endoscopic browlift, when performed correctly on the right patient, is an effective procedure for elevating the brow and improving the result of an upper blepharoplasty surgery.”
Sugar Land, TX plastic surgeon Peter Chang, MD performed an upper and lower blepharoplasty, browlift and laser pearl fractional skin resurfacing to give this 62-year-old patient an eye rejuvenation.
In Los Angeles, Dr. Sunder is actually seeing a spike in browlifts among younger patients seeking a subtle but lasting boost to their eye area. “Some want just the lateral part of the brows lifted to create a cat-eye effect, like Bella Hadid, others want the middle portion of their brows raised along with the sides for more of an Ariana Grande look,” she says. Both can be achieved with a conservative endoscopic browlift.
3 Surgery-Free Solutions for Aging Eyes
A Chemical Browlift
Neurotoxins work by weakening muscles. And, relaxing certain muscles can cause opposing ones to perk up. “If you’re very precise in injecting the brow depressors [or downward-pulling muscles] in isolation, you will get a compensatory, reflexive strengthening of the brow elevators, which give a lifting effect,” explains Dr. Fagien. (This injection technique requires a strong understanding of facial anatomy and is best left to board-certified plastic surgeons or dermatologists.) Doctors will sometimes incorporate hyaluronic acid filler, as well, using it to build up the aging brow, so it can better support the overlying tissue and keep it from falling into the eyes, notes Dr. Sunder.
Filler in the Tear Troughs
“There’s no reason why we can’t obliterate a tear trough with careful injections of a low-viscosity hyaluronic acid filler, like Belotero or Restylane Lyft. The problem is, fillers are expensive, and they don’t last forever,” says Dr. Jelks. What’s more, they’re not a universal fix, and generally work best on young patients with thicker skin that can conceal the product. In any case, whether altering the under-eye with surgery or injectables, “we want to preserve the natural shape of the lower eyelid,” says Dr. Fagien. “From the lower lashes to the cheek is not a bulge or convexity— it’s a gentle slope that is slightly concave and blends in with the ogee curve of the cheek.”
“Radio-frequency treatments shrink and tighten the skin on the eyelids, and also on the face, neck, arms, abdomen and legs,” says New York dermatologist Ellen Marmur, MD. One device in particular, Thermage, is approved for up to a five millimeter eyelid lift, she adds, and can help with lid laxity, hooding, bags and wrinkles. Results are best seen after six months of new collagen growth. “Delivering ultrasound energy to the forehead region via Ultherapy treatments is another effective, noninvasive treatment to minimally lift the brows,” says Dr. Jewell.