Upper Eyelid Surgery

Eliminating loose, baggy upper eyelid skin is the goal of upper eyelid surgery, medically known as blepharoplasty. Three basic causes of sagging upper lids are: 1) Excessive redundant tissue; 2) eyebrow droop (ptosis); and 3) the “thinned out” connection between the skin and the levator muscle, the muscle that opens the eyelid.

Many plastic surgeons believe that the problem of the droopy upper eyelid can be totally corrected by the excision of ever- increasing amounts of upper lid skin. In most cases, this overcompensation results in lagopthalmos (the inability to close the eyes while awake or asleep), dry eye syndrome and lid deformity. Also, such aggressive excision produces indistinct upper eyelid folds.

Instead of excising large amounts of excess skin, Dr. Benvenuti takes smaller portions of skin, recreates and deepens the upper eyelid folds and frequently adjusts the eyebrow level (to be discussed in a future issue of AFTER IMAGE). This allows for a significantly shorter eyelid incision.

This levator muscle-skin connection is called the anchor blepharoplasty because through surgery the skin becomes anchored to the muscles. It was invented by Dr. Robert Flowers of Honolulu. Dr. Flowers personally taught this technique to Dr. Benvenuti. Anchor blepharoplasty results in a neat, crisp and deep invagination (folding in) of the upper eyelid skin.

During the anchor blepharoplasty proce- dure, the surgeon removes the pretarsal extension of the levator aponeurosis (the tendon that opens the eye). This is followed by cleaning connective tissue and fat from the pretarsal space and attaching the free margin of the lower skin flap to the edge of the tarsus (cartilage-like material of the lid) and to the free edge of the levator aponeurosis (See Figure 1.) Swelling and temporary asymmetry are common after the procedure. The final result leaves a deep, crisp upper Upper Eyelid Surgery eyelid fold. Anchor blepharoplasty can be of benefit to members of the Asian population when performed to create a lid fold.

Lower Eyelid Surgery

As with the upper lid procedure, Dr. Benvenuti has mastered the most advanced techniques available in lower lid blepharoplasty and incorporated it into his practice. If fat alone is a problem, it can be removed using a transconjunctival approach (an incision placed inside the lining of the lower lid). This “scarless” surgery is best utilized in younger patients with baggy eyelids due to fatty tissue, not excess skin.

Lower eyelid surgery on aging lids involves the removal of small amounts of skin. The tone of the lower eyelid must be carefully evaluated when determining which technique to use. When hypotonia is present (muscle weakness, floppiness), the mere raising of the skin flap can result in a slightly lowered lid position due to scar contraction. In the worst cases, the white area (sclera) of the eye near the lid becomes visible below the iris. The typical results of eyelid surgery can be seen from across a room. This is not desirable as it alters a patient’s natural look and appears “plastic.”


To prevent these problems, a lid-tighten ing procedure must be performed. Most techniques (i.e. the Kuhnt-Szymanoski and tarsal flap operations) shorten the length of the eye and can give a “rounded” appearance. A state-of-the-art procedure known as the canthopexy secures the lateral tarsus to the base of the orbital rim (supports the lower lid from the eyebrow bone). This is very effective for several reasons.

Although the use of glycolic (fruit) acid and lactic acid in over-the-counter skin care products have mush- roomed in the last few years, the usage of these products is not new. Sour milk (lactic acid) was used in ancient Egypt and spoiled wine (tartaric acid) was used by French royalty during the 1700’s to improve skin texture.

First, canthopexy can prevent the pulling down of the lower lid if it is weak and prone to post-operative scarring. In addition, patients with a congenital downward slant of the lower eyelid (“sad” -looking eyes) can have the corners of their eyes lifted with a canthopexy. (See Figure 2.) Patients who have undergone previous lower lid blepharoplasty and show large amounts of white sclera will benefit greatly from this technique. Finally, in patients with enlarged (or “prominent”) eyes from thyroid disease, the canthopexy is very effective. The procedure is frequently combined with cheek implant surgery to further decrease the prominence of the eyes.

All of these advanced techniques have become a delight for Dr. Benvenuti to perform and have produced outstanding results for his patients to enjoy.

Questions and Answers About Eyelid Surgery

    1. How do I know when I am ready for blepharoplasty?
      A man or a woman is ready for blepharoplasty when he or she experiences the following symptoms:
      (1) Upper eyelid skin begins to sag, perhaps enough to touch the upper eyelashes;
      (2) Lower eyelid skin appears puffy or loose; and/or
      (3) Ongoing “tired” look even though you feel rested. Often friends and family will comment on how fatigued you appear. In some cases, heavy upper eyelids are heredi- tary making more young people candidates for the procedure.
    2. Where are the incisions?
      Upper eyelid incisions in men fall in the fold of the lid and extend past the corner of the eye into the “crow’s feet” area. This is a traditional blepharoplasty. In women, the incision does not extend past the corner of the eye. This is known as anchor blepharoplasty and affixes the skin to the underlying muscle which gives the patients stellar results. I do not perform this technique on men because the resulting look is too feminine.
    3. What type of anesthesia is used?
      Patients are only sedated and are able to breathe on their own during surgery. They are not aware of the procedure and do not experience any discomfort. If preferred, general anesthesia can be used.
    4. How do the scars look?
      Immediately after surgery, the scars are slightly raised and red in color. After one or two months, the scars begin to flatten and return to the color of your skin. At this point they are hardly noticeable.
    5. How long and painful is the recovery?
      The first day patients experience minimal pain and soreness. The second day the soreness subsides. The amount of bruising and swelling is very individual. In most cases, bruises can be camouflaged with makeup while they continually disappear over several weeks. Lower eyelid stitches are removed three days after surgery and upper lid stitches are removed in five days. After the stitches are out, patients may return to their normal daily routine with the exception of rigorous exercise.
    6. Does it affect my vision?
      Yes, but only temporarily. You will
      experience slightly blurred vision for a couple of days following surgery. Reading or focused eyework during this time is discouraged. After a couple of days your sight will return to normal. In addition, if you wear contacts you will have to go without them while the lower lid sutures are in place.
    7. How long do the results last?
      The results are permanent. Most patients do not require further eyelid surgery. If the upper lids begin to sag again, it is not due to loose skin but to the natural aging process of the brow. A brow lift can then be performed to correct the sagging.
    8. Can I have blepharoplasty if I have had eye problems or related surgery?
      Yes. You may have the surgery if you have a history of eye problems or related procedures.


    1. Do my eyes look different after
      surgery or take on a “sad” appearance?

      No. I take extreme care in supporting the corners of the eyes so they are not pulled downward or rounded out to look droopy or sad.


    1. Can eyelid surgery help correct prominent (“buggy”) eyes or eyes similar damage due to thyroid disease?
      Yes, there are several procedures to correct prominent eyes. The conservative approach involves surgery to support the corners of the eyes by lifting and affixing them to the bone. A recent advance is the canthopexy which involves changing the angle of the eye through surgery. In addition, it is possible to disguise the prominent eyes by inserting cheek implants and making the eyes appear smaller.