Upper vs. Lower Eyelid Surgery: Seattle Surgeons Explain the Differences

Walk through any Seattle neighborhood on a bright July morning and you will notice how much our eyes do the talking. Squinting into the light, smiling across a farmers market, glancing up from a cappuccino under a Ballard café awning, small changes around the eyes shape how others read our mood and energy. That is why eyelid surgery, or blepharoplasty, remains one of the most requested facial procedures here. Yet “eyelid surgery” is not a single operation. Upper and lower eyelid procedures address different anatomy, solve distinct problems, and ask for different planning. Knowing which is right for you, and when they make sense together, prevents regrets and sets expectations on healing, cost, and outcome.

This guide comes from years of operating on Northwest faces in a climate that alternates between mist and sunbreaks. I will break down how upper and lower eyelid surgery differ in goals, technique, scarring, anesthesia, recovery, risks, and how we coordinate them with other facial plastic surgery procedures like facelift surgery, necklift, and even rhinoplasty when harmony of features is the priority.

What upper eyelid surgery accomplishes

Most patients ask about upper eyelids when they notice three things: their eye makeup vanishes against skin that now rests on the lash line, friends ask if they are tired even after eight hours of sleep, and hats or sunglasses start to feel necessary just to keep heavy lids from drooping by mid-afternoon. In medical terms, the upper lid can show redundant skin, a weakened eyelid crease, and fullness from fat that has shifted forward with age. Brow descent can also mimic “extra eyelid skin,” so distinguishing brow ptosis from true upper lid redundancy is an essential step.

Upper blepharoplasty targets redundant skin and, when needed, a measured amount of fat. The core goal is not to make the eye look different, only fresher and more open, with a defined crease and a natural contour from the brow bone to the lash line. If someone you see weekly thinks you changed your shampoo, we did it right. If they think you had plastic surgery, we probably pushed too far.

For some, there is a functional component. Severe overhang can obstruct the upper field of vision. When a formal visual field test shows a measurable deficit that improves with taping the lids up, insurance can sometimes help with the cost. That threshold varies by plan and carrier. In practice, many Seattle patients pay out of pocket because they want the cosmetic finesse that a strictly functional operation does not include, such as symmetry work and precise crease placement.

How upper eyelid surgery is performed

The incision hides in the natural eyelid crease. The marked height varies by gender, eye shape, and ethnicity, as well as personal preference. A 7 to 9 millimeter crease suits many women of European descent, while men often look more natural with a slightly lower or softer crease. Asian eyelids deserve particular attention to crease height, medial fold anatomy, and preaponeurotic fat handling so that the shape remains authentic.

After a thin ellipse of skin is removed, a careful assessment guides whether to trim a modest amount of preaponeurotic fat or redistribute it. Aggressive fat removal belongs to the past. Hollowed upper lids age a face. In my practice, less than a quarter-teaspoon equivalent of fat is typical, and often none is removed. The orbicularis oculi muscle is generally preserved. The skin is then closed with fine sutures. Absorbable versus non-absorbable is a trade-off: non-absorbable gives crisp edge approximation but requires a quick removal visit around day five to seven.

Most upper lid surgeries take about 45 to 75 minutes for both eyes. Local anesthesia with oral sedation works well. Many patients appreciate being able to walk out comfortably, go home, and nap. For those joining upper lids with lower lids or another cosmetic surgery, brief general anesthesia may make more sense.

Recovery after upper eyelid surgery

Expect swelling and mild bruising for one to two weeks, with tightness when you first open the eyes in the morning. Silicone scar gel, clean cold compresses, and head elevation help. By day five to seven, most people are able to video conference with a little concealer and good lighting. Contact lens wear resumes after the first week for most. Soft activities like neighborhood walks or stationary cycling are fine early, while strenuous workouts and inversion poses should wait two weeks.

The incision heals predictably, fading from pink to pale over six to twelve weeks. Sunscreen is nonnegotiable. In Seattle, even winter UV reflects off water and snow at Snoqualmie, which darkens healing scars. A pea-sized dab of SPF 30 or higher, applied daily, pays dividends.

When the problem is not the eyelid at all: brow position and ptosis

Upper blepharoplasty cannot fix a low brow or weak eyelid lift muscle. A descended brow, especially laterally, piles skin onto the eyelid. You can test this yourself in the mirror: place your fingers just above the tail of the brow and lift a centimeter. If the eyelid looks ideal with no extra skin to pinch, the brow, not the lid, is the culprit. In that scenario, a brow lift, sometimes limited to the outer brow through small temporal incisions, can restore space without removing eyelid skin. Conversely, if the brow sits appropriately and there is still pinchable skin, upper blepharoplasty makes sense.

True eyelid ptosis is different. The levator muscle, which lifts the lid, weakens or its tendon stretches. The pupil can be partially covered even when the forehead strains. Fixing ptosis involves advancing the levator aponeurosis, a separate maneuver from removing skin. In a combined operation, we address ptosis first to center the pupil and match lid height, then tailor skin conservatively.

What lower eyelid surgery accomplishes

Lower lids tell a different story. The classic complaints are “bags,” a sharp line between the lower lid and the cheek, and fine crepey skin that catches on concealer. The underlying causes vary with age and facial structure. Fat pads behind the lower lid can push forward. The natural rim of the eye socket casts a shadow that reads as a dark circle, even in a well-rested person. Skin may thin and crease. The midface can descend a few millimeters over decades, deepening the lid-cheek junction.

Lower blepharoplasty focuses on the fat and the contour transition. The modern approach prefers fat preservation and repositioning over aggressive removal. By bringing some of the protruding fat down over the orbital rim, we soften the hollow and blend the lid into the cheek. That change is subtle but powerful, especially in cross-light common in Pacific Northwest winters. For patients with good skin tone and distinct bags a transconjunctival approach that hides the incision inside the eyelid solves the bulge without an external scar. For those with extra skin or very fine wrinkles, a small external skin pinch or laser resurfacing can refine texture.

How lower eyelid surgery is performed

Technique depends on the problem we are solving.

Transconjunctival lower blepharoplasty places the incision on the inner surface of the lower lid. The fat pads are exposed and either conservatively trimmed or, more commonly now, repositioned over the orbital rim with internal sutures. No skin is removed through this route, so it suits patients with good skin elasticity and visible puffiness.

Transcutaneous lower blepharoplasty uses a fine incision just below the lash line. It allows access to both fat and skin. The risk with this approach is not the scar, which usually heals beautifully, but the temptation to remove too much skin. Even a millimeter too aggressive can pull the lower lid down, called ectropion, or create roundness that looks surgical. I prefer a graded plan: address fat primarily, then test the lower lid snap-back and tone. If extra skin persists, remove a narrow, conservative strip or complement with skin resurfacing.

In my operating room, lower lids take 60 to 120 minutes, depending on whether we reposition fat and whether we add canthopexy for lid support. Canthopexy tightens the outer corner of the eye to prevent droop in patients with laxity, a common need in those over 55 or anyone with marginal snap-back on exam. These steps add safety and longevity more than drama to the result.

Recovery after lower eyelid surgery

Lower lids swell more than uppers and bruise easier. Expect a full two weeks of visible recovery. Vision remains clear, though eyes can feel gritty for a few days. Preservative-free artificial tears help. Most patients are presentable by day 10 to 14, with residual yellow-green bruising that makeup can cover. For transconjunctival work without skin incisions, the outer appearance improves faster, but internal swelling still takes time to settle.

Dry eye symptoms can flare temporarily. Seattle’s indoor heating in February and spring pollen both aggravate this, so I advise a simple eye-care routine for three weeks: tears by day, lubricating gel at bedtime, and sunglasses when outdoors. Avoid rubbing. If you must sneeze from cedar or alder pollen, open the mouth to decrease pressure.

Scarring: where it hides and why it matters

Upper eyelid scars live in the crease and, after several weeks, are invisible in normal conversation. Lower lids demand more planning. An internal incision leaves no visible mark but cannot remove skin. An external subciliary incision can remove skin, though judicious laser or chemical peel often tackles texture better than a strip of skin removal. When I do remove lower lid skin, I favor a “skin pinch” just below the lashes with minimal undermining. This keeps the orbicularis muscle attached, which protects eyelid tone.

Keloids in eyelids are rare, but post-inflammatory hyperpigmentation can occur in darker skin tones after peels or lasers. In those patients I tend to stage resurfacing and choose gentler energy settings, then use sun vigilance and topical pigment inhibitors for a month or two.

Which procedure makes sense for which concern

Think in terms of the look you hope to change, not the operation you think you need. If makeup smears on upper lash lines and you pinch a fold of skin that overlaps your lashes, upper blepharoplasty is the workhorse. If you have persistent morning puffiness in the lower lids that improves by afternoon, the fat pads are likely the culprit and a transconjunctival lower lid approach fits. If the hollow from the inner corner toward the cheek bothers you more than puffiness, fat repositioning across the orbital rim helps smooth that trough. If the skin itself looks crepey like tissue paper, you may pair lower lid surgery with laser resurfacing or do resurfacing alone if fat is not a problem.

There are gray zones. A thin, athletic runner in her 40s might have minimal fat but a long lower lid-cheek distance from midface descent. In that scenario, lower blepharoplasty alone risks a flat, operated look. A subtle midface lift through the lower lid incision can elevate the cheek a few millimeters, restoring youthful transition without the telltale sweep of an overdone facelift surgery.

Anesthesia, surgical setting, and safety

Upper eyelid surgery alone fits well in an accredited office-based operating room with local anesthesia and light sedation. Lower eyelid procedures, especially when repositioning fat or adding canthopexy, often benefit from deeper sedation or general anesthesia for patient comfort and precise control.

A few safety points that do not get enough airtime:

• Blood pressure control matters. Eyelids are vascular. Keeping systolic pressures under control during and after surgery reduces bruising and the rare but serious risk of a retrobulbar hematoma.
• Medication review is not optional. Fish oil, high-dose vitamin E, gingko, NSAIDs, and certain antidepressants can increase bleeding. We stop or adjust what is safe to pause, usually for 7 to 10 days.
• Dry eye screening saves misery. I ask about contact lens tolerance, screen time habits, and current tear supplements. Anyone already reliant on drops deserves a cautious plan, perhaps staging procedures or softening goals to protect the tear film.

How upper and lower eyelid surgery interact

Upper lids create openness. Lower lids create smoothness. Done together, they can quietly take five to ten years off a face. The key is restraint and proportion. An overly wide upper lid with a still-hollow lower lid looks top heavy. A perfectly smooth lower lid beneath a heavy upper fold looks odd in the other direction. In combined cases, we define the desired crease height and lower lid contour to match, then remove the least tissue needed to achieve that.

When combined with other cosmetic surgery procedures, the order of operations changes. In a face and necklift, for example, I typically address the deep neck and jawline first, then lift the midface, and finish with eyelids. Lifting the cheek often improves the lid-cheek junction on its own, which means less work on the lower lid and a lower risk of lid malposition. Rhinoplasty rarely interacts mechanically with eyelid surgery, but when the goal is whole-face harmony, changing the nasal profile may influence how much eyelid refinement a patient still desires. I advise patients considering both to decide which feature bothers them most and stage accordingly, often nose first, eyelids second.

Non-surgical options and when to consider them

Not every eyelid concern needs a scalpel. Neuromodulators soften crow’s feet and can slightly elevate the lateral brow by one to three millimeters, a tasteful tweak that sometimes buys two to three more years before experts in plastic surgery upper blepharoplasty. Hyaluronic acid filler along the tear trough can help a mild hollow, particularly in younger patients. That said, lower eyelid filler near the orbit is unforgiving. Tyndall effect, swelling, and lumpy texture are common when too much product is placed too superficially. If you have visible fat bags, filler will not fix them and can make puffiness worse.

For texture, fractional laser or a medium-depth chemical peel improves fine lines in the lower lid. Those treatments demand meticulous aftercare and sun protection. They also pair well with a transconjunctival fat procedure when skin is the main leftover issue.

Expected longevity of results

Upper blepharoplasty results often last a decade or more. Skin continues to age, but most patients do not need a second upper lid surgery sooner than 8 to 12 years, if at all. Lower lids, particularly when fat is repositioned rather than removed, have similar longevity. Midface descent continues slowly with time, but a well-executed lower lid remains smooth for many years.

Weight fluctuation can change results. A 20-pound swing can alter fat prominence. Allergies and sinus issues also affect lower lids through chronic puffiness. Managing those foundations preserves the investment.

Risks, trade-offs, and how to minimize them

Every operation carries risk. In eyelid surgery, the complications we actively prevent include asymmetry, dry eye that lingers, injury to the levator muscle, contour irregularities in the lower lid, visible scarring, and, very rarely, bleeding behind the eye. That last one is an emergency. Clear postoperative instructions on what to watch for matter as much as the technique itself.

Patients can reduce risk by controlling blood pressure, avoiding blood thinners when medically safe, stopping smoking and vaping for several weeks before and after surgery, and following aftercare precisely. Surgeons reduce risk by conserving tissue, supporting the lower lid when needed, and respecting eyelid function over cosmetic ambition.

A Seattle-specific perspective

Our climate shapes both expectations and recovery. The low, reflective winter light exaggerates under-eye shadows, which is one reason lower lid concerns spike from November to March. The dry indoor air often worsens tear film stability, so I plan for more aggressive lubrication in winter patients. On the other hand, summer’s bright sun challenges scar care. Sunglasses, hats, and sunscreen should be viewed as part of the procedure, not accessories.

Seattle’s active lifestyle also nudges timelines. If you climb at Vertical World or train for a Cascade summit, plan a realistic pause. Upper lids alone usually allow a return to moderate exertion at two weeks. Lower lids push that to three or sometimes four, especially for heavy lifting or prolonged inverted positions that increase periorbital pressure.

What a typical journey looks like

Consultation starts with photographs and a careful exam. We assess brow position, eyelid crease, snap-back, fat prominence, tear trough depth, and skin quality. I will often show simulated changes on a mirror with simple maneuvers: lifting the brow tail with a fingertip, smoothing the trough with a cotton swab, or revealing how much skin is truly redundant by pinching. We discuss your tolerance for downtime, your professional calendar, and whether you wear contact lenses. If you are considering other facial plastic surgery like a necklift or facelift surgery, we map the sequence.

Surgery day is efficient. For uppers under local anesthesia, patients arrive with a clean face, no eye makeup, and a zip-up top that does not brush the face. We mark the crease sitting up, confirm symmetry, and begin. Music on, lights soft, anesthesia local. Most people chat comfortably. For lowers or combined cases under deeper sedation or general anesthesia, you meet the anesthesia team and drift off. A loved one drives you home with a lightweight gel ice pack and written instructions.

The first 48 hours are the most swollen. Small amounts of oozing from the incision or the inner corner of the eye can occur. Cold compresses for 10 minutes each hour while awake, head elevation, and alternating Tylenol with the prescribed medication if needed keep discomfort minimal. By day three, swelling starts to migrate and bruise colors change. By day seven, sutures for upper lids come out if we used them. Day 10 to 14, social downtime is mostly over. The next several weeks refine quietly.

Cost, value, and how to think about investment

Prices vary across the city based on surgeon experience, facility fees, and anesthesia. As broad ranges, upper blepharoplasty alone might sit between the low four figures and into the mid four figures. Lower lids often cost more because of time and complexity, sometimes in the mid to high four figures. Combined cases reflect efficiencies but still account for longer time. Add facility and anesthesia when not done purely under local. Be wary of quotes that sound too good to be true. Eyelids are unforgiving. The most expensive surgery is often the revision of a cut-rate operation.

Insurance occasionally helps when documented visual field obstruction exists for the upper lids. That coverage rarely extends to cosmetic refinements. It almost never applies to lower lids. If insurance participates, make sure you understand whether the surgeon’s cosmetic enhancements, such as crease design or fat contouring beyond the functional minimum, are out-of-pocket.

Deciding between upper and lower eyelid surgery

If you have to choose one, pick the one that bothers you daily in the mirror and in photos. For many, that is the upper lid because makeup and vision collide with the redundancy. For others, the lower lid’s tired shadow wins by a mile. When both bother you equally and you are ready for a two-week social pause, combining them produces the most balanced, efficient transformation.

Finally, be honest about your taste. Some people love a more sculpted, high-crease upper lid. Others want to keep their soft, low crease and barely remove skin. On lowers, some prefer absolute smoothness even if it looks a little stylized for a few months. Others prefer a modest improvement top plastic surgery Seattle that reads completely natural immediately. There is no single correct target, only the one that suits your face and your style.

A note on surgeon selection

Training matters, but eyelids require something beyond board certification. Look for a surgeon who performs eyelid surgery weekly, not monthly, and who can show a range of outcomes that align with your aesthetic. Ask about their approach to fat preservation, their threshold for canthopexy, and how they handle dry eye. If you are considering combining eyelids with other procedures like a facelift surgery or necklift, insist on a coherent plan that protects eyelid function while delivering facial harmony.

Good communication predicts satisfaction. Bring old photos. Point to examples you like and do not like. Ask about worst-case scenarios and how they are handled. You should leave the consultation understanding the find a plastic surgeon in Seattle plan in plain language and the trade-offs involved.

Seattle patients tend to value subtlety, function, and quick returns to hiking, rowing, or yoga. Upper and lower eyelid surgery can fit that profile beautifully when tailored appropriately. In the right hands, the results look like you on your best-rested day, morning after morning, without calling attention to the work. That is the quiet power of well-done blepharoplasty.

The Seattle Facial Plastic Surgery Center, under the direction of Seattle board certified facial plastic surgeons Dr William Portuese and Dr Joseph Shvidler specialize in facial plastic surgery procedures rhinoplasty, eyelid surgery and facelift surgery. Located at 1101 Madison St, Suite 1280 Seattle, WA 98104. Learn more about this plastic surgery clinic in Seattle and the facial plastic surgery procedures offered. Contact The Seattle Facial Plastic Surgery Center today.

The Seattle Facial Plastic Surgery Center
1101 Madison St, Suite 1280 Seattle, WA 98104
(206) 624-6200
https://www.seattlefacial.com
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