Periorbital rejuvenation through blepharoplasty: Current concepts and surgical perspective

INTRODUCTION

The eyes are an essential component of the face, and the periocular region is often the first area to display signs of aging. As a result, blepharoplasty – commonly known as eyelid surgery – has become a cornerstone of facial rejuvenation. Blepharoplasty is defined as a surgical procedure for the esthetic or functional manipulation of the upper and lower eyelid so as to improve the appearance of the eyes while maintaining the natural shape of the eyes.

The term was coined by Karl Ferdinand Von Graefe, in which the word “Blepharon” stands for eyelid and “plastikos” means to mold.^[1] Blepharoplasty for the upper lid is usually done for both functional and esthetic causes, while for the lower lid is done mostly for improved esthetic outcomes. It involves the removal of the fold of skin and fat pads. Previously, the focus was usually on attaining functional correction for most patients, but now, the trend is changing towards esthetic rejuvenation.^[1] Tired-looking eyes, sagging eyelids, circles around the eyes, and excess skin folds are some of the conditions that benefit from blepharoplasty, especially in the Southeast Asian population.

This review outlines current approaches to upper and lower eyelid rejuvenation, including adjuncts such as brow lift, fat repositioning, and mid-face lifting, as well as the management of complications.

ANATOMY AND PHYSIOLOGY

Successful periorbital rejuvenation depends heavily on a sound understanding of eyelid anatomy. The eyelid serves the following functions: protection of the globe from external sources, providing sufficient and appropriately located aperture for vision, tear production, and distribution, and plays a role in facial expression.^[2]

The eyelid is a complex anatomical structure composed of distinct lamellae, each contributing to its functional and esthetic characteristics. The anterior lamella comprises the skin, subcutaneous tissue, and orbicularis oculi muscle, while the posterior lamella is formed by the tarsal plate and conjunctiva. Separating these components, particularly in the upper eyelid, is the orbital septum, a fibrous barrier whose laxity can lead to herniation of orbital fat and the clinical appearance of eye bags.^[2]

The tarsal plates, measuring approximately 10 mm in the upper lid and 4 mm in the lower lid, provide structural integrity to the lid margin and serve as anchoring points for muscles and aponeurotic attachments. The lateral and medial canthal tendons, each with superior and inferior crura, play critical roles in maintaining eyelid position; the lateral tendon attaches to Whitnall’s tubercle just posterior to the lateral orbital rim, whereas the medial tendon anchors to the anterior and posterior lacrimal crests [Figures 1 and 2].

Close

Figure 1:

Anatomy of the upper and lower eyelid.

Export to PPT

Close

Figure 2:

Anatomy of the frontal view of the eye.

Export to PPT

Postseptal fat compartments further define eyelid contour. In the upper eyelid, these include the preaponeurotic and nasal fat pads, separated by the interpad septum. In the lower eyelid, nasal, central, and lateral fat pads are delineated by the inferior oblique muscle and the Lockwood ligament [Figure 3].

Close

Figure 3:

Anatomy of periorbital fat compartments.

Export to PPT

The tear trough or nasojugal groove, a hallmark of aging, is anatomically defined by the orbital retaining ligament and extends from the medial canthus toward the medial corneoscleral limbus.

The levator apparatus consists of the levator palpebrae superioris, innervated by the superior division of the oculomotor nerve (CN III), and Müller’s muscle, which receives sympathetic innervation. The levator aponeurosis inserts into the superior tarsal plate and sends fibers to the skin approximately 8–10 mm above the tarsus, creating the supratarsal crease. The lacrimal apparatus, responsible for tear production and drainage, is clinically significant both for functional integrity and esthetic considerations; hypertrophy of the lacrimal gland may produce lateral bulging, and surgical compromise can result in dry eye syndrome. The orbicularis oculi muscle, organized into pretarsal, preseptal, and orbital portions, is central to eyelid closure and periocular expression.^[2]

INDICATIONS

1. Dermatochalasis – excess of skin of the lower or upper eyelids, skin hangs over the ciliary margin

2. Blepharochalasis – loss of tone, relaxation of upper eyelid skin, interferes with the upward field of vision

3. Steatoblepharon – a fat protrusion in the upper and lower eyelids

4. Upper eyelid ptosis^[2]

5. Lower eyelid ectropion – turning out of the lid, exposing the conjunctiva

6. Hypertrophy of the orbicularis oculi muscle – a ridge of bulging muscle running horizontally along the lower lid.^[3,4]

EXAMINATION AND PREOP PLANNING

Before performing blepharoplasty, a thorough pre-operative assessment is essential. A full medical history, along with ophthalmological examination, should be done on the patient before planning for blepharoplasty. Specifically, patients should be questioned regarding pre-operative visual acuity, symptoms of dry eyes, and visual obstruction.

Objective evaluations include the Schirmer’s test for basal tear production, visual field analysis to document functional impairment, and Jones testing to assess the patency of the lacrimal drainage system.^[2]

MANAGEMENT

The management of periorbital aging requires an individualized, anatomy-driven approach that accounts for patient age, structural characteristics, functional needs, and esthetic goals. Broadly, interventions range from non-surgical rejuvenation in younger patients to combined surgical techniques in those with more advanced tissue changes.

NON-SURGICAL REJUVENATION

In patients in their 30s and 40s with early manifestations of periorbital aging, minimally invasive strategies may suffice. Chemodenervation can reduce early brow ptosis and soften dynamic wrinkles, while soft tissue fillers are useful for augmenting the infraorbital hollow in negative-vector patients. Adjunctive laser or photodynamic therapies may address mild skin laxity, allowing for esthetic improvement without the morbidity of surgery. These approaches also help establish a long-term therapeutic relationship with patients, facilitating gradual and tailored rejuvenation over time.

BROW LIFT

When brow descent contributes to upper eyelid redundancy or alters the brow–lid continuum, surgical brow elevation may be indicated. Brow ptosis, defined as the eyebrow resting below the superior orbital rim, can impair both function and appearance. Techniques include the direct brow lift (skin excision just above the brow), pretrichial or coronal lifts (incisions along or within the hairline) [Figure 4], and the endoscopic brow lift, which offers a minimally invasive option for mild-to-moderate ptosis. Regardless of technique, the surgical objectives are to restore brow position, attenuate brow depressor activity (corrugator and procerus), and rejuvenate the forehead contour.^[4]

Close

Figure 4:

Markings for direct brow lift.

Export to PPT

UPPER EYELID SURGERY: EVOLVING TECHNIQUES

Upper eyelid blepharoplasty has evolved from traditional en bloc excision of skin, muscle, and fat to modern approaches emphasizing tissue preservation and volume maintenance. The incision is placed within the natural supratarsal crease – typically 7–9 mm above the lash line – and at least 20 mm of vertical lid height is preserved. Conservative fat excision is generally confined to the medial and central compartments and may be combined with browpexy or brow lift for optimal results. Preservation of the orbicularis oculi muscle and periorbital fat maintains youthful convexity, while muscle resection is reserved for hypertrophy or significant fold asymmetry.^[5]

SKIN-ONLY BLEPHAROPLASTY

For select patients, skin-only blepharoplasty offers a natural esthetic outcome while preserving pretarsal orbicularis muscle volume. The supratarsal crease is maintained at approximately 7–8 mm in women and 6–7 mm in men. Lenticular incisions are favored in younger patients, while a trapezoidal lateral extension may be used in older patients to address skin redundancy. Incision extension beyond the lateral orbital rim or medial canthus is avoided to minimize scarring and webbing. A small amount of post-operative lagophthalmos (1–2 mm) ensures tension-free closure [Figures 5 and 6].^[6]

Close

Figure 5:

Upper eyelid blepharoplasty – basic incision. (a) Redundant skin of upper eyelid indication for blepharoplasty, (b) Incision for upper blepharoplasty, (c) Suturing post skin excision, (d) Results post blepharoplasty.

Export to PPT

Close

Figure 6:

(a) Pre Blepharoplasty and fat pad removal, (b) Post blepharoplasty and fat pad removal.

Export to PPT

ANCHOR (INVAGINATION) BLEPHAROPLASTY

In patients seeking a more defined eyelid crease, the anchor technique sutures pretarsal skin to the levator aponeurosis. This method requires minimal skin excision (2–3 mm), limited orbicularis removal, and precise creation of a pretarsal skin–muscle flap. It is particularly effective for pseudoptosis correction while preserving eyelid contour, though it demands greater surgical expertise and time.^[7,8]

ORBITAL FAT MANAGEMENT

Conservative fat debulking, rather than aggressive removal, is a key to avoiding hollowing and A-frame deformity. The medial fat pad (white) and central/lateral compartments (yellow) can be selectively reduced through the blepharoplasty incision, with undercorrection preferred to maintain a youthful contour. Septal attenuation may be treated with selective diathermy rather than extensive plication to reduce scarring risk [Figure 7].

Close

Figure 7:

Upper lid blepharoplasty. (a) skin incision, (b) skin and orbicularis muscle resection, (c) fat pad excision.

Export to PPT

BLEPHAROPTOSIS CORRECTION

Addressing coexistent ptosis during upper blepharoplasty improves both function and esthetics. Mild ptosis (~1 mm) may respond to selective orbicularis myectomy, while more significant cases require levator aponeurosis advancement to the superior tarsus, secured with precise horizontal mattress sutures. Intraoperative lid height, contour, and symmetry assessment are critical, and overcorrection should be avoided to prevent lash eversion or corneal injury.^[9,10]

LOWER EYELID BLEPHAROPLASTY

Lower eyelid surgery has shifted from aggressive tissue removal toward structural preservation and support restoration. The transcutaneous approach allows wide exposure for fat excision or repositioning but carries higher risks of ectropion and scleral show. The transconjunctival route is preferred for patients with good skin tone and lid support, enabling fat management without violating the orbital septum. Excess skin can be treated secondarily with subciliary pinch excision or resurfacing [Figure 8].^[11]

Close

Figure 8:

Transconjunctival lower eyelid blepharoplasty. (a) Visualisation of conjuctiva for incision, (b) Transconjunctival incision for lower eyelid blepharoplasty

Export to PPT

Fat repositioning – such as pedicled transposition over the arcus marginalis – maintains periorbital volume and corrects tear trough deformity. Septum plication returns fat to its anatomical location, while capsulopalpebral fascia tightening reinforces lid support.^[12] In selected cases, orbicularis suspension shortens the lid–cheek junction and improves contour, though it carries risks of denervation or nerve injury. Across all techniques, lateral canthal support through canthopexy or canthoplasty is essential to maintain lid position and prevent postoperative malposition [Figure 9].

Close

Figure 9:

Decision-making flowchart for lower lid blepharoplasty.

Export to PPT

CANTHOPEXY AND CANTHOPLASTY

Canthopexy reinforces the lateral canthal tendon, restoring lid tension and contour in cases of mild laxity (<6 mm distraction) [Figure 10]. It is performed by anchoring the lateral tarsal plate to the lateral orbital rim periosteum above Whitnall’s tubercle. For severe laxity (>6 mm), lateral canthoplasty with wedge resection and tendon reattachment is required to re-establish lid tone and symmetry.^[13]

Close

Figure 10:

Sagging of the lateral canthus with age. (a) Normal, (b) Sagging of lateral canthus.

Export to PPT

MIDFACE LIFTING

Midface descent contributes to tear trough formation, nasolabial fold deepening, and lower lid–cheek elongation. Midface lifting, often through a transconjunctival approach, repositions the malar fat pad and suborbicularis oculi fat in a superolateral vector after orbitomalar ligament release. This procedure is commonly combined with lower lid blepharoplasty and canthopexy to restore youthful midface projection and lid support.^[14]

POST-OPERATIVE CARE

Post-operative management is critical for optimal healing. Patients are expected to experience swelling, bruising, transient ptosis, and upward tugging. Recovery is gradual, but most patients appear socially presentable by 2–3 weeks post-surgery.

There is debate over the use of compressive dressings. While compression helps reduce edema and bruising, it can mask retrobulbar hemorrhage – a rare but vision-threatening complication. Patients are usually advised to apply cool compresses intermittently in the first 36 hours and to rest in a semi-upright position. Prophylactic measures include lubricating eye drops, antibiotic ointments, and avoidance of direct sun exposure. Contact lenses should be avoided temporarily.

Supportive techniques such as Steri-Strips or Frost sutures may be used to prevent lid retraction when canthopexy is not done. Rarely, temporary tarsorrhaphy is used postoperatively in cases of aggressive skin resection.^[15]

COMPLICATIONS

Complications are uncommon but must be anticipated and addressed promptly:

• Asymmetry: Common due to swelling, sleep position, or pre-existing undiagnosed asymmetry. Reoperations should be deferred for at least 8 weeks.

• Retrobulbar hemorrhage: The most feared complication, requiring immediate decompression to avoid permanent vision loss. Presents with severe pain, vision changes, and proptosis. Early diagnosis followed by surgical decompression to relieve pressure over the optic nerve. Canthotomy or cantholysis may be needed sometimes.^[16]

• Peribulbar hematoma: Usually self-limited but may need drainage if large.

• Diplopia and visual changes: Usually temporary, related to edema or minor trauma. Permanent strabismus from extraocular muscle injury is rare.

• Chemosis: Due to lymphatic disruption, it manifests as conjunctival swelling. Usually resolves with cold compresses and topical steroids.

• Dry eye: Common early post-operative symptom, especially if lagophthalmos is present. Managed with lubricants and ointments.

• Other: Include lower lid retraction, undercorrection, overcorrection, and ectropion. These may require revision surgery after complete healing.^[2]

NON-SURGICAL ENHANCEMENTS

Adjunctive non-surgical modalities can enhance and prolong surgical outcomes, but their effectiveness and limitations must be critically considered. Hyaluronic acid fillers (e.g., Juvederm) are useful for correcting tear trough deformity, restoring infrabrow volume, or augmenting the midface after blepharoplasty. While fillers can offer immediate volume restoration and improved contour, results are temporary, operator-dependent, and may carry risks such as edema, contour irregularities, or rare vascular complications. Off-label use requires informed consent and is usually delayed for at least 3 months postoperatively.

Laser resurfacing of the eyelids (ablative or non-ablative) can address residual wrinkles and texture changes, potentially reducing the need for skin excision. However, downtime, risk of pigmentary changes, and variable long-term benefits should be discussed with patients. Energy-based devices such as radiofrequency or micro-focused ultrasound may tone the lower lids and manage post-operative swelling, but evidence on sustained tightening remains limited. These are typically applied 1–2 weeks postoperatively or later in cases of persistent laxity or fat protrusion.^[17]

ETHNIC VARIATIONS AFFECTING BLEPHAROPLASTY

Upper eyelid morphology exhibits significant ethnic differences, which are essential to recognize in surgical planning. In many Asian patients, the orbital septum inserts lower onto the levator aponeurosis, often at or even below the superior tarsal border, allowing the preaponeurotic fat pad to descend anteriorly and contribute to a fuller, monolid appearance without a defined crease.^[18] Studies show that Asians typically have more subcutaneous and preseptal or preaponeurotic fat and a thinner insertion of levator fibers into the skin compared to Caucasians. These factors, along with a lower or absent septal–aponeurotic fusion, prevent levator fibers from pulling on the overlying skin, resulting in an absent or low eyelid crease. Clinically, aggressive fat excision or high crease placement in these patients can lead to unwanted hollowness or unnatural results. Therefore, contemporary Asian blepharoplasty emphasizes preservation or repositioning of fat, creation of a crease with levatoraponeurosis anchoring rather than excision, and tailoring the crease height to the individual’s anatomy for both natural esthetics and functional preservation.^[19]

CONCLUSION

Blepharoplasty and periorbital rejuvenation encompass a wide spectrum of techniques aimed at restoring youthful anatomy while preserving function. With proper anatomical knowledge, individualized planning, and incorporation of adjunctive procedures such as brow lift and fat repositioning, high patient satisfaction can be achieved. In addition, awareness of complications and their early management is essential. Non-surgical tools such as fillers and neuromodulators further enhance results and broaden treatment possibilities for diverse patient needs.