Upper vs Lower Blepharoplasty: Which Eyelid Surgery Do You Need?

Eyelid surgery is not one operation. Upper and lower blepharoplasty treat different parts of the eye area, for different reasons, and the right choice depends on what you see in the mirror and why it is happening.

In short: upper blepharoplasty treats heavy, hooded upper eyelids caused by excess skin. Lower blepharoplasty treats under-eye bags, loose skin and the contour between the eyelid and cheek. Many people need only one, some need both, and a few are better served by treating the brow first.

Dr Maryam Zamani is an oculoplastic surgeon and facial aesthetics doctor, and eyelid surgery is her primary clinical specialty. This guide explains how she decides between the two at her Chelsea clinic.

What is the difference between upper and lower blepharoplasty?

You can read about each on its own page: upper eyelid blepharoplasty and lower eyelid blepharoplasty.

Which concerns point to upper blepharoplasty?

• A fold of skin that overhangs the eyelid crease or rests on the lashes
• Upper eyelids that look heavy, tired or smaller than they used to
• Difficulty applying eye make-up, or make-up that transfers into the fold
• A feeling of heaviness, or a reduced upper field of vision

Which concerns point to lower blepharoplasty?

• Soft bulges or puffiness on the lower lids that do not change with sleep or skincare
• Loose or crepey lower lid skin
• A visible step or groove between the lower lid and the cheek
• Bags that make you look tired when you are not

How do I know which one I need?

Ask yourself three questions.

1. Where do I see it? Above the eye points to the upper lid. Below the eye points to the lower lid. If both bother you, you may need both.
2. Is my brow in a good position? If your brow sits low, the upper lid may look heavy because of the brow, not the lid.
3. Is it skin, fat or a hollow? Loose skin, a bulge and a groove can look similar in a photograph but are treated differently.

It helps to bring a photograph of yourself from ten years ago to your consultation. It shows how your eyes have changed, which is more useful than how they look today.

Do I need upper and lower blepharoplasty together?

Many patients have concerns above and below the eye, and treating both in one operation means one recovery. Combined blepharoplasty is common for this reason. Others have clear lower lid bags and little upper lid excess, or the reverse, and need only one procedure. The decision rests on your anatomy, not on a standard package.

Why the brow is assessed first

Upper blepharoplasty removes excess eyelid skin. It cannot lift a brow that has dropped. When the brow is the main problem, operating on the eyelid alone can leave the eye looking heavy, and the better plan may include brow ptosis repair or internal brow pexy. Dr Zamani's guide to the best treatment for hooded eyelids explains how to tell the difference.

What about skin quality?

Blepharoplasty removes or repositions tissue. It does not treat the fine, crepey texture of thinned eyelid skin. For that, Dr Zamani often combines surgery with CO2 laser in one procedure, known as blepharoplasty with laser eyelid resurfacing. Her guide to crepey skin around the eyes explains the non-surgical options.

If your concern under the eye is a hollow rather than a bag, read her guide to the best treatment for under-eye hollows first, as filler or fat transfer may be a better fit than surgery.

What happens at an eyelid surgery consultation?

A good consultation looks at far more than the skin. Expect your surgeon to assess:

• Your upper eyelids, lower eyelids and the position of your brows
• The position and support of the eyelid edge
• The surface of the eye, including any dry eye symptoms
• Your vision, if you feel your upper lids are in the way
• Your general health, medication and expectations

You should leave knowing what is recommended, what is not, and why. Dr Zamani's pre-procedure guide and post-procedure guide explain what to expect before and after.

What are the risks?

Blepharoplasty is a routine procedure in specialist hands. Risks include bruising, infection, bleeding, asymmetry, scarring and temporary dry eye symptoms. More serious problems, such as difficulty closing the eyes or changes in vision, are very rare. A full discussion of risks is part of every consultation.

Is there a non-surgical alternative?

For mild concerns, yes. Brow support, skin tightening and filler can soften early hooding and hollows, but they cannot remove excess skin or a fat bulge. Significant upper lid excess or lower lid bags are best corrected surgically. The complete guide to blepharoplasty covers the procedure in full, and the guide to the ideal age for blepharoplasty covers timing.

Book a consultation with Dr Maryam Zamani

If you are considering eyelid surgery in London, the first step is a proper assessment of your eyelids, brow and skin. Book a consultation at Dr Maryam Zamani's Chelsea clinic and she will explain which procedure, if any, is right for you. You can also read more about Dr Zamani, see her feature in Tatler's guide to the UK's best eyelid surgeons and view current pricing.