Eyelid surgery research: past, present and future

Where eyelid surgery came from

The word blepharoplasty dates to 1818, when it named an operation to rebuild an eyelid (PMID 21246457). The German surgeon Karl Ferdinand von Graefe coined it as "Blepharoplastik" (The History of Cosmetic Oculoplastic Surgery). In 1896 the Japanese physician Mikamo reported the first double-eyelid operations done for appearance (PMID 9047184). In 1924 the French surgeon Julien Bourguet described taking out lower-lid fat through the inside of the lid (PMID 21319687).

For decades, eyelid surgery meant cutting tissue out (PMID 21319687). In 1951 Salvador Castanares described the anatomy for removing bulging eyelid fat (PMID 14864073). The standard operation removed loose skin, muscle and fat, often leaving a hollow, "operated" look (PMID 15536308). Through-the-skin lower-lid surgery left some sagging of the lower lid in about 1 in 7 patients in one series (PMID 1892615). Removing the fat through the inside of the lid avoided that problem in a 1989 series (PMID 2771349).

Both main operations for a droopy upper lid date from 1975 (PMID 1156224, PMID 1156223). Lester Jones, Max Quickert and Jerry Wobig repaired the tendon of the main lid-lifting muscle through a cut in the lid crease (PMID 1156224). Arthur Putterman and Marvin Urist shortened a smaller lifting muscle, Müller's muscle, from inside the lid in patients whose lid rose after a phenylephrine eye drop (PMID 1156223). In 1979 Richard Anderson and Dwight Gordy described the lateral tarsal strip, which tightens a loose lower lid at its outer corner (PMID 508189).

From the mid-1990s, lower-lid fat was moved or kept instead of removed: Sam Hamra advanced it over the bony rim of the eye socket to avoid the hollow look (PMID 7624408). In 2000 Robert Goldberg moved the fat through an incision inside the lid (PMID 10697189). Anatomy studies then found a ligament that ties the under-eye groove to bone (PMID 22634656). By 2016 the stated trend for upper and lower lids was to preserve volume and sometimes to add it with fat or filler (PMID 26710052).

For the brow, a 1994 report found that a forehead lift done with an endoscope, a thin camera passed through small scalp cuts, matched the open lift with fewer complications (PMID 8122572). In 2020 the US Food and Drug Administration approved oxymetazoline eye drops for droopy lids in adults, still the only drug approved for that use (PMID 40861715, PMID 40172501).

What changed in the last six years

Fat repositioning. Lower-lid surgery has changed from cutting fat out to keeping it and repositioning it (PMID 42089982). The tear trough is the groove that runs from the inner corner of the eye down onto the cheek. For bags with a groove below them, the usual operation slides the bulging fat down into the groove after releasing the ligament that holds the groove down (PMID 36456652). In recent series about 9 in 10 patients had the bag and groove fully corrected (PMID 41051496, PMID 39429197). Deep grooves improved less (PMID 39909883). Upper-lid surgery changed the same way: a review describes removing fat only when needed and restoring lost volume (PMID 38899282). In one clinic, about 8 in 10 sunken upper lids followed earlier upper-lid surgery (PMID 42315793).

Under-eye filler. Hyaluronic acid filler, an injectable gel, is the most common filler around the eyes (PMID 33546985). It smooths a mild tear trough for up to about a year (PMID 35478038). About 8 in 10 patients were satisfied in the first months, and somewhat fewer later (PMID 33693530). From 2024 more papers studied late swelling, hollowing after filler is dissolved with the enzyme hyaluronidase, and surgery on lids that still hold old filler (PMID 39395232, PMID 38655103, PMID 41358743). Among people seeking lower-lid surgery after under-eye filler, about 8 in 10 had a filler-related problem (PMID 41358743). Newer lactic-acid and calcium-based fillers rest on small studies, and some caused hard lumps that needed surgery (PMID 42043184, PMID 40212090).

Droopy upper lids. A lid that sits too low (ptosis) can hide behind loose skin: it went undiagnosed in about 1 in 7 people seeking upper blepharoplasty, and uneven eyebrows were the main clue (PMID 37694225). Adults usually have one of two operations: tightening the main lifting muscle through the lid crease, or shortening the smaller Müller's muscle from inside the lid with no skin cut (PMID 36692699). Both reach the same final lid height, with fewer overcorrections and repeat operations after the inside approach (PMID 36692699). At one specialist eye hospital about 9 in 10 age-related repairs succeeded (PMID 37921352). About 1 in 10 needed a second operation within a year (PMID 37921352).

Recovery. Pooled randomized trials found that tranexamic acid, a drug that helps blood clot, reduced bruising and returned patients to daily activities about a day sooner (PMID 40334125). A pressure dressing did not reduce swelling or bruising (PMID 38624150), arnica showed no benefit after blepharoplasty (PMID 31800557), and antibiotic or steroid ointment did no better than plain lubricant (PMID 41400848). Pain is low, and patients took about 2 opioid tablets on average (PMID 42038003, PMID 32852374). Swelling that needed attention affected about 1 in 4 patients in one study, more often in East and Southeast Asian patients (PMID 36680851).

Dry eye and vision. Tear tests worsened in the first month after upper blepharoplasty (PMID 40453787). They returned to baseline by 3 to 6 months (PMID 40453787). A pooled analysis of randomized trials found dry-eye symptoms lower after upper blepharoplasty than before (PMID 40152471). Lifting a droopy lid from the inside raised dry-eye symptoms more than skin-only blepharoplasty (PMID 31770512). Lid surgery also changes the curve of the cornea, the clear front of the eye, by a small amount, which affects the lens-power calculation for cataract surgery (PMID 35018494, PMID 36148816).

Benefits in daily life. An American Academy of Ophthalmology report found that upper blepharoplasty and droopy-lid repair improved vision-related daily life, self-consciousness and headaches (PMID 40913605). In a large records study, droopy lids were linked to more falls, and repair to about a third fewer falls within a year, a link that does not prove cause (PMID 41335095). Patients reported looking about 3 years younger after upper blepharoplasty (PMID 34791033). Their satisfaction held through the first year (PMID 34791033).

Double-eyelid surgery. The operation creates an upper-lid crease in a lid without one and is common among Asian patients (PMID 36999142, PMID 33368081). About 9 in 10 patients were satisfied in a recent series (PMID 42623493), and uneven creases are the most common complication (PMID 33368081). Buried-stitch surgery forms the crease with stitches under the skin and no skin cut (PMID 36999142). One clinic followed these patients for four years, and a loosening stitch was the main reason for a redo (PMID 40571750). About 1 in 8 needed a redo with a continuous stitch (PMID 40571750). With a two-point stitch about 1 in 4 did (PMID 40571750). A loose stitch end can scratch the cornea until it is removed (PMID 37653179).

Medicines. Thyroid eye disease, an immune condition that can pull the upper lid too high, is increasingly treated with drugs (PMID 40699109). The drug teprotumumab lowered the lid in about 6 in 10 eyes (PMID 38466206). GLP-1 drugs for diabetes and weight loss were linked to more brow droop, more loose lid skin and more eyelid surgery (PMID 41251628, PMID 41945654). A droopy lid is the most frequently reported significant complication of botulinum toxin face injections (PMID 41640941). Toxin placed too low drops the brow, and toxin placed too deep drops the lid (PMID 41469806). The droop usually improves within 1 to 3 months (PMID 39918212).

AI and chatbots. Phone photos and AI programs measure lid height about as well as a ruler (PMID 42175441, PMID 41981030). AI age estimators judged patients younger after blepharoplasty (PMID 40167099). Chatbot answers about eyelid surgery were mostly accurate but left out less common risks and needed college-level reading (PMID 41603902, PMID 40691658). In one test only about 3 in 10 of the references ChatGPT cited existed (PMID 38684536).

What the studies agree on

• Upper blepharoplasty improves vision-related daily life, and most patients are satisfied (PMID 40913605, PMID 42507513).
• Serious complications are rare: about 4 in 1,000 patients had a major complication in a large multicenter study (PMID 29369102).
• Bleeding behind the eye, which can threaten sight, followed about 1 in 2,000 cosmetic eyelid operations (PMID 15599241).
• Dry eye after upper-lid surgery usually settles within months (PMID 40453787, PMID 40913605).
• Removing a strip of the eyelid's ring muscle (orbicularis) with the skin gives no better long-term result and more early swelling and bruising (PMID 33538853).
• Upper blepharoplasty lowers the brow slightly, and double-eyelid and droopy-lid surgery lower it more (PMID 36890345).
• Tightening the lower lid at its outer corner corrects most lids that turn in or out (PMID 37846389, PMID 33985336).
• Most of the evidence comes from case series, and none of the most-cited blepharoplasty papers reached the highest level of evidence (PMID 34798655).

What is still argued

• How long a brow lift lasts: a pooled analysis found a lasting lift of a few millimeters (PMID 40788666), and a critical review found the height fades, most at the outer end (PMID 42077543).
• Whether the phenylephrine drop test predicts droopy-lid results: it predicted success of the skin-crease repair (PMID 38771896) and did not predict the height after the inside repair (PMID 39752473).
• Whether to move under-eye fat or graft it: grafted fat narrowed the groove more in one comparison (PMID 33595637), and another found the two similar (PMID 37463504).
• What forms the under-eye groove: bulging fat (PMID 40858736) or ligament and muscle attachments (PMID 38036923).
• How to give tranexamic acid: mixed into the numbing injection, it raised bleeding in one trial (PMID 38789809) and lowered it in another (PMID 41687031).
• The best operation for severe droop present from birth (PMID 42059847, PMID 41179375).
• Whether a pulled-down lower lid needs a spacer graft, and which material (PMID 38499878, PMID 37904540).

Where it is heading

Fat repositioning. New papers adjust how moved under-eye fat is anchored and trimmed so it fills the groove without overfilling the cheek (PMID 41140680, PMID 41137243). For hollow upper lids, surgeons move nearby fat pads, sometimes with a camera through small incisions, and add grafted fat (PMID 41628599, PMID 42495998). Reviews still call for long-term comparisons between methods (PMID 38899282, PMID 36456652).

Filler. Lower-lid surgery is now planned around filler a patient already has, often by dissolving it first (PMID 41358743). An MRI study found that filler in the face took up nearly three times the volume injected (PMID 42396227).

Drops and devices for droopy lids. Oxymetazoline drops lift the lid about 1 millimeter, starting within minutes and lasting hours (PMID 34211263). A six-month trial, with the drug maker among its authors, found the lift did not fade with daily use (PMID 41961227). A study of FDA adverse event reports found problems not on the label, including events in the retina and the vitreous, the gel inside the eye (PMID 41949436). The American Academy of Ophthalmology rates its long-term effect and safety as uncertain (PMID 40172501). For severe droop, a magnet mounted on glasses opened the eye as well as tape in a randomized trial, with better natural blinking (PMID 39932468, PMID 38038607).

Phone and AI tools. A phone 3D scan system diagnosed droopy lids and suggested the type of operation in agreement with specialists (PMID 42783353). One phone system screens children for droopy lids from blink videos (PMID 41844953). AI estimates of how old a face looks, and AI brow measurements, are used to score surgical results (PMID 42655948, PMID 42486933).

Recovery drugs. Across eyelid trials, tranexamic acid was the most consistently effective treatment for bruising (PMID 41264874). The best dose and route, by vein or under the skin, are not settled (PMID 41344611).

Measuring results. Questionnaires such as FACE-Q, and SCAR-Q for scars, now sit beside surgeons' photos (PMID 42151608, PMID 34791033). A recent review found no validated questionnaire yet captures the symptoms of heavy upper lids, and said the visual-field test used to decide coverage misses part of the burden (PMID 42693598). Nearly all US insurers that cover the surgery for loose lid skin require that test (PMID 39258929).

Who leads the research

Plastic surgeons and oculoplastic surgeons, eye surgeons trained in eyelid and eye-socket surgery, write most of this research: senior authors of the most-cited blepharoplasty papers came mainly from plastic surgery centers, then from eye and oculoplastic centers (PMID 34798655).

The United States led blepharoplasty research over two decades, and the University of California system was among its most productive institutions (PMID 36203097, PMID 37153349). China produces much of the new surgical technique work, including most new methods for holding moved under-eye fat in place (PMID 37010464, PMID 40937917). The hospitals with the most eyelid papers since 2020 include the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences and Peking Union Medical College in Beijing (PMID 41198885, PMID 37768088) and Shanghai Ninth People's Hospital (PMID 37010464, PMID 35166873), both publishing on double-eyelid and droopy-lid surgery. Groups led by Baoqiang Song at Xijing Hospital in Xi'an and Xiao Long at Peking Union Medical College Hospital study brow-line incisions, crease design and brow position after lid surgery (PMID 35668229, PMID 36890345).

In Japan, Yasuhiro Takahashi and Hirohiko Kakizaki at Aichi Medical University Hospital map eyelid anatomy (PMID 40131769, PMID 39382560), and Hiroo Teranishi's clinic in Osaka tracks how long buried-stitch double eyelids last (PMID 40571750). In South Korea, Kyu-Ho Yi of Yonsei University in Seoul is senior author on many papers on under-eye fillers and energy devices (PMID 41583410, PMID 41438879). Eye hospitals in Turkey publish many of the studies on the cornea, eye pressure and tear film after lid surgery (PMID 35018494, PMID 39306627). In the United Kingdom, Raman Malhotra at Queen Victoria Hospital in East Grinstead publishes on eyelid care in facial palsy (PMID 31765627), and Daniel G Ezra at Moorfields Eye Hospital in London on filler safety and lower-lid anatomy (PMID 37305194, PMID 39585706). Other active groups work in Germany, Italy, the Netherlands, Israel, Iran and India (PMID 36915328, PMID 42151608, PMID 34791033, PMID 39106961, PMID 37694225, PMID 37155333).

US surgeons who operate and publish often as first or senior author on eyelid papers since 2020:

• Daniel B Rootman, Doheny and Stein Eye Institutes, UCLA: choosing a droopy-lid operation (PMID 33906756).
• Michael T Yen and Richard C Allen, Cullen Eye Institute, Baylor College of Medicine: droopy-lid repair in adults and children (PMID 32387434, PMID 41575466).
• Don O Kikkawa and Bobby S Korn, Shiley Eye Institute, UC San Diego: lid reconstruction, festoons (swollen pouches on the upper cheek) (PMID 38722563, PMID 40327813).
• Jeremiah P Tao, Gavin Herbert Eye Institute, UC Irvine: lower-lid retraction, safety of oxymetazoline drops (PMID 32427733, PMID 41949436).
• James E Zins and Julian D Perry, Cleveland Clinic and its Cole Eye Institute: brow lifts, festoons (PMID 37409963, PMID 33906762).
• Basel A Sharaf and Lilly H Wagner, Mayo Clinic: combined lid and brow surgery, video visits (PMID 38315110, PMID 35030149).
• Philip L Custer and Steven M Couch, Washington University School of Medicine: lower-lid reconstruction (PMID 34812184, PMID 35893769).
• Anne Barmettler, Montefiore Medical Center: brow-lift results, tranexamic acid (PMID 40788666, PMID 38624153).
• Alon Kahana, University of Michigan: forehead-muscle flaps for severe droop (PMID 39072581).
• Roman Shinder, SUNY Downstate Medical Center: tranexamic acid, the inside droop repair (PMID 41687031, PMID 40326565).
• Hui Bae Harold Lee, Indiana University School of Medicine: lower-lid position after eye-socket fracture repair (PMID 37944347).
• David T Tse, Bascom Palmer Eye Institute: scalp-lining flaps for reconstruction (PMID 40488246).
• Yao Wang, Cedars Sinai Medical Center: tissue-preserving blepharoplasty (PMID 41203322).

Bascom Palmer Eye Institute in Miami also published the falls and GLP-1 studies (PMID 41335095, PMID 41251628).

What it means if you are considering eyelid surgery

• Ask to be checked for a droopy lid. It can hide behind loose skin and was missed in about 1 in 7 people seeking upper blepharoplasty; a missed droop can spoil the result (PMID 37694225).
• Plan for some dry or irritated eyes. Tear tests returned to normal by 3 to 6 months after upper blepharoplasty (PMID 40453787). Droopy-lid repair from inside the lid raised dry-eye symptoms more than skin-only surgery (PMID 31770512).
• Tell your eye doctor about lid surgery before cataract or laser vision surgery. Lid surgery shifts the corneal measurements used to plan those operations (PMID 35018494, PMID 38534074).
• Get same-day care for pain, swelling or vision change after surgery. Bleeding behind the eye most often starts within hours (PMID 15599241). Eye injuries after blepharoplasty caused symptoms within a day but reached an eye doctor after a median of a week (PMID 38372611).
• Match the under-eye treatment to the problem. Filler suits a mild groove with good skin, and surgery is more predictable for moderate to severe bags (PMID 42150047). Old filler complicates later surgery, so list past injections (PMID 41358743).
• Recovery care is simple. Pain is low (PMID 42038003), tranexamic acid reduces bruising (PMID 40334125), and plain lubricant did as well as antibiotic ointment (PMID 41400848).
• Expect some unevenness to remain. About 7 in 10 people have uneven lids or brows before surgery, often without knowing it (PMID 39193249).
• Check where advice comes from. Chatbot answers left out less common risks (PMID 41603902), and TikTok videos on blepharoplasty scored very low for reliability (PMID 34297053).