Perking up those peepers

When it comes to facial expression, the eyes have it. And eyelid surgery is an increasingly popular way to look younger.

When Greek essayist and poet Nikos Kazantzakis wrote, “Since we cannot change reality, let us change the eyes which see reality,” he might as well have been talking about the reality of aging and the physical effect it can have on our eyes.  Stress, kids, work, genetics, pollution, diet, sun exposure and so on all contribute to the bags, crepey skin, dark circles, puffiness and wrinkles around our eyes. Studies show that people who look tired are perceived as less attractive, less healthy, more lethargic and, surprisingly, less trustworthy.

While many people can improve the appearance of their eyes by improving their lifestyles and decreasing stress, life moves fast and slowing down is hard to do. So instead, we turn to nightly cosmeceuticals to lift, brighten, firm, sculpt and rejuvenate our eyes. We tell ourselves the more expensive the better and if we use it consistently we’ll realize the benefits that we see in the picture-perfect models. I think we know these products have trumped up claims, but don’t take my word for it. In her book “The Beauty Myth,” Naomi Wolf found that the ingredients of crème de la crème and rank and file facial creams were nearly identical and not at all effective. (Not that they don’t have their place, as per my recommendations below.)

Neurotoxins and fillers have done wonders to improve the appearance of our eyes and, when used in moderation, they are my go-to treatments. Neurotoxins treat wrinkles by decreasing muscle activity and fillers fill in fine lines and creases by adding volume where it’s needed. But caveat emptor because discerning friends can tell when too much of a good thing is too much. When neurotoxins and fillers have run their course or just aren’t appropriate, eyelid surgery can work miracles.

Performed to revitalize the appearance of the eyes, blepharoplasty is among the top five cosmetic procedures performed in the United States. More than 206,500 such surgeries were done in 2018, according to the latest statistics reported by the American Society of Plastic Surgeons.  And the reasons for the procedure’s popularity are clear.  Eyes play a critical role in overall facial expression. Yet, as we age, skin loses elasticity. Our eyelids, which are primarily composed of skin less than one millimeter thick, generally become the first areas of the face to show the effects. Excess skin and fat begin to collect in the upper and lower eyelids, resulting in puffiness, sagging, under-eye bagginess, “heavy”-appearing lids and a “tired” – even “angry” or “irritated” – look that may prompt friends and family members to ask, “Are you feeling all right?” Aging can also weaken muscles that control blinking and affect eyelid support structures, causing lids to droop.

“The eye is the jewel of the body,” wrote American philosopher Henry David Thoreau, but sometimes that jewel needs polishing.  Blepharoplasty can play an important role in re-establishing what scientists in the Journal of Cutaneous and Aesthetic Surgerycall “facial harmony” by limiting the “perception of aging.” Studies show that procedures to improve facial aesthetics, particularly those rejuvenating the area around the eyes, not only improve a patient’s quality of life but enhance others’ perception of that individual as being more attractive, appealing and sociable.

Perhaps that’s why even the ancient Greeks and Romans practiced procedures to enhance the eyes. In his book “De Medicina,”first-century Roman medical writer Aulus Cornelius Celsus described how physicians cut into the skin to relax the eyelids.

Of course, cosmetics are not the only reason blepharoplasty is performed. Medical issues may necessitate it. These can include excess upper eyelid skin that droops so low it impairs reading and other close work, a mispositioned upper eyelid that interferes with central vision, irritation from excess eyelid-skin folds rubbing against each other, forehead muscles that have become uncomfortably strained from lifting saggy eyelid skin, and neoplasms or sties that develop on the lids.  Droopy eyelids can occur following cataract surgery.

Normally performed as an outpatient procedure, blepharoplasty targets either the upper or lower eyelid or both. Incisions are made in the eyelid’s natural folds – in the crease of the upper eyelid and beneath the lashes or behind the lower lid — to hide scarring.  When appropriate, I often use a laser or chemical peel to improve the appearance of the skin.  Upper-lid blepharoplasties are performed to remove or reposition fatty deposits, excess skin and sometimes to tighten the muscles in the upper eyelid.  Often, surgery on the upper lid is done in conjunction with other cosmetic procedures, including brow lifts and injection of fillers or your own fat.  Lower-lid blepharoplasty removes under-eye bags, eliminates “sunken eyes,” improves eyelid symmetry, and can even tighten or lift the lower eyelid.

Patients considering blepharoplasty must have realistic expectations and understand the procedure is meant as a “facial enhancement,” not a permanent restoration like that rendered by a mythical Fountain of Youth.  First, eyelid surgery alone may not fully achieve the anticipated look a patient was seeking.  Secondly, while the beneficial effects of blepharoplasty can last for 10 years or more, actual duration in any one patient depends on the continuing effect of the aging process and personal lifestyle. 

Because blepharoplasty, like other surgical procedures, is not without its risks and because it requires an appropriate, prior medical assessment, finding an experienced plastic surgeon certified by the American Board of Plastic Surgery is a critical planning component. Not all patients are good candidates for blepharoplasty, including those with pre-existing eye problems such as dry eye or glaucoma or with serious medical conditions like diabetes, hyperthyroidism and heart disease.  Major complications are rare, but patients who do undergo the procedure may experience post-surgical problems like dry eyes, eyelid discoloration, abnormal folding of eyelid skin, inability to close eyes completely and overcorrection or under-correction of eyelids.

Of course, the best way to guard the face from the ravages of aging is to take care of the skin.  You can look — and feel — younger by:

  • Not smoking and avoiding excessive amounts of alcohol
  • Following good nutrition guidelines and exercising regularly
  • Always wearing proper sunscreen – and sunglasses – outdoors. Sun damage causes premature aging and wrinkling of skin.
  • Increasing use of rich moisturizers on facial skin as you age.

When it comes to your lids, “the eyes have it.” Protect them.

Stephen M. Warren, M.D. is a board-certified plastic surgeon who specializes in facial rejuvenation. For more, visit


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