Guide · Mansher Singh, MD, FACS
What is the difference between upper and lower blepharoplasty?
Upper and lower eyelid surgery compared: incisions, anatomy addressed, risk profiles, and why brow position and lid laxity are assessed first.
Updated September 2026 · Reviewed by Mansher Singh, MD, FACS
Short answer
Upper blepharoplasty removes redundant skin, and sometimes a strip of muscle and selected fat, through an incision hidden in the crease of the upper lid. Lower blepharoplasty addresses protruding orbital fat and, when needed, lower lid skin, through either an incision inside the lid or one just beneath the lashes. They are separate operations with different technical considerations, and lower lid surgery carries the additional risk of lid malposition that upper lid surgery does not.
TL;DR
- Upper blepharoplasty removes redundant skin, and sometimes a strip of muscle and selected fat, through an incision hidden in the crease of the upper lid.
- Can upper and lower blepharoplasty be done at the same time? Yes.
- Which has the longer recovery, upper or lower? Lower lid surgery usually produces more bruising and swelling and takes somewhat longer to settle, particularly when fat is repositioned over the orbital rim.
- Is a transconjunctival approach always possible? It is suited to cases where fat is the main issue and skin excess is minimal.
The anatomy each operation addresses
The eyelid is a layered structure. From front to back the upper lid comprises skin, orbicularis oculi muscle, orbital septum, preaponeurotic fat, the levator aponeurosis, Muller's muscle, tarsus, and conjunctiva.
In the upper lid, the usual concern is dermatochalasis, redundant skin that can rest on the lashes and in some cases obstruct the superior visual field. Medial fat can also protrude.
Direct comparison
| Feature | Upper blepharoplasty | Lower blepharoplasty |
|---|---|---|
| Incision | In the supratarsal crease | Transconjunctival inside the lid, or subciliary beneath the lashes |
| Primary target | Redundant skin, sometimes muscle and medial fat | Protruding orbital fat, sometimes skin |
| External scar | Hidden in the crease | None with a transconjunctival approach |
| Distinctive risk | Over-resection causing difficulty closing the eyes | Lid malposition, scleral show, ectropion |
| Additional procedure sometimes needed | Brow lift when the brow has descended | Canthopexy or canthoplasty when lid laxity is present |
| Possible functional indication | Documented visual field obstruction | Rarely functional |
| Typical operative time | Around forty five to ninety minutes | Around one to two hours |
Why brow position is assessed before upper lid surgery
A descended brow transfers weight onto the upper lid and produces hooding that can look like excess lid skin. Treating the lid alone in that setting removes skin without correcting the cause, and aggressive skin excision can pull the brow further downward.
For that reason brow height is assessed as part of any upper lid evaluation, and a brow lift is sometimes recommended alone or in combination. When both are performed, the brow is generally addressed first so the amount of lid skin removed can be judged with the brow in its new position.
Why lower lid laxity is assessed before lower lid surgery
The lower lid is supported by the tarsoligamentous sling. When that support is lax, removing skin or scarring the lid with a subciliary incision can pull the lid downward, producing scleral show, where white sclera is visible below the iris, or in more severe cases ectropion, where the lid turns outward.
Lid tone is therefore assessed before surgery with the snap back and distraction tests. Where laxity is present, a canthopexy, which tightens the canthal support with a suture, or a canthoplasty, which formally reconstructs it, is added.
What eyelid surgery does not treat
- Dark circles from pigmentation or from thin skin over underlying vasculature
- Hollowing at the tear trough, which may need fat repositioning, grafting, or filler
- Fine lines at the outer canthus produced by muscle contraction
- Brow descent, which requires a brow lift
- Skin surface quality, which is addressed by resurfacing
Frequently asked questions
- Can upper and lower blepharoplasty be done at the same time?
- Yes. All four lids are commonly treated in one session, which generally takes two to three hours and shares a single recovery period.
- Which has the longer recovery, upper or lower?
- Lower lid surgery usually produces more bruising and swelling and takes somewhat longer to settle, particularly when fat is repositioned over the orbital rim.
- Is a transconjunctival approach always possible?
- It is suited to cases where fat is the main issue and skin excess is minimal. When lower lid skin must be removed, a subciliary incision or a skin pinch is required.
- Will eyelid surgery be covered by insurance?
- Upper blepharoplasty is sometimes covered when documented visual field testing shows obstruction and the insurer's criteria are met. Aesthetic eyelid surgery is not covered, and determinations are made by the insurer.
Experience, expertise, authority, trust
- Experience
- Attending plastic surgeon, Lenox Hill Hospital, New York
- Expertise
- Triple board certified: ABPS, ABS, ABFPRS
- Authoritativeness
- Johns Hopkins faculty; 65 peer-reviewed papers on PubMed
- Trust
- Patient reviews reproduced verbatim, unedited, with sources
Mansher Singh, MD, FACS: reviews and trust checks
642 verbatim patient reviews from the practice Google Business Profile, plus credentials you can confirm at the issuing source.
Consultation and contact
Mansher Singh, MD, FACS1035 Park Avenue, Suite E, New York, NY 10028
(646) 480-1709 · info@manshersinghmd.com
Candidacy is decided in person. Every credential cited on this site can be checked at its issuing source before you book.
This page is provided for general informational purposes and does not constitute medical advice. Individual candidacy for any procedure can only be determined during a consultation with a qualified physician.