Upper Vs. Lower Eyelid Surgery
One of the most common questions patients ask during consultation is whether upper or lower eyelid surgery makes the biggest difference. The answer depends on what area is contributing most to a tired or aged appearance.
In this video, Dr. Dimitri Koumanis discusses the differences between upper and lower blepharoplasty, what concerns each procedure addresses, common misconceptions, and how to determine which option is right for you. The full video transcription is included below.
Video Transcription
Today, I’m answering one of the most common questions I hear in consultation: upper versus lower eyelid surgery, which one makes the biggest difference?
The honest answer is this: there isn’t one universal winner. The biggest difference depends on what is aging first on your face, your natural anatomy, and what specifically bothers you when you look in the mirror. This question matters because the eyes are the focal point of the face. When the eye area looks tired, heavy, or puffy, the entire face can appear older — even if the rest of the face still looks great.
Choosing the right procedure between upper and lower eyelid surgery can be one of the highest-impact, natural-looking improvements a patient can make.
Let’s break this down.
Upper Eyelid Surgery (Upper Blepharoplasty)
Patients typically consider upper eyelid surgery because they feel their eyes look smaller than they used to, they notice excess skin resting on the eyelids, hooding over the lash line, or heaviness — especially later in the day or in photographs. Some patients also say they’re constantly lifting their eyebrows without realizing it, subconsciously trying to open the eye area. Over time, that can lead to forehead tension and deeper forehead lines.
Upper eyelid aging is largely about skin laxity. The eyelid skin is thin and stretches with time. In some patients, there is also fat fullness that adds to the heaviness. Upper blepharoplasty removes excess skin and, in some cases, a small amount of fat to restore a cleaner, more open eyelid contour.
A key point here is that a well-performed upper blepharoplasty should not change the shape of your eyes. The incision is placed in the natural crease, and the goal is to restore a natural-looking lid. When done correctly, patients don’t look operated on — they just look more awake and refreshed. People often hear comments like, “You look rested,” or “You look great, did you do something?” That’s the ideal outcome.
In certain cases, upper eyelid surgery can also be functional, improving peripheral vision if excess skin is blocking the field of view. Even when done purely for cosmetic reasons, it can be an extremely high-impact procedure because it opens the eyes and brightens the expression.
Lower Eyelid Surgery (Lower Blepharoplasty)
Lower eyelid concerns are usually different. Patients often say, “I have bags under my eyes,” “I always look tired,” or “No matter how much I sleep, I still look exhausted.” They may also notice puffiness, shadows, or a deeper groove between the lower eyelid and the cheek.
It’s important to understand that under-eye bags are not always about lifestyle. They’re often structural. As we age, the support structures around the eye change and natural fat pads can shift forward. At the same time, the skin becomes thinner and less elastic. Even very healthy patients with great sleep can develop under-eye bulges and shadows.
Lower blepharoplasty is designed to improve the under-eye contour. Modern lower eyelid surgery is not simply about removing fat. Removing too much fat can create a hollow look, which can actually make someone appear older. In many patients, the goal is to smooth and blend the under-eye area in a natural way — sometimes by carefully reducing fullness, sometimes by repositioning tissue, sometimes by tightening skin, and often by redraping fat for a smoother transition into the cheek.
So Which Makes the Biggest Difference?
It depends on the problem you’re trying to solve.
If you look in the mirror and feel your eyelids look heavy, your eyes look smaller, or upper lid skin seems to weigh the eyes down, upper eyelid surgery often makes the biggest difference.
If the main issue is that you look tired because of under-eye bags, puffiness, or shadows, lower eyelid surgery usually has the greatest impact.
Many patients have elements of both, but not everyone needs both. The best plan is always individualized.
A Common Mistake
One of the most common mistakes is trying to treat the wrong problem with the wrong tool. For example, some patients use filler under the eyes when they actually have true under-eye bags caused by prominent fat pads. In those cases, filler can make the area look heavier or more swollen. On the other hand, patients with under-eye hollowing and minimal bags may do very well with filler alone and no surgery.
Similarly, some patients focus on crow’s feet or forehead lines and assume Botox will fix a tired look. Botox can soften expression lines, but it doesn’t remove excess upper eyelid skin or under-eye bags. Eyelid surgery addresses structural changes.
What Happens in a Consultation?
During a consultation, I evaluate eyelid skin quality, the degree of hooding, under-eye puffiness, cheek position, and overall eye balance. I also consider your natural eye shape because preserving your identity is always the goal. Then we talk about what bothers you most and what type of result you want — a subtle refresh, a more dramatic improvement, or something in between.
Recovery Considerations
Upper eyelid surgery usually involves swelling and bruising that improves significantly within one to two weeks. Lower eyelid surgery can also involve bruising and swelling, sometimes a bit more depending on technique and healing. Most patients look presentable within a couple of weeks, with continued refinement as swelling settles.
Final Takeaway
The biggest difference comes from treating the area that is truly driving the tired look in your face. Upper eyelid surgery opens and brightens the eyes. Lower eyelid surgery smooths puffiness and reduces an exhausted appearance. For many patients, the most natural solution is a customized approach , upper, lower, or both, based on anatomy.
If you’re wondering which option is right for you, the best next step is a consultation so we can evaluate your eyelids and give you an honest recommendation for the most beneficial, natural result.
For more information about eyelid lift procedures, or to schedule a consultation with Dr. Koumanis, please contact Saratoga Springs Plastic Surgery today.
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