There is no single blepharoplasty: the technique is chosen according to the clinical diagnosis, the area to be treated and the result expected — upper, lower, transconjunctival, with laser or combined.
The upper corrects excess skin — and, where appropriate, muscle and fat — of the upper eyelid, with the scar hidden in the natural crease; the lower treats bags, lax skin and the hollow between eyelid and cheek, and is technically more complex.
The transconjunctival approach enters through the inner surface of the eyelid, with no external incision; it is indicated where there are bags with no excess skin, since this route does not allow skin to be removed.
The CO₂ laser has two roles: as a scalpel (greater precision, less bleeding) and as a complementary treatment to tighten the skin and soften fine lines; badly applied it can cause eye irritation or hyperpigmentation, so it calls for specific experience.
The choice is not made by personal preference: it requires assessment of the state of the skin, the muscle tone, the orbital fat, the position of the eyeball and general eye health.
Blepharoplasty is an operation intended to rejuvenate the eyes by correcting the tissues of the eyelids. The surgery is adapted to the particular needs of each patient, since not everyone has the same signs of ageing or the same anatomical conditions. That is why, at the Instituto de Cirugía Plástica del Mediterráneo, in Valencia, different types of blepharoplasty are used according to the clinical diagnosis, the area to be treated and the aesthetic result expected.
Knowing the differences between the main types of blepharoplasty helps in understanding the treatment and in making informed decisions. Each technique has its own indications, surgical characteristics and aims. This article gives a clear and precise description of the most common types: upper, lower, transconjunctival and laser blepharoplasty.
If you are not yet clear what the operation involves, the general guide to blepharoplasty explains what it corrects, how it is carried out and what recovery to expect.
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Upper blepharoplasty concentrates on correcting the excess skin, muscle and fat that builds up in the upper eyelid. This change is common with ageing, but it can also appear in younger people with a genetic predisposition.
The most frequent indications for this technique include:
Folds of skin that hide the natural crease of the eyelid.
A feeling of heaviness in the eyes.
Difficulty applying make-up to the upper eyelid.
Partial obstruction of the field of vision.
Eyes that look aged or tired.
The operation is carried out through an incision placed strategically in the natural crease of the upper eyelid. Through that route the excess skin is removed and, where necessary, part of the orbicularis muscle and the pads of fat. The resulting scar is hidden when the eye opens, which allows a very satisfactory aesthetic recovery.
The result is a more open, rested look, in harmony with the rest of the face. The expression becomes lighter without losing its natural quality.
Lower blepharoplasty
Lower blepharoplasty is indicated to treat the pads of fat that form under the eyes, along with lax skin and drooping of the lower eyelid. This technique is more complex than the upper one, since it requires detailed analysis of the quality of the skin, the amount of orbital fat and the muscle tone.
The most common situations in which this technique is indicated are:
The appearance of prominent bags under the eyes.
A hollow at the junction between the lower eyelid and the cheek.
Lax skin with marked lines in the lower area.
A constantly tired or puffy appearance.
There are two main routes for this surgery: external (subciliary) and transconjunctival. The choice depends on the type of change and on the state of the skin.
The external route consists of an incision just below the lash line. This technique allows both fat and skin to be removed. It is particularly useful in patients with moderate or severe laxity.
Lower blepharoplasty improves the transition between the eyelid and the cheek, reduces the bags and restores the contour around the eye, giving a younger, healthier expression.
Transconjunctival blepharoplasty
Transconjunctival blepharoplasty is a surgical technique used to treat the fat pads of the lower eyelid without any visible external incision. In this procedure, access is through the conjunctiva, the internal membrane of the lower eyelid.
The main indications for this technique are:
The presence of fat pads with no excess skin.
Firm skin with good muscle tone.
Younger patients with inherited changes.
This approach reaches the fat pads without disturbing the skin of the eyelid, which reduces the risk of visible scars or of changes to the position of the eyelid. It is of no use where there is lax skin, since it does not allow skin to be removed.
Its advantages include:
No external incision.
Quick recovery.
A lower risk of aesthetic complications.
Natural results.
Transconjunctival blepharoplasty is an excellent option for anyone with bags but no other advanced signs of ageing in the lower eyelid.
Laser blepharoplasty
Laser technology can be used in blepharoplasty both as a surgical tool and as a complement to improve the texture of the skin. In recent years the use of fractional CO2 laser has established itself as an effective and safe option, particularly in combination with conventional techniques.
There are two main applications of the laser in this surgery:
Laser as a scalpel: it allows incisions to be made with great precision, reducing bleeding and helping healing. It can also be used to seal blood vessels and remove fat.
Laser as a complementary treatment: after surgery, fractional laser can be applied to tighten the skin, improve its texture and soften fine lines.
The advantages of using the laser include:
Less bleeding during the operation.
Quicker recovery in some cases.
An aesthetic improvement in the quality of the skin.
A reduction in superficial lines.
This type of blepharoplasty has to be indicated by a specialist experienced in laser surgery, since applying it improperly can cause eye irritation or hyperpigmentation.
Combined blepharoplasty
In many cases the ageing of the eye area affects both the upper and the lower eyelid. Combined blepharoplasty is an integrated approach that corrects the changes in both areas at the same time.
This type of operation is indicated when:
There is excess skin on the upper eyelids.
There are bags or lax skin on the lower eyelids.
The patient’s aim is to rejuvenate the eyes as a whole.
Combined surgery makes use of the same operation and the same recovery period to treat both eyelids, with results that are harmonious and coherent with the facial anatomy.
Where each technique enters. In the lower eyelid, the transconjunctival route leaves no external scar.
The decision about which type of blepharoplasty to perform should not be taken on personal preference alone. It calls for a precise medical assessment that includes:
Analysis of the state of the skin of the eyelids.
Assessment of muscle tone and laxity.
The presence and location of orbital fat.
The position of the eyeball and of the outer corner.
A review of general eye health.
Every patient has a unique anatomy and specific needs. At the Instituto de Cirugía Plástica del Mediterráneo, the choice of technique rests on objective medical criteria, with the aim of results that are natural, functional and lasting.
What the evidence decides and what the case decides
With so many variants on the table it is easy to think the choice is a matter of preference. In fact there are three decisions the literature does narrow down, and it is worth knowing which before getting into tastes.
Whether the upper lid is aesthetic or medical. This is not an impression: there are measurable thresholds — a margin-to-reflex distance of 2 mm or less and a loss of upper visual field of at least 12 degrees or 24% — below which surgery improves visual function, not just appearance. We set it out in functional blepharoplasty.
How much is removed in the upper lid. In a study in which each patient had one technique on each eyelid, removing a wide strip of muscle made no difference to the aesthetic result and did add temporary lazy closure and dryness. The narrow strip we do remove is after something else — making the eyelid less bulky and the crease better defined: what that work narrows down is its width, not its existence. It is in upper blepharoplasty.
Whether both eyelids are done at once. Across 892 operations, operating on the upper and lower lid in the same sitting is among the factors associated with more dryness and chemosis — both temporary, but worth saying. Combined blepharoplasty has the figures and also what there is to gain.
What the evidence does not decide is everything else: the route of approach in the lower eyelid, the use of the laser as an instrument or the exact shape of the crease all depend on the eyelid in front of you — its thickness, the position of the brow, the quality of the tear film — and on what bothers that particular person. That is why the choice of technique is the end of an examination, not a starting point.
Benefits common to all the techniques
Despite their differences, all types of blepharoplasty offer notable benefits when they are well indicated and well executed:
Removing the tired or aged look about the eyes.
Reducing bags and excess skin.
Restoring the natural contour around the eye.
Improving facial symmetry.
Increased self-esteem and personal satisfaction.
The success of the surgery depends largely on choosing the right technique and on the surgeon’s experience. That is why it is essential to trust a specialist team that carries out a complete assessment and uses procedures backed by evidence-based medicine.
Understanding the different types of blepharoplasty and how they differ allows informed decisions and access to genuinely individual treatment. Each technique answers to a different anatomical and aesthetic profile. If you are considering eyelid surgery, we recommend booking a consultation with a specialist in facial plastic surgery. At the Instituto de Cirugía Plástica del Mediterráneo you will find a medical team that puts safety, a natural result and the patient’s long-term wellbeing first.
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There is no single blepharoplasty. The main ones are upper, lower, transconjunctival, the one using a laser and the combined procedure. The technique is chosen according to the clinical diagnosis, the area to be treated and the result expected.
What does upper blepharoplasty correct?
The excess skin and, if necessary, part of the orbicularis muscle and the fatty bags of the upper eyelid. It is indicated for folds of skin that hide the natural crease, a feeling of heaviness in the eyes, difficulty applying make-up to the eyelid, partial obstruction of the visual field or a tired-looking gaze. The incision goes in the natural crease and the scar is hidden when the eye opens.
And the lower one?
It treats the fatty bags under the eyes, slack skin and the sagging of the lower eyelid, along with the hollow where the eyelid meets the cheek. It is technically more demanding than the upper one, because it requires analysing the quality of the skin, the amount of orbital fat and the muscle tone.
What is transconjunctival blepharoplasty and when is it used?
It reaches the fatty bags through the inner surface of the eyelid, with no visible external incision. It is indicated when there are fatty bags without excess skin, with firm skin and good muscle tone, or in young patients with inherited changes. It is no use if there is slack skin, because this route does not allow skin to be removed.
What is the laser used for in this surgery?
It has two roles. As a scalpel, it allows very precise incisions, reduces bleeding and aids healing, and can coagulate vessels and remove fat. As an adjunct, the fractional laser is applied afterwards to tighten the skin, improve texture and soften fine lines. It calls for a specialist experienced in laser surgery: applied wrongly it can cause eye irritation or hyperpigmentation.
When is the combined procedure done?
When ageing affects both eyelids: excess skin above along with bags or slackness below, and the aim is an overall rejuvenation of the eyes. It allows the same procedure and the same recovery to cover both eyelids.
Can I choose the technique myself?
It is not a matter of personal preference. It requires a medical assessment covering the state of the eyelid skin, the muscle tone and laxity, the presence and position of orbital fat, the position of the eyeball and lateral canthus, and general eye health. The choice of technique is the end of an examination, not a starting point.
What does the evidence decide and what depends on the case?
The literature settles three things: whether the upper procedure is aesthetic or functional — there are measurable thresholds: a margin-reflex distance of 2 mm or less and a loss of superior visual field of at least 12 degrees or 24%; how much muscle is removed in the upper eyelid — a wide band does not improve the aesthetic result and adds temporary lazy closure and dryness; and that operating on both eyelids at once is among the factors associated with more dryness and chemosis. The rest — the route in the lower eyelid, the use of the laser, the shape of the crease — depends on the eyelid in front of you.
Sources
Cahill KV, Bradley EA, Meyer DR, Custer PL, Holck DE, Marcet MM, Mawn LA.Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118(12):2510-2517. PMID 22019388 — the thresholds that separate a functional indication from an aesthetic one.
Kiang L, Deptula P, Mazhar M, Murariu D, Parsa FD.Muscle-sparing blepharoplasty: a prospective left-right comparative study. Arch Plast Surg. 2014;41(5):576-583. PMID 25276652 — a left-right comparison within the same patient: a wide strip of muscle adds nothing to the aesthetic result and does add symptoms of impaired closure; it narrows down the width of the resection, not whether to do it.
Prischmann J, Sufyan A, Ting JY, Ruffin C, Perkins SW.Dry eye symptoms and chemosis following blepharoplasty: a 10-year retrospective review of 892 cases in a single-surgeon series. JAMA Facial Plast Surg. 2013;15(1):39-46. PMID 23329270 — operating on the upper and lower lid in the same sitting is among the factors associated with dryness and chemosis.
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