Blepharoplasty (Eyelid surgery) in New York

Frequently Asked Questions

I have seen some people after they have had their eyes done and have noticed that they have too much of the white part of their eye showing?  How do you avoid this?

This may happen as the result of poor lower eyelid tone.  Preoperatively, patients are examined for this potential deformity.  Sometimes a tightening procedure called a canthopexy or canthoplasty is performed to provide better support to the lower lid.  This is performed by suspending the corner of the eye at the latheral canthus to prevent “the white of the eye” or sclera from showing too much.

Should I have a brow lift instead?

Some patients request eyelid surgery, when in fact they are better off having a brow lift first.  They often complain about hooding of the upper lids.  Commonly, the eyebrows are too low and require elevation.  The elevation of the brow that is performed during a brow lift procedure also can treat the hooding of the upper eyelid and may preclude the need for eyelid surgery completely.

I’ve seen people with very hollow looking eyes after their surgery.  How do you prevent it from happening?

It is very important to perform a conservative upper eyelid procedure.  The goal is to preserve the soft tissue so that the upper eyelid does not appear “hollow” but yet looks rejuvenated.

I have very puffy lower lids, can you treat them without adding scars to my face?

The puffy lower lids are usually due to pockets of fatty tissue. Sometimes the puffiness may be due to edema, or swelling which can occur in the lower legs. If it is due to fat, then I can perform surgery using an incision on the inside of the lower lid.  This eliminates any scar on the outer skin of the lower lid.  Pockets of fat can be removed conservatively or redraped over the orbital rim to improve the contour.

What can I do about the fine wrinkles and loose skin of my lower lid?

Often the lower lid skin can be treated conservatively by direct excision. If there are only fine lines, these can be treated by chemical peeling or by laser treatment.

My upper eyelids have a lot of excess skin. Should I get my upper eyelids done or have a brow lift?

I see many patients that complain of upper eyelid hooding as they age.  They often request an upper lid blepharoplasty to remove what appears to be excess skin. Interestingly, in many patients this is usually due to eyebrow ptosis or sagging. Elevating the brow, especially the lateral brow, often improves this lateral hooding. The eyes can then be re-evaluated when the brow is placed in a normal position, and usually there is less upper eyelid skin to remove. In general, some patients can benefit from the upper lid blepharoplasty alone, a brow lift alone, or a combination of the two.  Even Botox and fillers may play a role in improving the aesthetics of the periocular region.  The exam and the patient’s operative goals assist in determining the appropriate treatment regimen.

What is done in an upper lid blepharoplasty?

Traditionally, an upper lid blepharoplasty entails removing a crescent shaped amount of skin and muscle at the level of the upper eyelid crease at or just above the tarsus.  Fat is removed from both the central and medial compartments. Many times patients become very hollow. My thought process has changed over the years, and I think that the youthful eye is full. So, usually I will only take a small strip of excess skin at the crease level, leave the muscle intact and the underlying central fat.  The medial fat, if it is herniated or protruding, will be removed conservatively.  The incision is then closed and the sutures are removed within the week.  In my opinion, this will often give the most natural results.

How do you perform a lower lid blepharoplasty?

There are several ways to perform a lower lid blepharoplasty, and my choice of procedure depends upon the specific anatomical issues that occur during a physical exam.  Usually a skin muscle flap is elevated just below the eyelash margin.  The fat in the three compartments is conservatively removed and the excess skin and muscle is trimmed and sutured.  Nowadays, I perform a transconjunctival procedure, which is using an incision along the conjunctiva inside the eyelid to expose the fatty compartments.  I either remove fat conservatively or drape the fat along the lower lid-cheek crease. Many times I will free the crease of the lower lid-cheek junction.  If there is excess skin, “pinching” the excess and removing it conservatively at the level just below the lash line is done. If the patient has poor lower lid tone, I will perform a canthopexy (see below).  If lower lid skin is removed, the sutures are removed usually within several days to a week.

What is a canthopexy?

A canthopexy is a procedure to support the lower eyelid in patients with poor lower lid tone.  This is often detected by a lid distraction test or while performing a lid retraction (snap back) test.   Patients at risk for poor lower lid tone and the sequelae of an ectropion or scleral show are those with a poor snap back test, distraction test, and a negative vector or very flat cheeks.  A canthopexy is performed by placing a suture through the lateral canthal ligament and suspending it to the periostium (or connective tissue) along the inner lateral orbital rim.  My analogy is like suspenders on a pair of pants that hold the lower lid in place during the healing process. Early post-op, the patient’s eye may appear slightly almond shaped, but as the area heals the shape usually returns to normal.

What is a canthoplasty?

A canthoplasty is similar to a canthopexy except that it is used to shorten the lower lid because of laxity and stretching of the lateral canthal tendon. The lateral canthal tendon is shortened in a similar fashion to a canthopexy, which is suspended to the inner lateral orbital rim.  This is performed to support the lower lid to minimize the risk of ectropion or scleral show.  One issue with this technique is that it will change the eye shape a bit.

What is scleral show?

Scleral show refers to the appearance of more “white” of the eye, especially lateral to the pupil. This can naturally occur with age or as a result of the progressive weakening of the lower lid. This may also occur as a result of a lower lid blepharoplasty or midface lift when the lower lid is not supported.

What is a pinch blepharoplasty?

A pinch blepharoplasty is performed to remove excess skin in the lower lid.  The surgeon “pinches” the skin along the lower lid margin just below the lash line. The excess skin that is in the “pinch” is then trimmed and the resulting incision is closed.  This is performed without violating the muscle layer.

What is a traditional blepharoplasty?

A traditional blepharoplasty can be performed for both upper and lower eyelids.  A crescent of skin and muscle is removed from the upper eyelid usually six to eight mm’s above the lash line and a variable amount of fat is removed from the central and medial fat pockets. For the lower lid, an incision is made just inferior to the lash line elevating a skin-muscle flap. Variable amounts of fat from the three fat pockets is removed or draped over the orbital rim.  The lower lid skin–muscle flap is trimmed to remove the redundant tissue.  Sutures are usually removed within a few days to a week.  Generally, I try to preserve fullness in the upper eyelid and try to avoid violating the lower lid muscle layer. Often the lower lid is supported by a canthopexy when the lower lid tone is poor.

What is lagophthalmos?

Lagophthalmos refers to the condition in which the eyelid does not close completely.  Sometimes this can occur with swelling after eyelid surgery and when too much skin is removed from the upper eyelid.  Patients with this condition will often complain of dry eye.  When this occurs after surgery, it is often a transient condition that can be treated with eye drops, ointments, and/or taping of the lids at night to keep them shut until the swelling diminishes.

What is a tear trough deformity?

A tear trough deformity occurs in the lower lid-cheek junction. This is usually a depression or hollowing between these two regions often just inferior to the inferior orbital rim. This depression can become more apparent with patient aging and overall facial deflation. Sometimes facial fillers like Restylane, or other similar hyaluronic acid products can be used to camouflage this region.  Fat injections may also show some benefit. There are surgical treatments available as well. This can include releasing the orbito-malar ligament to lift the tissue that is depressed, as well as conservatively removing fat from the lower lid fat pockets or even conservatively draping the fat over the depressed area.

Can a tear trough deformity be treated by a blepharoplasty?

During blepharoplasty, the tear trough region can be treated. I commonly approach this region through a transconjunctival approach and release the orbitomalar ligament along the arcuate line.  Sometimes I will perform conservative fat removal and drape the fat along this region.

Can fat that is bulging in my lower lid be used as a fat graft?

I do not commonly take the fat from the lower eyelid pockets to use as free fat grafts, but will on occasion use it to camouflage the tear trough region by draping the fat over the orbital rim.

What is an ectropion?

An ectropion refers to a lower lid deformity in which the lower lid gets pulled down secondary to scarring and causes the conjunctiva of the inner lid to be visibly pulled outward. Treatment may require release of scar tissue, skin grafting, spacer placement, canthoplasty, and taping to name a few.

Who is at risk for an ectropion or scleral show?

Ectropion is more common in patients with lower lid laxity. Patients who have scleral show (more white of the eye showing) or a negative vector in which the cheek bone is slightly behind the bony orbital rim have a higher risk of ectropion. During a physical exam, if the patient shows poor tone of the lower lid during a distraction test or the lid retraction test (snap back), they are more prone to develop an ectropion.

What is entropion?

Entropion occurs when the lower lid margins actually curls inward and the lashes irritate the eye. Treatment often requires excision of skin and muscle along the lid margin to help evert the lash line.

What is chemosis?

Chemosis is a condition in which the conjunctiva swells. From a surgical standpoint it is usually related to having recent surgery and more commonly with a transconjunctival procedure than a more traditional skin-muscle flap blepharoplasty.  Irritation from sutures, surgical swelling, lagophthalmos, and disruption of tear production are just a few causes of chemosis. It is commonly treated with moisturizing agents, sometimes steroids, and occasionally eye patching.

How is chemosis treated?

Depending upon the cause, there are several different treatments. For typical cases of chemosis, moisturizing agents and potentially steroid eye drops are the first line treatment. This can also include taping the eye shut or patching it.  If there are recalcitrant cases of chemosis, sometimes a snip conjunctivoplasty can help improve the condition.

What is the recovery like from blepharoplasty surgery?

In general, the recovery is fairly easy.  Most patients do not have a lot of discomfort. They will see bruising and swelling, but this will vary from patient to patient.  Sutures usually are removed within several days to a week.


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