Blepharoplasty in São Paulo, Brazil

I recommend blepharoplasty for:

• excess upper eyelid skin that weighs on the eyes or affects vision;

• fat pouches in the lower eyelids that create a tired look;

• redundant lower eyelid skin;

• anyone who wants a more rested, expressive look, without appearing operated on;

• generally from age 35 onward, when there is a pre-existing change or early aging of the area.

I do not recommend — or I postpone — when:

• there is uncontrolled dry eye: surgery can make it worse;

• there is active or unstable thyroid eye disease, or uncontrolled glaucoma; systemic thyroid disorders must also be adequately controlled before surgery;

• the expectation is to eliminate expression lines or blemishes — that is not what blepharoplasty does;

• the patient smokes and does not plan to stop during the pre- and postoperative period;

• the eyelid droop is due to weakness of the levator muscle (true ptosis) rather than excess skin: in that case the surgery is different, and ptosis correction is indicated, alone or combined.

In the upper eyelid, I measure the excess skin with the pinch test — gently pinching the redundant skin — and I check for a drooping eyebrow, because part of the "excess skin" may actually be a low eyebrow; in that case, removing too much skin makes the droop worse. I assess levator muscle function and the visual field.

In the lower eyelid, I assess three things: how much fat pouch there is, how much skin there is, and the eyelid's tone — the snap-back test shows whether the eyelid returns well to position. A loose eyelid that receives only skin resection is at risk of scleral show or ectropion; in those cases, I add a support procedure, such as a tarsal strip. I also assess the groove between the eyelid and cheek, which may call for fat repositioning rather than removal.

The examination determines the approach: about 20% of my lower blepharoplasties are transconjunctival — patients with pouches and little redundant skin, in whom I remove or reposition the fat from the inside, with no external scar.

In selected cases, I request an ophthalmologic evaluation before surgery.

Isolated upper eyelid. At the clinic, under local anesthesia alone, in about 1.5 hours. I mark the incision in the natural crease, remove the strip of skin measured with the pinch test and, when necessary, a small amount of medial fat. Closure is with fine sutures, removed in 5 to 7 days. Same-day discharge, with 3 to 5 days of rest.

Lower eyelid or four eyelids. In my practice, exclusively in a hospital, under general anesthesia. Blepharoplasty can be performed with different anesthesia strategies; this is the choice in my protocol for lower and combined cases. In the transcutaneous approach, the incision sits just below the lashes; I treat the pouches, reposition fat when there is a groove, and remove only the excess skin left after repositioning — never before, because what looks like excess while lying down changes once the patient sits up. When the eyelid is loose, I add a tarsal strip. In the transconjunctival approach, the access is from the inside and there is no external scar.

The amount of skin removed is the single most important decision in blepharoplasty. Removing too much from the upper eyelid leaves an eye that will not close; from the lower eyelid, scleral show. Removing too little leaves the complaint unresolved. The precision is measured in millimeters, and that is where the difference between technique and experience lies.

• Bruising (ecchymosis) and swelling — expected; cold compresses for 15 minutes every 2 hours during the first 4 to 6 hours reduce both.

• Hematoma — rare; an orbital/retrobulbar hematoma is a potentially vision-threatening emergency. Severe pain or eye pressure associated with a change in vision requires immediate evaluation and emergency treatment. In my practice, this is one of the reasons I perform lower blepharoplasty in a hospital setting, with monitoring and the capacity for an immediate response.

• Transient dry eye — common in the first weeks; lubricant every 2 hours, avoiding contact lenses, and wearing corrective glasses during this period.

• Scleral show and ectropion — the risk is reduced through preoperative assessment of eyelid tone, conservative skin resection, and support procedures such as canthopexy or tarsal strip when indicated.

• Difficulty closing the eye (lagophthalmos) — almost always transient, due to swelling; prevention is conservative skin resection.

• Asymmetry — small asymmetries are part of normal anatomy; significant asymmetries may be revised after full healing.

• Visible scar — rare in the upper eyelid, because it sits in the crease; in the lower eyelid, the subciliary incision matures into a fine line.