The Quick answer
A guide framing blepharoplasty as a family of techniques rather than one operation: upper, lower through the skin, and lower through the inside of the lid, plus add-ons like skin pinch, canthopexy, and fat transfer. It compares them on scarring and risk, explains how anatomy drives the choice, and covers recovery and pricing at Dr. Sistare's West Palm Beach office.
Most people who research eyelid surgery have already decided they want it. The harder question is which version they need. Blepharoplasty isn't one operation, it's a small family of techniques, and the approach that suits a friend's under-eye bags can be the wrong choice for your hooded upper lids.
Eyelid surgery is now the most-performed surgical aesthetic procedure in the world. There were 2,115,360 of them in 2024, according to ISAPS, which puts eyelid surgery ahead of liposuction and breast augmentation. When one name covers that many operations, the details underneath it start to matter.
At Palm Beach Cosmetic Surgery in West Palm Beach, FL, the technique is chosen from what your eyelids are actually doing, not from a standard menu. Two people with the same complaint often need two different operations. This guide covers what each approach treats, where the incisions sit, and how the techniques compare on scarring and risk. You'll also see how the choice gets made and what recovery looks like afterward.
Key takeaways
- Blepharoplasty is a family of techniques, not one operation. The main divisions are upper eyelid surgery, lower eyelid surgery through an external incision, and lower eyelid surgery through an incision inside the lid.
- Upper eyelid surgery treats hooding and excess skin, and it can restore part of the upper field of vision when that skin hangs low enough to block it. Lower eyelid surgery treats bags and puffiness.
- Transconjunctival surgery leaves no external scar. Transcutaneous surgery is the route for loose skin, but leaves a fine line under the lashes.
- Smaller additions do a lot of the work. A skin pinch handles mild extra skin, canthopexy supports a loose lower lid, and fat transfer can fill a hollow. Under-eye filler is more precise for small contour irregularities.
- No technique is universally better. The right one depends on skin quality, lid tone, where the fat sits, and whether your goal is functional or cosmetic.
What can blepharoplasty actually treat, and which eyelid needs surgery?
Blepharoplasty treats the eyelids themselves, meaning the loose skin, the muscle, and the small pads of fat above and below your eye. It doesn't lift your brows, and it won't smooth the fine lines at the outer corners. Knowing that boundary early keeps the rest of the decision honest.
On the upper lid, the usual concern is excess skin that folds over the crease and makes the eye look heavy. Sometimes a strip of muscle or a pad of fat toward the inner corner adds to the fullness. The clinical name for that skin excess is dermatochalasis, and it's a common reason people look into eyelid surgery at all.
Under the eye, the picture is more layered. Bags most often come from small pads of orbital fat that push forward as the tissue holding them back loosens. Loose skin, a hollow tear trough, and a cheek that has drifted downward all add to the same tired look.
Here's the part that changes the plan. A few conditions look like excess eyelid skin without being it, and treating them as skin excess doesn't work.
- A low brow pushes the upper lid skin down, so the lid looks heavy when the real change is above it. Removing skin alone can let the brow settle further.
- True eyelid drooping, called ptosis, means the lid margin itself sits low. That is a muscle issue rather than a skin issue.
- Fine lines and crow's feet sit outside the lid and respond to nonsurgical treatments instead.
- A hollow tear trough with no real bag is a volume problem, and taking fat out can deepen it.
Eye health matters as much as anatomy. Dry eye, thyroid disease, prior LASIK, glaucoma, and blood thinners all shape what can safely be done and when. None of these rules you out, but each changes the conversation.
So the first question isn't which technique you want. It's which structures are causing what you see in the mirror.
What are the main types of blepharoplasty, and how does each technique work?
There are three core operations and a handful of refinements layered on top. Upper blepharoplasty, lower blepharoplasty through the skin, and lower blepharoplasty through the inside of the lid are the main types of blepharoplasty. Everything else is an addition to one of those three.
| Technique | What it treats | Where the incision sits |
|---|---|---|
| Upper blepharoplasty | Hooding and excess upper-lid skin, sometimes muscle or a fat pad | Inside the natural crease of the upper lid |
| Transcutaneous lower blepharoplasty | Loose lower-lid skin and wrinkles | Just below the lower lashes |
| Transconjunctival lower blepharoplasty | Under-eye bags caused by fat, when skin is still firm | Inside the lower lid, with no external cut |
| Skin pinch | A small amount of extra lower-lid skin | A thin strip at the lower lid margin |
| Canthopexy | A lower lid that sits loose and needs support | At the outer corner of the eye |
Board-certified cosmetic surgeon* Dr. Sistare performs upper blepharoplasty, canthopexy, and both the transcutaneous and transconjunctival lower approaches. Which of them ends up in your plan is decided in person, not from a photo.
Upper blepharoplasty
The incision follows the natural crease of your upper lid, so the scar sits in a fold that's already there. Your surgeon removes a measured amount of skin and, depending on your anatomy, a conservative strip of the muscle underneath.
Fat is a judgment call rather than a routine step. It comes out only when there's genuine excess, usually toward the inner corner. Taking too much from the center hollows the socket and can read as older rather than fresher, so preserving fat is often the safer instinct.
Upper eyelid surgery can be performed under local anesthesia, so you're numb but awake and home the same day.
Transcutaneous lower blepharoplasty
This is the external route. The incision runs just below the lower lashes, sometimes extending a little into a smile crease at the corner, letting your surgeon lift a flap of skin or skin and muscle together.
That access is the point of it. Because the skin itself is elevated, this approach can tighten loose skin, soften wrinkles, and support the outer corner in one operation. It suits a lower lid where the skin itself has loosened and creased.
The tradeoff is that altering the front layer of the lid asks more of the lid's support. That's why canthal support is so often added here.
Transconjunctival lower blepharoplasty
Here the incision goes inside the lower lid, on the pink surface against the eye. Because the skin of the lower lid is never opened, there's no visible scar afterward.
It suits a specific patient: prominent fat bags with skin that's still firm. Excess fat is removed conservatively, so the lid looks smoother without looking hollow, and the muscle in front is left undisturbed. What this route can't do is tighten skin, so it isn't the answer for crepey skin.
This is the one blepharoplasty approach that calls for twilight or general anesthesia. Every other eyelid technique can be done with local numbing.
Skin pinch blepharoplasty
A skin pinch is exactly what it sounds like. Your surgeon pinches a thin strip of excess skin at the lower lid margin and removes just that strip, without lifting a full flap or disturbing the muscle beneath.
It's most often paired with the transconjunctival approach, which handles the fat while the pinch handles a modest amount of skin. Published comparisons have found a conservative pinch doesn't meaningfully change where the lower lid ends up sitting, which is why it's such a useful middle option. Too aggressive a pinch, especially toward the nose, pulls on the lid.
Support and add-on techniques
Canthopexy tightens and stabilizes the outer corner of the eye. It removes nothing. It's added when the lower lid is lax, when the lid shows a sliver of white below the iris, or when your anatomy makes downward pull a real concern.
Fat transfer is another refinement worth knowing. Some surgeons move the under-eye fat into the hollow instead of removing it. At our office, excess fat is removed conservatively, and fat transfer from another area of the body adds volume to the groove when needed.
Under-eye filler is another option worth knowing. It's more precise than fat transfer, so it's the tool for small contour irregularities that remain or that surgery isn't meant to address. Injectables are performed by Jackie, our physician assistant injector.
Laser resurfacing is a common companion for eyelid surgery, because surgery moves tissue but doesn't change skin texture. At our West Palm Beach office, resurfacing means erbium or CO2 laser, with RF microneedling from Leah, our aesthetician, as another skin-texture option. Full-face CO2 laser resurfacing is commonly combined with eyelid surgery here, as are facelift and neck lift procedures.
How do the different techniques compare on scarring, results, and risk?
Every one of these techniques works. The comparison isn't about which is better in the abstract, it's about which set of tradeoffs matches your face.
Scarring is the most visible difference and also the least dramatic one. Upper eyelid incisions hide inside the crease and effectively disappear once the eyes are open. Lower lid incisions either sit as a fine line under the lashes or, with the transconjunctival route, don't exist on the outside at all.
Scars do form, though, and honesty is better here than reassurance. Incisions are placed as inconspicuously as possible and can be genuinely hard to notice once healed, but they are real lines that need months to settle.
The upper lid's harder question is how much to take. Skin-only surgery tends to recover faster and preserves the fullness that reads as youthful. More extensive removal of muscle and fat gives a sharper, more defined result that some patients prefer, at greater risk of a hollowed socket that ages the eye.
| Transcutaneous (external) | Transconjunctival (internal) | |
|---|---|---|
| External scar | A fine line under the lashes | None |
| Best suited to | Loose skin and wrinkles | Bags with firm, elastic skin |
| Tightens skin directly | Yes | No, a skin pinch can be added |
| Main concern | More potential for the lid to pull down or round at the corner | Cannot address lax skin on its own |
The lower lid deserves that side-by-side because the stakes differ there. Working through the front of the lid alters the layer that holds it up, so surgeons watch for retraction, a rounded outer corner, and a visible strip of white below the iris. Going in from the inside leaves that support untouched.
Cole, who had under-eye blepharoplasty at our West Palm Beach office, described how the options were laid out for him:
"Dr. Michael Sistare took the time to listen to my concerns and he clearly explained the procedure, its benefits, and the expected outcomes. His expertise and attention to detail were evident, making me feel confident in my choice."
There's one more comparison worth naming, and it isn't about scars. Any eyelid surgery can unsettle the tear film for a while, and that risk rises with combined upper and lower work, aggressive removal, and dry eye you already had. Most of it is temporary and manageable, which is why your tear film gets checked before anything is planned.
How is the right blepharoplasty technique chosen for your anatomy?
The technique is chosen in an in-person consultation, and that appointment is more of a two-way evaluation than most people expect. Your surgeon assesses your anatomy. You're deciding whether this is someone you trust with your face.
The examination itself is specific. Brow position, skin quality, and where the fat pads sit all get checked, along with how quickly your lower lid snaps back when it's drawn away. Each finding narrows the options, and skin that has lost elasticity means a more conservative excision no matter what you came in asking for.
Your history matters just as much as the exam. Previous eyelid surgery, facial trauma, fillers, LASIK, thyroid disease, and any blood thinners you take can change both the technique and the timing. LASIK usually means waiting several months, and thyroid eye disease should be stable before anyone operates.
Then there's what you actually want, which isn't always what a chart would predict. Some patients want the change invisible to everyone but themselves. Others want a crisper, more open eye and accept that it will be noticed. Both are legitimate, and they lead to different amounts of tissue coming out.
Goals can also be functional rather than cosmetic. When upper eyelid skin blocks enough of your field of vision, insurance may cover the procedure, though qualifying typically requires an eye exam and photographs documenting the impairment.
Bring what you've gathered, too. If you arrive holding photos of the results you want, or notes from your own reading, there's nothing to apologize for. It shows you've taken this seriously, and that's exactly what your surgeon wants to see.
It's worth walking in with questions of your own. Useful ones include:
- How many of each approach do you perform, and which do you recommend for my anatomy specifically?
- Can I see before-and-after photos of patients whose starting point looked like mine?
- What's your plan for protecting my lower lid position and my tear film?
- How much fat would you remove in my case, and would fat transfer help with any hollowness?
- What does the quoted price include, and what sits outside it?
Dr. Sistare discusses the risks and the benefits during that visit, so the decision is an informed one rather than a hopeful one. Consultations at Palm Beach Cosmetic Surgery happen in person at the West Palm Beach office, inside the Flagstar Bank building on Village Boulevard. A hands-on assessment of lid tone and tear film is something a screen can't replicate.
Cost belongs in that same conversation rather than being saved for the end. Upper eyelid surgery starts from $3,500, with monthly payment options, and lower or combined surgery is quoted once the plan is set. To keep that accessible, we offer flexible financing through Cherry, CareCredit, and Alphaeon Credit.
What does recovery look like, and what results are realistic?
Eyelid surgery is an outpatient procedure, done right in the office, and total surgical time is generally about an hour. You'll spend some time in the recovery suite, and we'll coordinate a ride home in advance.
Whichever technique you have, it helps to know what recovery looks like before you plan time off. Bruising is usually minimal after both upper and lower eyelid surgery unless you take blood thinners such as aspirin.
Swelling is the main complaint. It tends to settle down onto the lower lid even after an upper-only procedure, so expect some puffiness under the eye either way.
For the first three days, the aftercare routine is simple and repetitive: 20 minutes of heat, then 20 minutes of cold pressure, every two hours. Add preservative-free saline eye drops once an hour for the first few days after surgery. It sounds fussy on paper, but most patients find it gives them something useful to do while they wait.
Swelling is most noticeable through the first week and generally subsides within one to two weeks. Most people return to work and daily activities in that same window. Makeup and contact lenses wait until the two-week mark.
Sutures work differently top and bottom. Upper lid incisions are closed with small sutures, while the lower lid uses either non-dissolvable sutures for a skin incision or none at all with the transconjunctival approach.
One cost question comes up often enough to answer here. At Palm Beach Cosmetic Surgery, recovery essentials and all of your follow-up visits are included in the surgeon's fee rather than billed separately. The genuine extras are lab work and any medical clearance appointment, both handled by another doctor.
Kasey, a patient at our West Palm Beach office, described the result and the follow-up that came with it:
"My results are natural, balanced, and exactly what I hoped for. Even the follow-up care has been outstanding, with the staff checking in and making themselves easily available."
As for what you'll see, the upper crease reads as more defined, puffy bags are smoothed, and the overall impression is rested rather than altered. Incision lines keep fading for months, and fine asymmetries settle well past the point where you feel recovered.
Results typically last somewhere between five and 15 years, and staying healthy helps preserve them. Protecting the skin around your eyes matters just as much. Limit sun exposure and wear a broad-spectrum sunscreen every day, since sun damage changes tone and texture faster than anything else.
What surgery can't do is stop your face from aging, so think of it as resetting the clock rather than stopping it.
Conclusion
There's no single right version of eyelid surgery, only the one that matches what's actually happening to your lids. That comes down to which structures are causing the problem, how firm your skin still is, and how your lower lid behaves. Upper and lower eyelid surgery answer genuinely different questions, and the smaller refinements exist because faces don't sort into two neat categories.
Looking at real eyelid surgery results from patients whose starting point resembles yours is one of the more grounding things you can do next. After that, a consultation is where the abstract comparison in this article turns into a specific recommendation for your lids.
At Palm Beach Cosmetic Surgery, cost comes up early rather than late, the technique gets explained, and the plan is built around what your anatomy needs. Dr. Sistare and our team in West Palm Beach would rather you understood the choice than simply agreed to it.
When you're ready, reach out to our team or call 561-499-9000, and we'll take it from wherever you are.
Frequently asked questions
What is transconjunctival blepharoplasty?
It's a lower eyelid procedure performed through a small incision on the inner surface of the lid. Your surgeon reaches the fat that creates bags without cutting anything on the outside of your face. It suits patients whose skin is still firm.
Does transconjunctival blepharoplasty leave a visible scar?
No. Because the incision sits inside the lower lid, there's no external scar. If mild skin excess also needs treating, a skin pinch or laser resurfacing can be added, and the pinch leaves a very fine line at the lid margin.
What is a skin pinch blepharoplasty?
A skin pinch removes a thin strip of excess skin at the lower lid margin without lifting a full flap or disturbing the muscle underneath. It's usually combined with transconjunctival fat treatment, so fat and a modest amount of skin are both handled. It suits mild-to-moderate skin excess rather than significant laxity.
What happens to the fat during lower eyelid surgery?
Excess fat is removed conservatively, and only where there's genuine excess, so the lid looks smoother without looking hollow. When the area under the eye is also hollow, that removal can be combined with fat transfer from another area of the body. For small contour irregularities, under-eye filler is the more precise option.
Which blepharoplasty technique is best for under-eye bags?
For bags caused mainly by protruding fat with firm skin, the transconjunctival approach is usually the logical choice. When loose skin and wrinkles are part of the picture, an external approach or a skin pinch may serve you better. There's no single technique that's best for everyone.
Can blepharoplasty improve hooded upper eyelids or blocked vision?
Yes. Removing excess upper-lid skin can restore part of the upper field of vision when hooding blocks it, and it relieves the forehead strain of constantly lifting the brow. If the lid margin itself is drooping, that's ptosis, a separate condition treated by a dedicated oculoplastic surgeon.
Can laser resurfacing be combined with eyelid surgery?
Yes, and it's a natural pairing because surgery repositions tissue but doesn't change skin texture. Full-face CO2 laser resurfacing is commonly combined with eyelid surgery at our West Palm Beach office. Resurfacing does extend the aftercare, so ask what that means for your schedule.
What does upper eyelid surgery cost at your West Palm Beach office?
Upper eyelid surgery starts from $3,500, with monthly payment options available through Cherry, CareCredit, and Alphaeon Credit. Lower and combined eyelid surgery are quoted at consultation, because the plan varies so much with anatomy. Recovery essentials and your follow-up visits are included in the surgeon's fee.
*Disclaimer: The specialty recognition identified herein has been received from a private organization not affiliated with or recognized by the Florida Board of Medicine. Financing terms vary by credit approval. This content is for educational purposes only and does not constitute medical advice. A consultation with a qualified board-certified surgeon is required to determine the best treatment plan for your individual needs and any questions you may have about a medical condition or procedure.
