The typical complaints of a good candidate for eyelid surgery are heavy or droopy upper lids, bags and puffiness of the lower lids, or excess, wrinkled skin in the lids. A natural consequence of aging, these characteristics can also occur prematurely in younger individuals. The changes with age in both the upper and lower eyelids are a result of excess skin and protrusion of fat but other structures may be involved or even the root of the problem. 

In younger patients there may be little or no skin redundancy and all lid changes may be due to protrusion of fat due to weakness of the septum or muscle. In addition to the assessment of the skin, muscle, septum, and fat, it is important to appreciate any sagging of the eyebrows as a brow lift may be needed. Blepharoplasty in simplistic terms is directed at removal of the excess skin and fat bags from the upper and/or lower eyelids. Crow's feet, are not improved by a standard blepharoplasty. If excessive skin impairs the visual field, correction may be considered reconstructive and it may be covered by insurance. Outside of this situation, however, eyelid surgery is considered cosmetic, and is typically not covered by insurance.

Your evaluation
Certain medical conditions (i.e. Horner’s Syndrome and thyroid diseases) and eye conditions (i.e.  visual acuity changes, cataracts, glaucoma, ptosis, and dry eye) are important variables in determining the safety of eyelid surgery. 

The surgery
Surgery on the eyelids may be done as an isolated operation or in conjunction with other facial rejuvenation. Both upper and lower eyelids can be corrected at the same surgery, typically an outpatient procedure done with intravenous sedation and local anesthesia. Surgery for each set of lids takes approximately 1 hour. The main goals of an upper eyelid blepharoplasty are to remove excess skin and correct protruding orbital fat. 

With lower lid blepharoplasty, skin resection is usually limited or avoided and the focus is on lax muscle tightening, excess septal fat correction, and eyelid suspension. A canthopexy bolsters the lower lid support and a canthoplasty recreates the lower lid support. 

A tear trough deformity can be corrected by mobilizing septal fat to the area of depression. A skin incision is used if both skin and fat are to be removed, but if not, an incision on the inside of the eyelid, a transconjunctival blepharoplasty can avoid an external scar and skin resurfacing can treat minor skin laxity of the lower lids. A laser blepharoplasty utilizes a laser to make incisions which can reduce bleeding, bruising, and swelling. 

After the surgery
Postoperatively, ice and elevation help minimize swelling, bruising, oozing, and crusting, which usually peaks at 48 to 72 hours and resolves by day 5 - 7.  After surgery on all four eyelids, lids may swell to almost complete closure.  Pain is usually minimal. Contacts should not be worn until the swelling and dryness have resolved. Symptoms of blurry vision, light sensitivity, or tearing may occur but should slowly resolve over 2 to 3 weeks, and lubricating gel and eye drops provide symptomatic relief. Sutures are removed within a week and at that point, makeup can be used to cover up any residual bruising. It may take up to 3 months for the scars to settle down fully. Return to work and daily activities are variable with some people back as quickly as 3 days postoperatively. Strenuous activity should be avoided for 3 to 4 weeks.  

Understand the risks
Complications are rare, and most individuals can expect an excellent result with correction of their lid problems. There are, however, potential risks and complications. Bleeding behind the eye (retrobulbar hematoma) can threaten vision and presents as severe pain, visual changes with loss of visual field or bright lights/sparkles, proptosis (protrusion of the eyeball), or excessive bruising/swelling. Emergent release of sutures and canthal ligament is necessary in these situations. 

Itching, scratching, burning, light sensitivity, and discomfort characterize dry eyes. Symptoms may exist following blepharoplasty due to swelling and crusting, but is temporary in most cases and is managed with lubrication and artificial teardrops while waiting for improvement. 

Lower lid retraction (Ectropion) can occur but is usually correctable with massage and taping, but may require surgical correction when persistent. It may be difficult to fully close the eyes after the operation (Lagophthalmos) and protection with lubricating gel is recommended. 

All of the descriptions for the various procedures are condensed from the text of the upcoming textbook written by Dr. Christopher Park and Dr. Malcolm Marks and are copyrighted, "The Artistry of Plastic Surgery: Exploring the Experience” .