Four Lids, One Surgery: Blepharoplasty Explained

“The eyelids” are often referred to as a single feature, but in reality, they are four distinct parts that work together. There is an upper right lid, lower right lid, upper left lid, and lower left lid. When all are functioning as they should, they can protect the eye against harsh light, debris, and drying out, as well as help to convey emotions, such as wide-eyed surprise, narrowed suspicion, or a mischievous wink.

They can also sag.

Over time, eyelid skin loses its elasticity. This can be due to a combination of damage from ultraviolet radiation and the simple fact that skin loses collagen, hyaluronic acid, and elastin as it ages. The result: upper lids that droop—and possibly interfere with a clear field of vision—and lower lids that pull downward. The lower lid area can also develop an unwanted puffiness.

Surgery to correct these changes is known as blepharoplasty. San Francisco facial plastic surgeon Dr. Stanley Jacobs regularly works to explain to patients—both his own and those considering their options—that eyelid surgery is similar to the eyelids themselves: one name for something with several parts.

Blepharoplasty can be performed on any or all of the four eyelids. The goal is to tighten the skin to reduce sagging, to remove puffiness and under-eye “bags,” and to prevent further undesirable cosmetic changes while doing so. The lower eyelid can sometimes roll outward after typical blepharoplasty surgery, exposing the lowermost portion of the eyeball and the moist, red, inner lining of the lower eyelid itself. This condition is known as “ectropion,” and it is preventable.

A specific technique called “canthopexy” can be performed along with a lower lid blepharoplasty, tightening the canthal tendon that keeps the lower eyelid in its proper position. Though not all surgeons apply this technique, Dr. Jacobs believes they should.

Lower-lid surgery may also involve removing small amounts of skin, muscle, and fat that has shifted to address the baggy look that can cause a person to look tired or stressed. Note that dark circles under the eyes and other signs of actual exhaustion and stress are not addressed by eyelid surgery. Getting more rest and practicing calming exercises can help with those shadows, as can certain skin treatments.

Upper-lid surgery is a procedure to tighten a lax lid by removing a small amount of skin. This can keep the tissue in its proper place, providing both a more youthful look and an unobstructed field of vision. There is also removal of extra muscle, and sometimes fat.

In some cases, the problem it is not laxity in the upper eyelids, but a drooping brow that pushes the eyelids downward. A plastic surgeon should identify the true cause of any cosmetic or functional issue before recommending a course of action. Repositioning the forehead may create enough of a change to allow the eyelids to fully open and appear normal when at rest. It is even possible that a brow lift and eyelid surgery may be performed in concert to generate the best possible results.

Patients who need surgery on more than one lid may choose to spread their procedures out or get them all done at once. There are unique advantages to either option—and again, this is something best discussed during a consultation. When both an upper lid and lower lid are worked on during the same surgical session, this is known as dual-lid blepharoplasty.

Depending on procedure-specific details, the surgery typically lasts about one to two hours. Incisions are hidden in the natural creases around the eye, or may be made on the inside of the lower lid in order to hide the resulting scars, which are minimal. Swelling, bruising, and similar side effects will take a few days to resolve, and the area may need special care for several weeks as it heals.

Learn more about blepharoplasty in the San Francisco Bay Area by contacting Dr. Stanley Jacobs at The Jacobs Center for Cosmetic Surgery. Call the San Francisco office at 415.433.0303 or the Healdsburg office at 707.473.0220. Send a message online by visiting www.thejacobscenter.com.