There are many elements to aesthetic eyelid surgery, and very many different treatment options. It is most important is to have a clear idea of what you would like to achieve and to find someone who can discuss the options with you.
As we age our face loses its elasticity and volume, it then stretches and is pulled downward by gravity. Our range of facial expressions repeatedly creases our skin to give us the classic deepening wrinkles of an older face. Many of these lines are welcome as they give “character” to our faces. Many, however, are less welcome, especially if they make us look older than we feel, or crease the brow to suggest that we are concerned when we feel carefree.
While botox and fillers remain very useful, if the skin has stretched too much, or the deeper tissues have been pulled too far downward by gravity, then a surgical approach is required. An eyelid lift (Blepharoplasty) is the most popular facial surgery in both the UK and USA. The upper lids and lower lids can be lifted and tightened with the scars hidden in the upper eyelid crease or the sub-ciliary line.
A facelift is more dramatic and not particularly well named, as it is more of a jowl and neck lift than face lift. There are now many techniques described to try to lift the mid-face, but this area remains the most difficult, and the interface with the lower eyelid is key.
What can go wrong with any eyelid surgery?
1. Infection of the wound. This is minimised with sterile technique and by using antibiotic ointment to the stitches and antibiotic tablets. Wound infection can be minor but can lead to a worse scar.
2. Large bruise or haematoma. This is minimised by taking it easy for 2 weeks after surgery, stopping aspirin and other anticoagulants if safe so to do, and regular use of ice packs. A haematoma may mean you have to go back into theatre to have the blood clot evacuated and then be re-sutured with the risk of a worse scar.
3. Visible scar. The cuts to the skin should fade to a thin white line. Not every scar heals equally well. A thickened or reddened scar can be improved with silicone scar remodelling gel, but the treatment needs to be continues for months to have a good result.
4. Dry eye. The surgery can cause inflammation to the eyelids that affects the oil producing glands in the eyelids. This can lead to a dry eye or can make a pre-existing dry eye worse. You may need to use additional lubricant drops for weeks to months post-op if affected.
5. Theoretical risk to vision. Any eyelid surgery carries the risk that an undiagnosed infection or bleed could damage the optic nerve. This is so rare that in comparison a normal car journey is a much greater risk to your vision.

Lower Lid Blepharoplasty
The lower lid lift, or eye-bag removal remains one of the most difficult cosmetic procedures. The reason is that the lower eyelid cannot be considered on its own but must be taken in consideration with the whole mid-face and indeed face. The lower eyelid rests against the eyeball and needs to be in perfect position to protect the eye and carry the tears with each blink into the tear ducts. Any attempt to remove too much skin from under the eye carries a great risk of the eyelid hanging away from the eye. This is made worse if there is any underlying lid laxity. This leads to a poor cosmetic and functional result, and a very unhappy patient!
In a similar fashion the orbital fat that surrounds the eyeball in its socket can bulge forward as we age, and the temptation is to remove this fat. Removing too much orbital fat however, can lead to a hollow appearing socket, with again a poor cosmetic result and unhappy patient!
The factors that age the lower lid and mid-face are volume loss as much as any fat prolapse and tissue descent.
The steps required to achieve good results from lower lid blepharoplasty therefore include:
Always replace lost volume with tear trough filler and cheek filler.
Always assess and tighten a lax lower eyelid.
Release the arcus marginalis to reset the tethering that tucks in and accentuates the lower lid bag.
Move rather than remove orbital fat, and be very conservative in removing orbital fat when essential.
Release the deeper tissues over the orbital margin and into the mid-face, to allow the deeper layers to be lifted by sutures to the orbital rim.
Be conservative in trimming excess skin, measure the excess with the patient opening their mouth wide.
Even with all these factors in place I warn my patients that if we can achieve a 99% result for the upper lid, the best to hope for with a lower lid is 70%.