Upper vs Lower Eyelid Surgery: Key Differences and Combining It with a Facelift
Upper eyelid surgery mainly lightens the look of the eyes by removing excess skin and is usually performed under local anaesthesia; lower eyelid surgery addresses under-eye bags and the groove beneath them and usually requires sedation or general anaesthesia. In suitable patients, eyelid surgery can be performed in the same session as a facelift; this means a single anaesthetic and a single recovery period, but it makes the operation longer. Whether the combination is suitable is decided at consultation, after assessing your general health and the structure of your eyelids.
The area around the eyes is one of the first places where signs of ageing are noticed. "I slept well, but everyone tells me I look tired" is a complaint often heard from people considering eyelid surgery. This tired look sometimes comes from upper eyelid skin gathering over the lashes, sometimes from bags and hollows under the eyes, and often from a combination of both.
Eyelid surgery (blepharoplasty) is not a single, one-size-fits-all operation. Upper and lower eyelid surgery differ in their anatomical goals, surgical techniques, type of anaesthesia and recovery. In this guide, we look at the differences between the two operations, which problem each one addresses, and whether eyelid surgery can be performed in the same session as a facelift.
Why does the eye area age?
The skin around the eyes is the thinnest on the body, and ageing shows here in two different ways: excess skin is the main change in the upper eyelid, while fat bulging and volume loss are the main changes in the lower eyelid.
- In the upper eyelid: the skin loses its elasticity, and as the eyebrows descend, the upper eyelid skin loosens and folds over the lashes.
- In the lower eyelid: the membrane (septum) that holds the fat pads surrounding the eyeball (orbital fat) in place weakens over time. The fat bulges forwards and forms under-eye bags, and a groove becomes more visible below the bag, where the lower eyelid meets the cheek.
What does upper eyelid surgery correct?
Upper eyelid surgery (upper blepharoplasty) is a procedure that lightens the look of the eyes, mainly by removing excess skin above the eye and, if needed, a small amount of muscle and fat.
Problems it addresses
- Excess skin (dermatochalasis): eyelid skin that has become loose, folds over and touches the lashes.
- Hooded appearance: the lash line and the eyelid being covered by skin.
- Difficulty applying make-up: eyeshadow or eyeliner collecting in the skin folds.
- Narrowing of the field of vision: in advanced cases, sagging skin can block the upper and outer part of the field of vision; without realising it, the person constantly raises their eyebrows, which can deepen forehead lines.
Incision and scar
The incision is placed in the natural crease of the upper eyelid. Through this incision, the pre-measured excess skin, a thin strip of muscle if needed, and the bulging fat in the inner corner are removed. With the eyes open, the scar stays within the crease in most patients; with the eyes closed, it may be visible as a fine line that fades over time. Scar quality varies according to the person's skin type.
Anaesthesia and length of surgery
When upper eyelid surgery is done on its own, it can usually be performed under local anaesthesia (numbing only the area being treated) and generally takes around 1 hour. The patient can usually go home the same day.
What does lower eyelid surgery correct?
Lower eyelid surgery (lower blepharoplasty) aims to soften the transition between the eye and the cheek by correcting under-eye bags and the groove beneath them. Technically, it is a more extensive procedure than upper eyelid surgery.
Problems it addresses
- Under-eye bags: puffiness caused by fat bulging forwards.
- Tear trough: the hollow below the bag, where the lower eyelid meets the cheek, which deepens the shadow of the bag.
- Dark circle appearance: shadowing caused by hollowing and thinning of the skin.
- Skin laxity: fine, crepe-like wrinkles on the lower eyelid.
A fat-preserving approach
In the past, the bulging fat was usually removed during lower eyelid surgery; in some patients, this could lead to a sunken look under the eyes over time. In the fat transposition (repositioning) technique commonly used today, the fat that forms the bag is spread into the groove just below it instead of being removed, so the bag and the hollow are addressed together. The approach is chosen according to the size of the bag and the depth of the under-eye groove: if there is a marked hollow, preserving and repositioning the fat may be considered; if the groove is not prominent and excess fat is the main issue, removing a measured amount of fat may be considered. In some patients, both approaches are used together.
Incision options
- Transconjunctival incision (on the inside of the eyelid): the incision is made through the pink lining on the inner surface of the eyelid, so there are no stitches on the outside. It is usually preferred for patients whose main problem is bags rather than excess skin. Its advantage is that complications such as the lower eyelid being pulled down after surgery (both an aesthetic and a functional problem) are seen much less often; this is why it has been preferred more often in recent years. Its disadvantage is that it does not allow excess skin to be removed; removing excess skin requires an incision in the skin.
- Subciliary incision (just below the lashes): the incision is made 1–2 mm below the lower lashes, and the scar is usually hidden along the lash line. Its advantage is that excess skin can also be removed. Its disadvantage is that the lower eyelid being pulled down after surgery (lower lid retraction) is markedly more frequent with this incision.
- Combined technique (inner and outer incisions used together): the main surgical step, redistributing the under-eye fat, is carried out through the incision on the inside of the eyelid. If there is excess skin, only the excess skin is removed below the lashes in the same operation, without operating on the underlying muscle and tissues. This reduces complication rates while still allowing excess skin to be removed. This approach has been preferred increasingly often in recent years.
Because lower eyelid surgery involves deeper tissues, it is usually performed under sedation (a light sleep) or general anaesthesia and generally takes 1.5–2 hours. Which one is used is decided together with the anaesthetist, depending on whether the procedure is combined with upper eyelid surgery or other procedures, and on the person's general health.
Can upper and lower eyelid surgery be done together, and how does recovery differ?
Yes, upper and lower eyelid surgery are often performed in the same session; this is called four-lid blepharoplasty. Because upper eyelid sagging is often accompanied by lower eyelid bags, planning both together allows a more balanced result to be aimed for, with a single anaesthetic and a single recovery period.
| Feature | Upper eyelid | Lower eyelid |
|---|---|---|
| Length of surgery (usually) | 45 min – 1 hour | 1.5 – 2 hours |
| Anaesthesia | Mostly local | Sedation or general |
| Pain after surgery | Usually mild | Mild to moderate |
| Bruising and swelling | Usually minor | Moderate, may spread to the cheek |
| Stitch removal | Usually day 5–7 | Usually day 5–7 (if there is an external incision) |
| Return to social life (most patients) | About 1 week | About 7–10 days |
In the first 48–72 hours, cold compresses and sleeping with your head raised help reduce swelling. In the first few days, you may have watery, gritty or dry eyes; this usually eases with the drops your surgeon recommends. Timelines vary from person to person.
Which operation might suit you?
If gently lifting your upper eyelid with your finger clearly opens up your eyes, upper blepharoplasty may be considered; if bags and hollows that do not improve with sleep make you look tired, lower blepharoplasty may be considered. Often, both are present. If low eyebrows are also part of the picture, a brow lift is assessed separately; for the techniques, see our endoscopic brow lift guide. Eyelid surgery can be planned together with procedures such as a brow lift, a facelift and facial fat injection. Whether adding another procedure would be helpful is decided at consultation, where the eye area is assessed together with the brows and the midface.
Can eyelid surgery be combined with a facelift?
Yes, in suitable patients eyelid surgery and a facelift can be performed in the same session, and this combination is common in plastic surgery. The decision depends on the patient's general health, the total length of surgery, the structure of the eyelids and how much time the person can set aside for recovery.
Ageing does not stop at one area of the face: tiredness around the eyes is often accompanied by sagging cheeks, a less defined jawline (jowls) and laxity in the neck. If only the eyelids are corrected, the lower face may look older; if only a facelift is performed, the tired look around the eyes may remain. This is why the two areas are often assessed together. For facelift techniques, see our deep plane vs SMAS facelift comparison.
Who may it suit?
- People with both eyelid concerns (excess skin, bags) and noticeable sagging of the cheeks, jawline or neck
- People whose general health is suitable for a longer operation and general anaesthesia, and whose blood pressure and any long-term conditions are under control
- People who do not smoke, or who can stop smoking before and after surgery
- People who prefer to set aside a single, slightly longer recovery period rather than two separate recovery periods
Conditions such as significant dry eye, advanced lower eyelid laxity, uncontrolled blood pressure or the use of blood thinners may mean the plan needs to change or the procedures need to be split into separate sessions. In general, when a person has more than one systemic condition, or when the total length of surgery would become very long, splitting the procedures into two stages may be the safer option. Whether to plan one stage or two is decided at consultation, together with an anaesthetic assessment.
Advantages and disadvantages
| Advantages of the same session | Points to consider |
|---|---|
| A single anaesthetic and a single hospital stay | The operation and anaesthetic take longer, which makes the general health assessment more important |
| A single recovery period; total time away from work and social life is usually shorter than with two separate operations | In the first weeks, swelling and bruising around the eyes may be more noticeable than after a facelift alone |
| The transition between the eyelid and the cheek can be addressed in one plan, in harmony with the rest of the face | If the facelift also lifts the midface, the amount of skin removed from the lower eyelid needs to be planned more cautiously; otherwise the eyelid may be pulled down |
| The result can be assessed as a whole, aiming to avoid one area looking "older" than another | The risks of more than one procedure need to be considered together |
When lower eyelid surgery is combined with a facelift, the tension of the eyelid and the support of the outer corner of the eye are assessed separately. At consultation, lower eyelid laxity is assessed with simple tests, for example by checking how far the eyelid can be pulled away from the eye and how quickly it returns to its position when released. If the eyelid is markedly lax, additional measures such as canthopexy (a stitch technique that supports the outer corner of the eye) may be planned to prevent the eyelid from being pulled down.
Effect on recovery
When eyelid surgery is combined with a facelift, recovery generally follows the facelift timeline, and the eyelids heal within that period. Most patients can return to social life within 2–3 weeks. In the first few days, swelling around the eyes may temporarily affect your vision; cold compresses, keeping your head raised and eye drops are important during this period. The tissues usually settle and the final appearance becomes clear within a few months. Timelines vary from person to person and are planned according to follow-up appointments.
If you are travelling to Istanbul for surgery
If you are coming from abroad, plan your stay around recovery rather than the operation date alone: where there are stitches to remove, this is usually done around day 5–7, and if eyelid surgery is combined with a facelift, recovery generally follows the facelift timeline. The NHS advises that you should not fly for 7 to 10 days after facial cosmetic procedures. Your length of stay, and how follow-up will be arranged once you are home, are planned at consultation.
Are there non-surgical alternatives?
For mild skin laxity, some non-surgical methods can provide limited tightening; however, if there is significant excess skin or a fat bag, these methods do not replace surgery.
- For the upper eyelid: devices such as plasma energy or laser may help with very mild laxity; they do not remove a marked skin fold.
- For the lower eyelid: there is no cream or device that removes bulging fat. Filler or fat injection under the eyes can soften the appearance by filling the hollow below the bag, but it does not treat the bag itself.
What are the risks of eyelid surgery?
Eyelid surgery is a commonly performed operation, and most patients heal without problems; even so, like any surgical procedure it carries risks, and these should be discussed before surgery.
- Temporary dry eye, watery eyes and sensitivity to light
- Slight asymmetry between the two eyes
- The lower eyelid being pulled down, or more of the white of the eye showing (more likely when more skin is removed)
- A noticeable scar at the incision site, bleeding or infection
- Bleeding behind the eye, which is very rare but needs urgent assessment; if you have sudden pain, swelling or a change in vision after surgery, contact your surgeon immediately
Results vary from person to person; which operation or combination is right for you is decided at consultation. For all the options, see our eyelid surgery page, and for facelift planning, see our facelift page.
What is assessed at consultation when planning the eye area?
At consultation, the eyelids are not assessed in isolation; the position of the brows, excess skin in the upper eyelid, bags and grooves in the lower eyelid, lower eyelid tension and volume loss in the midface are assessed together. For example, a low brow can make it look as though there is more excess skin in the upper eyelid than there really is; in that case, removing skin from the eyelid alone may not give the expected result. A history of dry eye, current medications and general health are also part of planning. At the end of this overall assessment, the appropriate procedure or combination is decided.
For the stages of facelift surgery and recovery, see how a facelift is performed.
Frequently asked questions
What is the main difference between upper and lower eyelid surgery?
Upper eyelid surgery mainly lightens the look of the eyes by removing excess skin and can usually be performed under local anaesthesia. Lower eyelid surgery addresses under-eye bags and the groove beneath them; because it involves deeper tissues, it usually requires sedation or general anaesthesia.
Can eyelid surgery and a facelift be done at the same time?
Yes, in patients whose general health is suitable and who have sagging both around the eyes and in the lower face, the two procedures can be performed in the same session. This means a single anaesthetic and a single recovery period, but it makes the operation longer. Whether one session or separate sessions is more suitable is decided at consultation.
Does recovery take longer if eyelid surgery is combined with a facelift?
Recovery generally follows the facelift timeline, and most patients can return to social life within 2–3 weeks. Swelling and bruising around the eyes may be more noticeable in the first weeks. Overall recovery time is usually shorter than having the two operations at different times.
Does transconjunctival lower eyelid surgery leave a visible scar on the outside?
In the transconjunctival approach, the incision is made on the inner surface of the eyelid, so there is no incision or stitches on the outer skin. This approach is usually preferred for patients whose main problem is bags rather than excess skin. If there is also excess skin, a combined technique can be planned, adding removal of only the excess skin below the lashes to the incision on the inside of the eyelid.
How long do the results of eyelid surgery last?
Because skin is removed and fat is repositioned, the effect lasts for many years in most patients. However, ageing continues, so the eye area may change again over time. How long the result lasts varies with skin type, age and lifestyle.
Medical review: This article has been medically reviewed by Assoc. Prof. Dr. Yalçın Bayram, specialist in plastic, reconstructive and aesthetic surgery (Şişli, Istanbul). For his background and academic publications, see about us. This article is for general information; the right approach for you is decided at consultation.
