The Modern Fat-Preserving Approach
10 to 20 years ago, aggressively removing fat was the standard approach for lower eyelid rejuvenation. It solved the visible “bag” but often left patients with a hollowed, skeletonized appearance in their 60s and 70s, when facial fat continued to decline. Modern blepharoplasty aims to reverse that trajectory..
Where the anatomy allows, orbital fat is not removed. It is released from the septum that holds it forward and repositioned into the tear trough, the shadowed groove between the lower lid and cheek. That single change addresses the “bag” and the under-eye hollow in one operation, using the patient’s own tissue rather than filler. Patients report high satisfaction with this technique, and it eliminates the under-eye hollow in more than 85% of cases.
For patients who need both upper and lower lids addressed at the same time, careful surgical planning matters. Doing both at once, under one anesthetic, is safe and efficient for the right candidates. This combined approach has strong aesthetic outcomes and a low rate of the problem returning. Dr. Sohn decides on the approach case by case, based on your anatomy and your goals.
What to Expect During Surgery
Eyelid surgery is an outpatient procedure. Depending on the extent of the procedure, it may be performed under local anesthesia with sedation or under general anesthesia, in an accredited surgical facility. Most eyelid lifts take about one to two hours.
Incisions are placed so they heal discreetly. Upper-lid incisions sit inside the natural crease. Lower-lid incisions are typically transconjunctival (inside the lid) or, when skin tightening is needed, a fine line just under the lashes. Excess skin, small strips of muscle, and specific fat pockets are carefully addressed. Fat that would once have been removed is often repositioned into the tear trough instead, especially on the lower lid, so the under-eye area looks smoother without going hollow.
When both lids are treated together, Dr. Sohn plans everything in one sequence so the final balance between your upper and lower lid looks natural on your face. Suture material is chosen to minimize marks and speed removal, usually within five to seven days on the upper lid; lower-lid transconjunctival incisions typically require no external suture removal.
Risks and How We Minimize Them
Blepharoplasty is generally safe when performed by a board-certified surgeon in an accredited facility, but no eyelid operation is risk-free. The most common side effects, bruising and swelling, resolve on their own over weeks. More significant risks include dry eye symptoms, swelling of the eye’s surface (chemosis), lower-lid position changes, asymmetry, and, rarely, eye misalignment (strabismus).
Dry eye and eye-surface swelling are the most common non-cosmetic issues. One study found dry eye symptoms in about 27% of patients and eye-surface swelling in about 26%. The risk was higher for patients having both upper and lower surgery together, and for those with looser eyelids or a history of dry eye beforehand. That is why Dr. Sohn screens carefully for pre-existing dry eye and eyelid laxity, and why some patients are advised to start lubricating drops before surgery. If your eyelid doesn’t fully close after surgery (called lagophthalmos), it is managed with lubrication, eyelid taping at night, and time as tissues settle.
Strabismus (eye misalignment) and diplopia (double vision) are uncommon but real. One large study found new eye misalignment developed in 1.5% of patients after upper eyelid surgery and 2.0% after lower eyelid surgery, within three years. The numbers are small, but they are one reason Dr. Sohn is careful about how much fat he handles during surgery, avoids unnecessary work near the muscles that control eye movement, and reviews these risks with you in detail beforehand.
