Eyelid and brow surgery: blepharoplasty and brow ptosis
- Topic
Blepharoplasty removes excess lid skin and fat. A rare, blinding risk is bleeding behind the eye: pain, a bulging eye and vision loss need action within hours.
See it in 3D: Eyelids · Orbicularis oculi · Levator palpebrae · Frontalis
What it is
With age, excess upper-lid skin (dermatochalasis) and a descending brow can hang over the lashes and block the upper field of vision. Upper blepharoplasty removes skin and sometimes fat; lower blepharoplasty, through the skin or the conjunctiva, treats lower-lid bags; a brow lift corrects brow ptosis. These must be told apart from true ptosis (a weak or detached levator), which needs a different operation. Complications include dry eye, incomplete closure, lower-lid retraction, asymmetry and, rarely, retrobulbar haemorrhage.
Key facts
- Surgery is functional when skin rests on the lashes and narrows the upper field; fields are often compared with the lids taped up and down.
- Tell apart dermatochalasis (excess skin), brow ptosis (low brow) and true ptosis (low lid margin, measured by the margin-to-reflex distance and levator function).
- Before surgery, look for dry eye, incomplete lid closure, thyroid eye disease, earlier refractive surgery and anticoagulant or antiplatelet use.
- Retrobulbar haemorrhage usually appears in the first day: severe pain, proptosis, a tense orbit, falling vision and a relative afferent pupillary defect.
- Lower-lid surgery can pull the lid down (retraction or ectropion), exposing the cornea.
In clinical practice
- Retrobulbar haemorrhage is an orbital compartment syndrome: the retina tolerates the pressure only for a short time, so lateral canthotomy and cantholysis are done within about two hours.
- Anticoagulants and antiplatelet drugs are planned with the prescriber and the surgeon; they are never stopped without a plan.
- Incomplete closure after surgery dries the cornea (exposure keratopathy); lubricants and review are needed.
- A droopy lid can be the sign of myasthenia, Horner syndrome or a third nerve palsy, which cosmetic surgery would hide.
Next step / Initial management
- Pain, a bulging eye, tight lids or loss of vision after lid surgery: emergency; if vision is threatened, lateral canthotomy and cantholysis without waiting for imaging, and call ophthalmology.
- Before referring for blepharoplasty: record acuity, fields and dry eye, and whether the skin blocks vision.
- Lid droop that varies with fatigue, with unequal pupils or with limited eye movements: investigate myasthenia, Horner syndrome or a third nerve palsy instead of cosmetic surgery.
- Patients on anticoagulants or antiplatelets: plan with the prescriber and the surgeon before surgery.
- Dry, gritty eye with incomplete closure after surgery: lubricants and review by the surgeon.
Test yourself
Think of the answer, then tap the question to see it.
Hours after a blepharoplasty, a patient has severe pain, a bulging eye and falling vision. What is it and what is done?
A retrobulbar haemorrhage (orbital compartment syndrome); urgent lateral canthotomy and cantholysis.
How is dermatochalasis told apart from true ptosis?
In dermatochalasis the lid margin is in a normal position and excess skin hangs over it; in ptosis the margin itself is low, with a reduced margin-to-reflex distance.
Which complication is typical of lower-lid blepharoplasty?
Lower-lid retraction or ectropion, which can expose the cornea.
Connections
See it in 3D4
The structures of Durgical's 3D anatomy where it is found.
In Pharmacology2
Educational content; not a clinical guideline and no substitute for assessment by a health professional. For sudden visual loss, severe eye pain, a chemical burn or an eye injury, go to an emergency department at once.
Sources: Upper Eyelid Blepharoplasty (StatPearls Publishing (NCBI Bookshelf), 2023); Lower Eyelid Blepharoplasty (StatPearls Publishing (NCBI Bookshelf), 2023); Brow Ptosis (StatPearls Publishing (NCBI Bookshelf), 2025); Retrobulbar Hematoma (StatPearls Publishing (NCBI Bookshelf), 2022).
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Representative model, for educational purposes only.