Types of blepharoplasty, and how the techniques differ

"I want the laser one." "The one that leaves no scar." "The one with threads." The names of techniques arrive in the consulting room as though they were products in a catalogue, and choosing does not work that way.

The technique is the last thing to be decided. First you have to know what that eyelid has too much of and too little of, and that cannot be seen in a photograph.

Before the technique: what is being corrected

An eyelid can have five different things wrong with it, and it almost never has just one:

• Excess skin. This is what most people call a drooping eyelid.
• Fat pushing forward. The bags. It is orbital fat coming into view because the septum holding it back has given way.
• Muscle. The orbicularis can be thickened and form a ridge under the lash line.
• Tone of the lower lid. If it is lax, removing skin pulls it down and leaves the eye red and watering.
• Brow position. If what is descending is the brow, taking skin off the eyelid makes the look worse rather than opening it up.

And there is one distinction that changes the whole operation: ptosis is not excess skin. In ptosis the lid margin sits low because the muscle that lifts it is not pulling properly. That is a muscle problem and it is operated on in a different plane. Mistake it for skin, remove skin alone, and the eye stays half closed — with no skin left to spare.

The upper eyelid

This is the best known and the most codified. The incision runs inside the natural crease, which is where the scar hides as soon as the eye opens. What gets decided there is:

• How much skin comes off. A minimum has to remain for the eye to close. Taking more does not give a more open look: it gives an eye that does not quite close at night and a cornea that dries out.
• Whether the muscle is touched. Sometimes a thin strip of orbicularis is removed; often it is not needed.
• Whether the fat is touched. In the upper lid the excess is usually only on the inner side, next to the nose. Emptying the rest leaves the hollowed look that gives away surgery done thirty years ago.

It is almost always done under local anaesthetic, with or without sedation, and the stitches come out at around a week.

The lower eyelid: two routes

This is the decision people ask about most, and it turns on one thing: whether there is excess skin as well as bags.

The transconjunctival route

You go in from the inside, through the inner surface of the lid. It leaves no scar on the skin and barely disturbs the support of the lid margin, so the risk of the eyelid retracting is lower.

It is the route of choice when the problem is the bags and the skin is in good condition. What it does not do is remove skin: if there is excess, it is combined with a surface treatment — a peel or a laser — or with a minimal strip taken from just below the lashes.

The subciliary route

The incision runs on the outside, a couple of millimetres below the lashes. It allows the fat to be treated and skin and muscle to be removed as well, and the scar hides along the lid margin.

It reaches further and it asks more. Lifting the tissue from the front weakens the support of the lid, and if that lid was already lax and is not reinforced, the margin can drop — a band of white appears below the iris — or turn outwards. That is why it is usually paired with a supporting stitch at the outer corner.

Removing the fat or moving it

For years the bag was dealt with by emptying it. It works early and ages badly: the groove between eyelid and cheekbone deepens over the years and the look becomes hollow.

Where that groove already exists, the tendency now is to reposition the fat rather than discard it: it is released and spread downwards to fill the valley. Your own fat can also be added. What decides between the two is whether there is a hollow beneath the bag, and that is assessed standing up in ordinary light, not lying on the couch.

The technique is not picked from a catalogue. It is chosen after looking at how much skin is spare, how much fat there is, what tone the lid has and where the brow sits.

What gets added when it is needed

• Canthopexy or canthoplasty. Both reinforce the outer corner of the eye. The first supports it with a stitch; the second detaches it and fixes it higher. They are not a cosmetic extra: they stop the lower lid dropping afterwards.
• Ptosis correction. Work is done on the levator muscle or on Müller's muscle, from the outside or the inside. It is a separate operation that is sometimes done in the same sitting.
• Brow lift. If the problem above is the brow, it is lifted by a temporal, endoscopic or direct approach, with or without blepharoplasty.
• Lid crease surgery. In the Asian eyelid the aim is not to change the feature but to define a crease in keeping with it. It is done with an incision — which also allows skin and fat to be removed, and does not come undone — or with sutures, which is less invasive and can loosen over the years.
• Malar bags and festoons. These sit on the cheekbone, not the eyelid, and a blepharoplasty does not correct them. Better to know that beforehand than afterwards.

Laser, radiofrequency and scalpel

"Laser blepharoplasty" is advertised as a technique of its own. Strictly, the laser is the tool that cuts and coagulates, not a different operation. It cuts while sealing vessels, so there may be a little less bleeding and less bruising in the first few days. It does not change where the incision goes, or how much is removed, or how the eyelid looks a year later. The same is true of radiofrequency.

A different matter is laser applied to the skin of the lower lid to treat fine lines. That is not the surgery: it is a surface treatment that sometimes accompanies it.

"Non-surgical blepharoplasty"

The name is the problem. There are plasma and radiofrequency devices that tighten skin with small controlled burns, and they can somewhat improve skin with fine lines. That is all they do.

They do not remove bags, because the fat sits behind a septum they never reach, and they do not correct ptosis or lift a brow. On the eyelid, besides, the margin between tightening and burning is narrow, and a badly healed scar there is among the hardest to put right. If someone offers you the result of surgery without surgery, what they are comparing is not two techniques.

How it is chosen, in the consulting room

With checks that take seconds and decide almost everything:

1. Looking at you standing, with your face at rest — not lying down and not raising your eyebrows, which everyone does without noticing.
2. Holding the brow back in place with a finger. If the eyelid then stops being in excess, the brow is what needs treating.
3. Measuring where the lid margin falls relative to the pupil, which is what separates ptosis from excess skin.
4. Testing the lower lid's tone: it is drawn away from the eye and let go. If it is slow to return, there is laxity and the corner will need reinforcing.
5. Asking about dry eye, previous laser eye surgery, thyroid and allergies. All four change the plan and the margin of what can safely be removed.
6. A visual field test where the skin is suspected of cutting into vision from above.

What is up to you

You do not need to arrive knowing the technique. You need to arrive with the right question, which is not "will you do the laser one?" but "what do I have too much of, what too little, and why that route rather than the other?".

If the answer is a trade name instead of an explanation of your eyelid, the conversation has not started yet.