Blepharoplasty (Eyelid Surgery)

Before V-Beam laser for hemangioma in Worcester

You may feel younger than your age, but your eyes may make you look tired all the time and betray your age.

A Blepharoplasty is often the first aesthetic procedure requested in middle age, commonly around age 40-43.

Your eyes are an important focus of your face. People looking at your face look at your nose, then your eyes and then your mouth. If you have beautiful eyes, their gaze may stay right there. Unfortunately, if your eyes looks tired, their gaze may also stay there.

The skin, muscle, fat and eyelashes all contribute to the appearance of your eyes. Age, sun exposure and hereditary factors afftect the appearance of these attributes of your eyes. With aging, the membrane holding the small fat pads of your eye socket in place (the orbital septum) may weaken, allowing the fat to come forward, giving you a “puffy” look (“bags”) and increasing the shadows of the lower lids. Also, with aging, the opposite can happen. The upper and lower eyelids can become more hollow in appearance. In addition, lifelong muscle action around your eyes and sun exposure leads to wrinkles of the lower eyelids and deep crow’s feet wrinkles. All this adds up to looking “tired” and older than you really are or older than you feel. These changes in appearance can cause emotional distress, unwanted comments from co-workers about how “tired” you look, and sometimes even visual impairment.

Your genetics and sun exposure contribute to how your eyelids age. For that reason, your eyelid surgery should be customized to your needs.

Surgery customized for your eyes…

In past years, many surgeons often did basically the same operation on every patient, removing skin, fat and sometimes muscle from the upper and lower eyelids. We now understand, however, that the operation must be tailored to each patient’s particular needs. In some cases, just skin treatment or an office procedure may be what you need. In some cases you may need a surgical procedure. Some patients may need both.

Instead of just always removing tissue from the upper eyelids (upper lid blepharoplasty), some patients may really need a browlift to get a more appropriate appearance.

Instead of just removing fat and skin from the lower eyelids (lower lid blepharoplasty), some patients may actually need volume added to the lids to fill hollow areas such as a deep “tear trough”. Fillers like Radiesse®, Restylane™, Perlane™, Elevess™, and Juvéderm™ may help correct the hollow appearance. Operations such as a fat transposition blepharoplasty or SOOF lift may be what you need. In past years a lower lid blepharoplasty almost always included removal of fat. Today we are reluctant to remove such volume from the eyelids. Since there is a strong tendency to lose volume as you age, we now prefer to preserve volume by moving, not removing, the fat pads. A youthful lower eyelid should be a bit convex on profile, not flat or concave.

The appearance of the lower eyelid can also be significantly affected by loss of soft tissue volume (mostly fat) of the inner cheek near the nose and just under the lower eyelid. This flatness tends to give an elongated and washed out appearance to the lower eyelid. In a mid faceift this tissue is elevated up at about a 45 degree angle. This has the affect of shortening the appearance of the lower eyelid, giving back a more youthful appearance.

The dark shadows of your lower eyelids may be due to increased dark pigment in your lower lids, shadows from the fat in your lids, or a combination of both. Lightening the skin , tightening the skin, moving the fat, or removing some of the fat may help. Obagi® skin care, Portrait PSR3 Plasma Skin Rejuvenation, or carbon dioxide laser resurfacing can lighten these shadows. To the extent that the dark shadows are from fat protrusion, the lower lid blepharoplasty with fat transposition will help.

Often, an upper eyelid blepharoplasty consists of a conservative removal of excess skin to re-create the upper eyelid crease. A small amount of fat and muscle may also be removed. However, we now understand that loss of volume is a major factor in aging and continues after surgery. Therefore, instead of removing a lot of upper eyelid fat, Dr. Bentkover prefers to tighten the membrane that holds the fat in place. This repositions the fat that has been there your whole life so it no longer protudes so much. If your brow has become much lower with age, an upper eyelid blepharoplasty may be combined with a browlift at the same time or in a prior operation. Dr. Bentkover is highly skilled in Boston Blepharoplasty.

A lower eyelid blepharoplasty may flatten the lower eyelid or plump the lower eyelid, depending on what is needed. To tighten the skin and reduce eyelid and crow’s feet wrinkles, the lower eyelid and temple skin may also need to be resurfaced. A lower eyelid blepharoplasty can be as straight forward as a conservative reduction in the amount of protruding fat (the “bags”) in the lower eyelid. As with the upper eyelids, however, aging in the lower eyelid can result in the opposite problem, a loss of volume. In patients with significant hollow areas in the lower eyelid Dr. Bentkover may choose to move fat from the eyelid into a “tear trough” depression (fat transposition blepharoplasty)or lift the fat of the upper cheek to the eyelid (SOOF lift). To avoid drooping of the eyelid after surgery and a visible scar, Dr. Bentkover usually does his lower eyelid surgery through an incision just inside the eyelid (transconjunctival approach). He generally does not remove lower eyelid skin, but rather often combines his lower lid blepharoplasty with a laser or Portrait PSR3 Plasma Skin Rejuvenation resurfacing of the lower eyelids and crow’s feet to remove wrinkles and tighten the skin.

Lower Lid Blepharoplasty flattens or plumps your lower eyelids; resurfacing with a laser or Portrait PSR3 Plasma Skin Rejuvenation tightens the eyelid skin and decreases the crow’s feet wrinkles.


Occasionally, your insurance company may pay for part or all of the cost of an upper eyelid blepharoplasty if the procedure is performed to specifically improve impaired vision (as documented on a visual field test). If you think your vision is impaired by your upper eyelids, you should have a visual field test performed in an ophthalmologist’s office
prior to your consultation with Dr. Bentkover and bring a copy of that test with you to your consultation. Because coverage criteria vary among different insurance companies, it is recommended that you check with your own insurance company to determine the level of coverage and criteria for coverage prior to booking your consultation.


Before Surgery

Our staff will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and medications. If you smoke, we will ask you to quit for at least two weeks before and after your surgery, since smoking may have an effect on how well you heal. You must stop all anticoagulant medications or herbal preparations such as aspirin, ibuprofen, vitamin E, St. John’s Wart, gingko, garlic or ginseng 10 days prior to surgery. You may be required to take antibiotics to prevent infection.

For an upper eyelid blepharoplasty, Dr. Bentkover will carefully mark your upper eyelids prior to surgery with a temporary marker. An incision is made in the natural crease of the upper lid. Once healed, it is usually not noticeable when the eye is open. An appropriate amount of skin can be removed through this incision. For the lower eyelid blepharoplasty. Dr. Bentkover usually uses a transconjunctival approach. This technique for lower lid blepharoplasty involves an incision inside the lower lid so that there is no visible scar. It can also help prevent a drooping of the lower eyelid (excessive scleral show or ectropion) sometimes seen with external incisions. He may make some temporary marks on your skin to outline the lower eyelid fat pads.

The Surgery

A youthful lower eyelid has somewhat of a convex appearance on profile. In patients with excess fat that has moved forward with aging (commonly called “bags”) the convexity has often become excessive and can even cause shadows on the eyelid that make it look darker. The operation for this condition consists primarily of a tightening of the fat and the membrane holding it (the orbital septum) and/or a removal of some of the excess fat. Laser resurfacing or Portrait PSR3 Plasma Skin Rejuvenation often further enhances the appearance of the eyelid by tightening the eyelid, restoring a more youthful appearance to the skin. The goal is a tighter but not overly flattened eyelid. In patients with a loss of volume in the lower eyelid that causes a hollow appearance or a deep “tear trough”, the lower eyelid blepharoplasty is designed to restore the slight youthful convexity by adding volume. Common techniques include moving part of the fat pad into the “tear trough” (fat transposition) or moving upper cheek fat into the horizontal hollow of the lower eyelid (SOOF lift). As with the fat removal/tightening techniques, here too the skin may need to be tightened with a skin resurfacing technique. Also, various techniques may be used on one eyelid or another, depending on what is needed to achieve your goals.

Upper eyelid surgery is often performed with just local anesthesia in our office operating room. The discomfort is usually minimal, basically only the discomfort of the very brief anesthetic injection. If you wish, we can also give some oral medication prior to the procedure to help your relax. For safety reasons, we generally recommend intravenous sedation or general anesthesia for lower eyelid surgery.

Surgery performed under local anesthesia may be performed in our office operating room in our suite at Worcester Medical Center, Worcester, MA or in our office in Stoneham, MA, whichever is more convenient for you. Procedures requiring intravenous sedation or general anesthesia are usually performed in the Day Surgery Unit at Saint Vincent Hospital in Worcester Medical Center, Worcester, MA or at the Massachusetts Eye and Ear Infirmary in Boston. We are confident you will find all of these facilities to be state-of-the-art, comfortable and very patient friendly

Recovery: What to Expect

The area surrounding the eyes will remain swollen in the days following the surgery. With conscientious application of ice packs, it should begin to subside after the second or third day. Application of ice packs is important to minimize the swelling and temporary discoloration. Some temporary blurring of vision is normal. Sutures are necessary only in the upper eyelid incision and usually dissolve in a week. Noticeable swelling and bruising will persist for about 10 days or so, but usually you can begin wearing makeup in a week. You may expect to resume normal activity within a week to 10 days, except for strenuous exercise, and start enjoying your new look within approximately 14-21 days. You may resume strenuous exercise in about 3 weeks. You can go for walks or get on a slow treadmill or elliptical machine at 10 days. It may take about 6 months for the upper lid scars to fade to their final appearance and can take up to 3 months for slight to moderate residual swelling to subside. The scars generally hide nicely in a crease and or can be easily hidden with eye makeup. In the lower eyelids, skin treated by resurfacing is “new skin” and yours to protect from the sun. With smart skin care, second resurfacing procedures may be desired but are unusual. Also, it is unlikely that the “bags” will recur as bad as they were, because fat has been removed. Revision surgery for the upper or lower eyelids might be desired 8-15 years later or never.

Complications are uncommon in Dr. Bentkover’s experience. However, complications can occur with any surgery and may include bleeding, excessive swelling, delayed wound healing, infection, drooping of upper or lower eyelid, asymmetry, double vision and dry eyes. Yes, blindness is a risk and an extremely rare complication of any eyelid operation done by any surgeon; it is generally related to excessive bleeding. As already stated above, you must stop all anticoagulant medications or herbal preparations at least 10 days prior to surgery. This includes aspirin, ibuprofen, vitamin E, gingko, garlic pills, ginseng and St. John’s Wart. Smokers also have more bleeding, do not heal as well as non-smokers, and stay swollen longer. To help this situation as much as possible, you will be asked to stop smoking two weeks before surgery and not resume until 1 month after sugery (a good time to just stop smoking for good).


How long will I be swollen?

Upper eyelids in a non-smoke: You can expect significant noticeable swelling for 10-14 days. It will take about 3 months for all of the swelling to slowly disappear, but generally other people will not notice your swelling after 14 days. Lower eyelids of a non-smoker: about 10-14 days for a straight forward procedure that just reduces fat. Swelling with fat transposition or the SOOF lift is noticeable to you and others for 3-6 weeks. The residual swelling is noticeable probably only to you and will take 3 months or so to resolve. In a smoker noticeable swelling can last 30-50% longer.

Is the operation the same for Oriental upper eyelids?

Oriental upper eyelids have different anatomy than non-oriental eyelids. Oriental upper eyelid blepharoplasty should be performed by someone who does this very often. Dr. Bentkover can make some recommendations for surgeons.

Will he need to tighten my lower eyelids?

If you have very loose lower eyelids, Dr. Bentkover may need to tighten the lower lids prior to or at the time of blepharoplasty or resurfacing. Such a procedure may be called a canthoplasty or canthal suspension.

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