The differences between upper and lower blepharoplasty

A common aim, different techniques

Both techniques set out to improve the appearance of the eyelids and bring freshness back to the eyes. What is corrected in each of them, however, and the way the area is reached, differ considerably.

What upper blepharoplasty is

Upper blepharoplasty corrects excess skin and, in some cases, the fat that has built up in the upper eyelids. That surplus skin can form folds that give the eyelid a drooping look, and it may even interfere with the patient’s field of vision.

The main indications include:

• Excess skin over the upper eyelid.
• Partial drooping of the eyelid that hides the natural crease.
• A build-up of fat in the inner part of the eyelid.
• A feeling of heaviness in the eyes.
• Loss of the upper visual field through mechanical obstruction.

The operation is carried out through a precise incision in the natural crease of the eyelid. Through that incision the excess skin is removed, the fat is taken out or redistributed and the muscle is adjusted if necessary. The resulting scar is concealed within the eyelid crease, which allows an excellent aesthetic recovery.

The results of this operation are usually apparent quickly. The face recovers its natural expression, the permanently tired look disappears and the eyes become more open and brighter.

What lower blepharoplasty is

Lower blepharoplasty treats the signs of ageing in the lower eyelid, where prominent pads of fat, lax skin and loss of muscle tone tend to appear.

Its main indications include:

• Pads of fat in the infraorbital region.
• Laxity and lines in the lower eyelid.
• A marked groove between the eyelid and the cheek.
• Slackening of the orbicularis muscle.
• Eyes that look puffy, tired or aged.

In this operation there are two main techniques, depending on the patient’s case:

• Transconjunctival technique: the fat compartment is reached through the conjunctiva, with no external incision. It is the option indicated for younger patients or those with good skin quality, since it removes no skin.
• Subciliary technique: an incision is made just below the lash line. This route allows both skin and fat to be removed, and is more suitable in cases with evident laxity or excess skin.

In both cases the aim is to reduce the bags without leaving visible signs. At the Instituto de Cirugía Plástica del Mediterráneo, priority goes to conservative techniques that preserve the natural volume and avoid a hollowed or over-corrected look.

Anatomical differences to bear in mind

The differences between the two operations lie not only in the surgical technique but also in the anatomy of the area treated:

• In the upper eyelid, the main thing to correct is usually the skin. The fat is more localised and, in many cases, needs no work at all.
• In the lower eyelid, fatty tissue takes the leading part. Over time the bags become more evident through loss of muscle tone and laxity of the skin.

This means that in upper blepharoplasty the skin excision has to be exact, so as not to alter how the eyelid moves, while in the lower lid extreme precision is needed so as not to change the position of the eyelid or affect how it works.

Differences in the recovery

Both operations share a relatively short and well-tolerated recovery. There are, however, differences in how each one runs:

• In upper blepharoplasty, the swelling is confined to the eyelid crease and usually settles within a few days. The scar is completely hidden in the natural fold of the eyelid.
• In lower blepharoplasty, more marked bruising can appear in the area of the dark circle. The skin of the lower eyelid is thinner and more delicate, so the swelling may last a little longer. Full recovery is usually seen from the third week onwards.

In both cases it is advisable to apply cold locally during the first 48 hours, to take relative rest and to avoid exertion or direct sun exposure. Medical follow-up is key to ensuring the best possible recovery.

When each technique is indicated

The indication for each type of blepharoplasty depends on the clinical diagnosis and on the surgeon’s assessment. It is common for many patients to have changes in both the upper and the lower eyelid, and for a combined blepharoplasty to be recommended.

It can be summed up as follows:

• Upper blepharoplasty: indicated in cases of skin folds, mild ptosis, a feeling of heaviness in the eyes or a dull look caused by surplus skin.
• Lower blepharoplasty: recommended where there are visible bags, a deep groove or excess skin in the lower part of the eye.

In some cases surgery is accompanied by additional procedures such as tightening the outer corner of the eyelid (canthopexy or canthoplasty), to make sure the eyelid stays in a stable position in the long term, or fat transfer, to improve the transition of the lower eyelid and add volume to the dark circle and the cheek.

Aesthetic and functional results

Upper and lower blepharoplasty, carried out with the right technique, offer benefits that are both aesthetic and functional:

• Removal of the signs of facial ageing.
• Recovery of natural expressiveness.
• Improvement of the upper visual field.
• Correction of asymmetry between the eyes.
• A result that sits harmoniously with the rest of the face.

At the Instituto de Cirugía Plástica del Mediterráneo, patient safety, minimal invasiveness and the highest quality of result always come first. Every procedure is planned in detail, taking into account the anatomy, age, skin type and realistic expectations of the patient.

They are not two halves of the same operation

The underlying difference between the two lies not in the technique but in what they are for, and that shows in the evidence.

The upper lid can stop being aesthetic. When the skin of the upper eyelid encroaches on the field of vision, the operation becomes a functional one, and that shift has measurable criteria. The American Academy of Ophthalmology, reviewing the evidence, set out as indicators of functional improvement a margin-to-reflex distance of 2 mm or less and a loss of upper visual field of at least 12 degrees or 24%. Where those are met, correction improves sight, peripheral vision and quality of life.

The lower lid has no such equivalent. Bags and the tear trough do not obstruct sight: they are corrected for their effect on the eyes’ appearance. That is why lower blepharoplasty is, with rare exceptions, an aesthetic indication, and the bar for deciding on it is a different one — what is at stake there is the position of the eyelid, not the visual field.

Doing both at once has a price

This is the practical question that follows from everything above, and it has an answer. In a review of 892 blepharoplasties, 26.5% of patients had symptoms of dry eye and 26.3% had chemosis; and among the factors that significantly increased both was operating on the upper and lower eyelid in the same sitting, alongside pre-existing scleral show, eyelid laxity and the use of a skin-muscle flap.

It should be said at once that both usually settle on their own: they are phases of recovery, not lasting damage. Combining the two saves one trip to theatre and one recovery, and in many patients it is perfectly reasonable. But in an eye with little tear film, with laxity of the lower eyelid or with pre-existing symptoms of dryness, separating them is a defensible decision even though it means going through it twice. That is the conversation worth having, rather than simply “while we are at it, let us do all four”.

A full pre-operative assessment

Before any blepharoplasty, whether upper or lower, a complete medical assessment is essential. That assessment includes:

• Examination of how the eyelid works.
• Analysis of the state of the skin and the muscle.
• Study of the bony support and the position of the brows.
• Review of medical history and of previous treatments.

Only with an overall view can it be determined precisely which type of operation is the most suitable and which surgical technique offers the best guarantees of success.

Understanding the differences between upper and lower blepharoplasty allows the patient to make informed decisions and to have confidence in the surgical process. The two operations, although different in technique and purpose, share a common aim: to rejuvenate the eyes naturally, safely and lastingly.

If you are thinking about improving the look of your eyes and removing the signs of tiredness or ageing around them, we recommend a specialist consultation at the Instituto de Cirugía Plástica del Mediterráneo. The surgeon’s experience and a detailed medical assessment are essential to achieving safe and satisfactory results.