Combined blepharoplasty: upper and lower techniques in a single operation

What combined blepharoplasty is

Combined blepharoplasty is a single operation that treats, in the same sitting, the changes present in the upper and lower eyelids. It is not a simple addition of two procedures but an integrated surgical plan, adapted to the anatomical features of each patient.

Treatment may include:

• Removal of excess skin from the upper eyelid.
• Removal or redistribution of the fat pads in the upper eyelid.
• Removal of fat pads in the lower eyelid.
• Moderate removal of skin where there is laxity in the lower lid.
• Restoring volume or tightening the orbicularis area.
• Complementary skin rejuvenation (laser, tightening, canthopexy).

The aim is an overall improvement of the eyes, correcting the signs of ageing in both the upper and the lower eyelid without altering the natural expression of the face.

Clinical and aesthetic indications

Combined blepharoplasty is indicated in patients who have visible signs of ageing in both eyelids and who want a complete correction in a single operation. The most frequent situations include:

• Excess skin in the upper eyelid together with fat pads.
• Protruding pads in the lower eyelid, with or without lax skin.
• Fine lines or marked folds in the lower eyelid.
• A chronically tired look about the eyes.
• Asymmetry between the two eyes or between the eyelids.
• A wish to rejuvenate the eyes as a whole.

This type of operation is particularly useful in patients between 40 and 70 who have begun to notice a structural change in the area around the eyes, and who want a lasting solution without needing several procedures.

Pre-operative assessment

The consultation before a combined blepharoplasty has to be thorough, and directed at understanding both the anatomy and the patient’s goals. The assessment covers:

• A full analysis of the excess skin in both eyelids.
• Assessment of the volume and distribution of the fat pads.
• Examination of the quality and thickness of the eyelid skin.
• Assessment of the muscle tone of the lower eyelid.
• Study of the position of the brows and of facial symmetry.
• An ophthalmic review where there is a history of dry eye, chronic irritation or previous surgery.

Clinical photographs are taken and a specific surgical plan is defined, with a different technique for each eyelid region. The key lies in addressing each component of ageing in a coordinated way, respecting both the function and the appearance of the eyes.

The combined surgical technique

The operation is carried out in theatre under local anaesthetic with sedation or, in some cases, general anaesthetic, according to the patient’s clinical profile. The whole procedure takes between 90 and 120 minutes, depending on the techniques used.

The procedure runs in several stages:

1. Upper blepharoplasty
   • Marking the excess skin with the patient sitting up.
   • An incision on the natural crease of the eyelid.
   • Removal of the excess skin, fat and, where necessary, orbicularis muscle.
   • Closure with a fine suture in the eyelid crease.
2. Lower blepharoplasty
   • Choice of technique: subciliary if there is excess skin, or transconjunctival if there are only fat pads.
   • Access to the fat pads and their removal or redistribution.
   • Moderate removal of skin where there is laxity.
   • Possible reinforcement of the outer corner with a canthopexy if the eyelid is weak.
   • Careful closure with a cosmetic suture.
3. Complementary treatments
   • Fractional laser to the lower eyelid to improve texture and tone.
   • Injection of growth factors or hyaluronic acid into the lid-cheek groove where necessary.

Throughout the procedure the anatomy of the eyelid is respected, and the muscular and ligamentous structures are preserved so that the eyelid keeps working as it should.

Benefits of combined blepharoplasty

The main advantage of combined blepharoplasty is that it can rejuvenate the whole eye region harmoniously, avoiding partial or unbalanced results. Among its benefits:

• A complete improvement of the contour of the eyes.
• Bags, lines and folds dealt with at the same time.
• The symmetry between the two eyes.
• A more even and coherent result across the whole eye area.
• Less total recovery time than with two separate operations.
• Lower cost, by concentrating the work in a single procedure.

The aesthetic effect is also more striking, since the whole expression of the face around the eyes is transformed while the patient still looks like themselves.

What is really gained: what patients say

The underlying reason for treating both eyelids is a simple one: the eyes are read as a whole. Nobody looks at an upper eyelid on its own; they look at the whole expression. And when patients’ own views are measured, the results of this operation are among the most appreciated in aesthetic surgery.

The largest piece of work is a prospective study of 348 patients that used the FACE-Q questionnaire, the validated tool for measuring perceived results in facial surgery. It found significant improvement in every domain assessed: satisfaction with the eyes, satisfaction with the appearance of the face as a whole, satisfaction with the result, and — what matters most — psychological function and social function. Adverse effects were minimal and improved with time.

That last detail is worth underlining, because it tends to get lost in lists of risks: what improves is not only the reflection in the mirror. It improves how the patient feels and how she relates to other people, which is exactly what brought her to the consultation.

There is no need to wait until it gets worse

There is a very widespread idea — “it is not that bad yet, I will have it done later on” — that the evidence does not support. A prospective study of 79 patients asked precisely that: whether the severity of dermatochalasis before surgery predicts how satisfied the patient will be afterwards. The answer was that no such correlation exists.

Put another way: someone with a moderate excess ends up as satisfied as someone who arrived with a very marked one. The authors put it plainly: any degree of dermatochalasis can justify treatment if it bothers that particular person. In the same study, moreover, functional improvement was general, and visual field tests improved significantly in the most severe group.

The practical conclusion for anyone making up their mind: the timing is set not by how bad it is but by how much it affects you. Waiting until you are worse does not buy a better result.

Recovery after surgery

Recovery after a combined blepharoplasty is a little longer than after a single operation, but it is still well tolerated. The basic advice includes:

• Applying cold locally for the first 48 hours.
• Sleeping with the head raised to reduce swelling.
• Avoiding strenuous physical activity for at least 10 days.
• Not rubbing the eyes or wearing make-up until the sutures are removed.
• Following treatment with eye drops, topical antibiotics or anti-inflammatories if they are prescribed.
• Attending the scheduled follow-up appointments to monitor progress.

Swelling and bruising can last 7 to 14 days, and the aesthetic result begins to show clearly from the third week. The final result settles between the sixth and the eighth week.

Possible complications

Although combined blepharoplasty is a safe operation, there are risks inherent to any eyelid surgery. The complications, uncommon when the technique is correct, include:

• Slight asymmetry between the eyelids.
• Prolonged bruising.
• Retraction of the lower eyelid (more likely if too much skin is removed).
• Dry eye or watering.
• A visible scar (rare, if the suturing is precise).

The surgeon’s experience, the right choice of technique and postoperative follow-up are essential in keeping these risks to a minimum and ensuring the best possible recovery.

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Combined blepharoplasty is the most complete answer for anyone wanting to rejuvenate their eyes as a whole. By treating the upper and the lower eyelid at the same time, an aesthetic balance is achieved between the two areas, avoiding contrasts or partial results. The operation offers a marked improvement in facial expression, giving the face back its freshness and its natural look.

At the Instituto de Cirugía Plástica del Mediterráneo every operation is planned on rigorous medical criteria, adapted to the anatomy and the expectations of each patient. If you are looking for a complete solution to rejuvenate your eyes, request a specialist consultation. Our medical team will advise you honestly and precisely on the technique that best suits your needs, so that the result is safe, lasting and aesthetically coherent with your face.