Blepharoplasty: History, Indications, Etiology, Pathophysiology and Procedures

It is a plastic surgery to correct the eyelids’ defects, deformities, and disfigurements.

As well as to aesthetically modify the region of the eye of the face.

With removal and removal, or repositioning (or both) of excess tissue, such as skin and adipocyte fat, and reinforcement of the corresponding muscle and tendon tissues, the blepharoplasty procedure solves functional and cosmetic problems periorbital.

The periorbita is the area from the eyebrow to the top of the cheek.

The procedure is more common among women, who accounted for approximately 85% of the blepharoplasty procedures in 2014 in the US. UU And 88% of said procedures in the United Kingdom.

The operative objectives of a blepharoplasty procedure are restoring the correct functioning of the affected eyelid and restoring the aesthetics of the ocular region of the face, which are achieved by eliminating excess eyelid skin and smoothing the underlying ocular muscles.

Also, tighten the support structures and re-cover the excess fat from the retroseptal area of ​​the eye to produce a smooth anatomical transition from the lower eyelid to the cheek.


In an eye surgery procedure, the usual correction or modification (or both) is of the upper and lower eyelids and of the surrounding tissues of the eyebrows, the area of ​​the upper nasal bridge, and the upper portions of the cheeks, which are accomplished modifying the periosteal covers of the facial bones that make up the orbit.

The periosteum comprises two-layered connective tissues that cover the bones of the human body:

  • The outer layer of dense and connective tissue networks with blood vessels.
  • The inner and deep layer of collagen bundles comprises fusiform cells of connective tissue and a network of thin, elastic fibers.

Blepharoplasty is currently defined as removing excess skin from the eyelid, with or without orbital fat, for functional or cosmetic indications.

Blepharoplasty of the upper eyelid can be traditionally done using stainless steel instruments or modified with radiosurgery or laser incision techniques.

In addition to standard suture techniques, tissue adhesives have also been used for skin closure.

The eyes and the periorbital area are commonly the focal points during human conversation and communication.

Changes in the appearance of the eyelid caused by aging can convey an inappropriate message of tiredness, sadness, and lack of vigor, which can diminish the aesthetic appearance of the face.

In some cases, dermatochalasis (excess eyelid skin) or steatoblepharon (pseudogenization of orbital fat) is significant enough to cause a pseudoptosis.

These patients have symptoms related to the darkening of the upper visual fields.

Sex, race, and age influence the relationships of the periorbital anatomy milestones. The structures around the eyes differ significantly between people of different sexes and races.

These unique anatomical relationships are an essential framework when designing surgical periorbita alterations.

The cephalometric dimensions of the periorbital region are different in men and women. In the female, the fold of the forehead and eyelid is higher and more arched, and the fold of the lid is less prominent.

In men, the eyebrow protrudes more anteriorly, and the eyelid’s crease is closer to the margin of the eyelid. In white women, the fold is usually 8-11 mm above the eyelid margin; in white men, it is usually 6-9 mm above the eyelid margin.

In contrast to the white anatomy, the Asian eyelid has more fullness of the upper eyelid, narrower palpebral fissures, medial epicranial folds, and an eyelid crease closer to the margin.

The palpebral fold in the Asian population may be absent, nasally sharp, or flat but is usually lower and is more balanced than the typical white patient. The orbital septum adheres to the levator aponeurosis at or slightly above the superior tarsal margin or on the anterior tarsal surface.

Cosmetic surgeons must evaluate periorbital aesthetic relationships before performing blepharoplasty surgery. In addition, an essential ophthalmological examination should be performed, which includes the visual acuity test and the dry eyes examination.

Blepharoplasty can be performed as an isolated procedure or in combination with the repair of ptosis or rejuvenation of the upper and lower face.

In particular, the aging process affects the position of the forehead, the eyebrows, and the complex of the cheek. All these contribute to the function and appearance of the eyelids.

The actinic and degenerative changes of the facial skeleton and soft tissues lead to the loss of skin elasticity, atrophy or redistribution of fat, and the decrease of facial units and wrinkles.

These characteristics are evaluated in evaluating the upper eyelid and planning surgical procedures to alter the periorbital tissue.


Cosmetic eyelid surgery has been described for more than a century. As the techniques developed, the ancient Greeks and Romans began writing and collecting everything they knew about these procedures.

Aulus Cornelius Celsus, a Roman of the first century, described the realization of a split in the skin to relax the eyelids in his book ” De Medicina, “published in 1478.

In 1818, von Graefe used the term blepharoplasty to describe a case of eyelid reconstruction, when the technique was used to repair the deformities caused by cancer in the eyelids.

In 1817, Beers wrote and described the first illustration of eyelid deformity caused by herniated fat and mechanical ptosis due to excess skin.

Some authors called this finding fat ptosis. Fox introduced the term blepharochalasis to describe the apparent excess skin of the eyelids associated with changes in aging.


Blepharoplasty of the upper eyelid is performed for various functional or cosmetic indications. The upper eyelids protect the eyeball, distribute tears on the eye’s surface, and facilitate the drainage of tears through the lacrimal apparatus.

If any of these functions is affected or significant ptosis of the vision of the upper eyelid blocks vision, the doctor must determine if a surgical procedure is indicated.

Blepharoplasty with cosmetic upper eyelid is an elective procedure done to improve the appearance of the eyes.

This procedure requires the alteration of the relations of the eyebrows, the forearm fat, the dermatochalasis of the upper eyelid, or the steatoblepharon of the upper eyelid. Often, the patient describes tired or fallen eyes.

One of the most critical issues that all facial plastic surgeons should consider is the patient’s psychological state.

The two most important problems that must be evaluated before the surgeon agrees to perform an aesthetic blepharoplasty procedure include the patient’s motivation and the expectation of the result.

The best way to produce a satisfied patient is to have clearly defined and well-understood objectives for surgery. Patients who anticipate secondary gains such as improving personal relationships or professional status are not good candidates for cosmetic surgery.

Patients who expect this type of outcome judge the success of surgery for their satisfaction rather than for restoring aging changes.


Changes in the aging of the eyelid are caused by a combination of degenerative and pathological processes (sun damage) that alter the skin and periorbital structures.

Dermatochalasis results from changes in the aging of the skin and adnexal structures in the eyelid and eyebrow.

With age, the orbital septum, a distensible anatomical layer of the eyelid, weakens. The new evidence suggests that the orbicularis retains its morphology and function with age and may not be a contributing factor to dermatochalasis.

The action of gravity on the fat and the content of the orbit produces a downward and anterior displacement of the orbital fat due to a loss of the septal and muscular support of the fat pads.

Dehiscence or weakness of the levator aponeurosis can also cause involutional ptosis associated with dermatochalasis. Elastic fibers, collagen fibers, and the fundamental substance present secondary changes to sun damage and degenerative processes in the skin.

The resulting loss of elasticity in the skin creates enlarged surface areas of the epidermis necessary to cover the protruding fat. This contributes to the redundant tissues of the upper eyelid.


Dermatochalasis is a process that occurs as a result of changes in collagen fibers, elastic fibers, and milled substances in the dermis and epidermis. The eyelid skin is divided microscopically, from superficial to deep, into the epidermis, dermis, and subcutaneous tissue.

Aging and sun exposure are the main factors that produce dermatochalasis by reducing the amount of collagen and elastic fibers in the dermis. In addition, the epidermis becomes atrophic, the collagen content is reduced, and biochemical changes occur in the elastic fibers.

Detailed preoperative medical and surgical histories, and the physical examination of the patient’s periorbital area (from the eyebrow to the cheek and nose), determine whether the patient can undergo a blepharoplasty procedure safely to solve it feasibly.

Lower eyelid blepharoplasty can successfully address the anatomical issues of the excess eyelid skin, sagging eye muscles and orbital septum (palpebral ligament), excess orbital fat, and malposition of the lower eyelid.

Also, the prominence of the nasojugal sulcus, where the orbit (eye socket) meets the inclination of the nose.

Concerning the upper eyelid, a blepharoplasty procedure can resolve the loss of peripheral vision caused by the looseness of the upper eyelid skin covering the eyelashes; The external and superior parts of the patient’s field of vision are affected.


A blepharoplasty procedure is usually performed through external surgical incisions made along the natural skin lines (folds) of the upper and lower eyelids, which fold and hide the surgical scars, mainly when they occur in the skin folds under the lower lashes eyelid.

According to the technique applied by the plastic surgeon, the incisions can be made from the conjunctiva, the inner surface of the lower eyelid, as in the case of a transconjunctival blepharoplasty.

The technique of lower transconjunctival blepharoplasty was initiated by the Clinical Professor of Surgery at the University of Medicine of Chicago, Dr. Anthony J. Geroulisand presented to the medical trial in 1998.

The transconjunctival technique has become the norm in plastic surgery, and most surgeons prefer it to external surgical incisions. This technique is beneficial for patients with darker skin tones where the standard external incision often leaves a visible white scar.

The transconjunctival blepharoplasty technique allows the excision (cutting and removal) of the fatty tissue of the lower eyelid without leaving a visible scar. Still, the transconjunctival blepharoplasty technique does not allow the removal of excess eyelid skin.

A blepharoplasty operation usually requires 1-3 hours to complete. After the process, the initial swelling and bruising after the surgery will disappear and resolve within 1 to 2 weeks; The stable final results of the blepharoplastic correction will become apparent after several months.

The results of a blepharoplasty procedure are best seen when comparing pre-and postoperative (before and after) photographs of the patient’s eye region.

After the procedure, a type of stitch known as canthopexy is placed near the outer corner of the lower eyelid, which is inside the tissue.

This allows the position of the eyelid to remain fixed during the healing process. Canthopexy dissolves after four to six weeks of use.

A half-face lift may be necessary for individual patients to rejuvenate the lower eyelid complex.

The anatomical condition of the eyelids, the quality (wear) of the patient’s skin, their age, and the general condition of the adjacent tissues, as a consequence of the patient’s anatomical needs, affect the functional and aesthetic results achieved with eyelid surgery.

In addition to the anatomical conditions of the patient’s eye region, the occurrence or otherwise of medical complications is determined by factors such as:

Dry eye syndrome can be aggravated by altering the eyes’ tear film (tear).

Laxity of the eyelid skin: weakness of the lower margin of the eyelid, which predisposes to the poor position of the lower eyelid.

The prominence of the eyeball: the protrusion of the eyeball about the malar complex (cheek), which predisposes to the wrong position of the lower eyelid.

East Asian blepharoplasty (double eyelid surgery) is a procedure used to create a supratarsal epithelial fold in the patient’s upper eyelid that lacks that fold.

The supratarsal epithelial fold is common for most ethnic groups but is absent in about half of the Asian population.

Aesthetically, the eyes are an essential facial unit and a sensitive facial aging projector. Patients may experience tired eyes, sad eyes, or extra tissue around the eyes.

Dermatochalasis, hernia or fat protrusion, cephalic ptosis, and palpebral ptosis secondary to the desertion or dehiscence of the levator aponeurosis contribute to the patient’s perception of the need for upper eyelid blepharoplasty.


The number of blepharoplasties performed has continued to increase in the last 20 years. Blepharoplasty continues to be the most common invasive cosmetic surgical procedure on the face. Blepharoplasty is performed more frequently in women than in men.

Women continue to request the procedure at a younger age than men. Cosmetic blepharoplasty is performed more frequently in the fifth decade of life.

To be:

Laser blepharoplasty is the realization of eyelid surgery using a laser instead of a scalpel. Laser blepharoplasty is often combined with laser eyelid rejuvenation since the two procedures can be performed together.

Historically, there has been some controversy regarding the categorization of laser treatment in the upper or lower eyelids, such as blepharoplasty, which is by surgical definition.

The legal definition of surgery and the one supported by the American College of Surgeons indicates that surgery is the “treatment … for any instrument that causes a localized alteration or transport of living human tissue, which includes lasers …”.

Relevant anatomy

For any doctor involved in the care and surgery of the periorbital structures, deep knowledge of anatomy is vital to achieve optimal results and avoid possible complications.

Superior to the level of the tarsus, the upper eyelid consists of several individual layers from anterior to posterior: skin, orbicular muscle, orbital septum, preaponeurotic or orbital fat, eyelid retractors (levator palpebrae and Müller’s strength), and conjunctiva.

At the level of the superior tarsus, the anterior to posterior layers include skin, orbicular muscle, levator palpebral, tarsal, and conjunctive fibers. Superficially, the skin of the upper eyelid is the thinnest in the whole body.

The orbicularis muscle is divided into the pretarsal, preseptal, and orbital orbicularis, according to the structure immediately after it.

Several millimeters above the tarsus, the orbital septum joins the marginal arch’s bony orbital edge and the elevator’s aponeurosis. The fat in the upper eyelid consists of medium and medium fat pads.

The medial fat pad is located just medial to the medial horn of the levator aponeurosis on the upper eyelid and is considered orbital fat. It is often whiter than preaponeurotic fat. The medium fat pad is deemed preaponeurotic fat immediately before the levator aponeurosis.

The superior levator muscle originates at the apex of the orbit. It divides into an anterior aponeurotic layer innervated by the cranial nerve III and the superior tarsal muscle (Müller’s muscle) innervated by the cervical sympathetic system.

The anterior aponeurosis attaches to the anterior tarsal surface with fibrotic bands that attach to the muscle and pretarsal skin, and the Müller’s muscle is inserted into the superior tarsal margin.

Subsequently, the tarsus is a dense connective tissue plate that occupies the upper eyelid’s lower aspect with several meibomian glands on the lower border. The conjunctiva is attached to the tarsal and superior tarsal muscles.

On the eyelids of whites, the orbital septum is inserted into the anterior surface of the levator aponeurosis 2-5 mm above the superior tarsal margin. The preaponeurotic fat is located under the septum and is formed by the position of the orbital septum.

The fold of the eyelid is determined by the insertion of extensions of the levator aponeurosis into the skin. The position of the orbital septum influences the contours of the eyelid fold.

The fold and fold of the eyelid are important aesthetic reference points and are a vital feature of the appearance of the upper eyelid.

In white women, the fold is usually 8-11 mm above the eyelid margin; in white men, it is usually 6-9 mm above the eyelid margin.

On the contrary, the Asian lid has more upper eyelid fullness, a lower eyelid fold, and narrower palpebral fissures.

A medial epithelial fold may also be present. The fold of the lower eyelid is due to the insertion of the orbital septum in the elevator at or on the anterior surface of the tarsus. With this anatomical configuration, the eyelid’s crease overlaps and obscures the position of the fold of the eyelid.

Before surgery, the surgeon should analyze the position of the palpebral fold with the patient to determine the patient’s wishes regarding the postoperative status of the eyelid fold.

The location of the incision and the closure technique are modified according to the desired confirmation of the eyelid fold. Disinsertion of the levator aponeurosis may cause some asymmetry in the preoperative distance of the margin fold.

The surgeon should consider this before the surgical intervention. Blepharoplasty alone does not modify this asymmetry.

The position of the balloon (hypogeous, hyperglobus, enophthalmos) and the balloon extrusion should be evaluated before surgery. The asymmetry of the part of the balloon can alter the appearance of the superior sulcus, and blepharoplasty alone does not necessarily correct the complete asymmetry.

Asian eyelid surgery is unique and is not detailed in this article. However, it is essential to consider the varied form of the upper eyelid tarsus in Asians before performing a blepharoplasty.