You can renew your gaze with blepharoplasty.

Blepharoplasty in Brazil: rejuvenation of the gaze with fat grafting

The eyes are the first area of the face to reveal the signs of time. Heavy eyelids, under-eye bags, deep dark circles, and drooping eyebrows can make you look tired, sad, or older than you really are. Blepharoplasty — also known as eyelid surgery or eyelid lift — is the procedure that corrects these problems, restoring a rested and rejuvenated gaze.

I have been performing blepharoplasties for over twenty years, with more than eight thousand facial surgeries in my curriculum. My training with Professor Ivo Pitanguy and my experience as a full member of the Brazilian Society of Plastic Surgery and the American Society of Plastic Surgeons have given me a comprehensive view of periorbital ageing. As a board-certified plastic surgeon in Brazil, I can affirm: modern blepharoplasty goes far beyond the simple removal of skin and fat. Today, we work with volume replacement, cellular rejuvenation, and balancing of the entire eye area. International patients seeking cosmetic surgery abroad choose my clinic in Brazil for the combination of expertise, personalised care, and exceptional results in eye bag removal and eyelid rejuvenation.

Blepharoplasty is the surgical correction of the eyelids, addressing excess skin, under-eye bags, deep dark circles, and drooping eyebrows that create a tired or aged appearance. What many people do not realise is that this procedure benefits both mature patients seeking rejuvenation and younger individuals born with heavy eyelids or prominent fat pads that affect their confidence. In severe cases, excess upper eyelid skin can actually limit the visual field, making blepharoplasty a functional necessity as well. At my clinic in Brazil, I perform a detailed evaluation of each patient, mapping the specific changes present and designing a personalised surgical plan. My goal is never a generic correction but rather a result that respects each person's unique anatomy and natural facial balance. With over twenty years of experience and more than eight thousand surgeries, I have refined an approach that consistently delivers natural, refreshed results without looking overdone.

What modern blepharoplasty can treat

The eye area ages in multiple ways, and each patient presents a unique combination of changes. During the consultation, I carefully assess which problems are present in your case:

• Excess skin on the upper eyelids: that "curtain" of skin that weighs down the eyes, sometimes even obstructing vision;
• Under-eye bags: both on the upper eyelids (medial fat) and on the lower ones (the familiar puffiness beneath the eyes);
• Deep dark circles: the dark groove between the bags and the cheek, which gives a constantly tired appearance;
• Sunken eyes: loss of volume in the upper eyelids, creating a skeletal appearance;
• Loss of malar volume: sinking of the cheekbones that accentuates the dark circles;
• Drooping eyebrows: ptosis of the eyebrow that worsens the appearance of excess skin;
• Skin quality: fine wrinkles, loss of elasticity, and irregular texture.

My approach: beyond simple removal

Traditional blepharoplasty focused solely on removal: taking away skin, taking away fat, taking away muscle. This approach, while effective for some cases, often left the eyes looking "operated" or even prematurely aged. After all, ageing is not just excess tissue; it is also loss of volume.

My philosophy is different. I work with the concept of redistribution and replacement: I reposition the excess fat, add volume where it is lacking, and rejuvenate the skin with stem cells derived from the patient's own fat — a technique I detail on the page about facial fat grafting. The result is a naturally youthful gaze, not a "stretched" look.

Fat grafting: the differential of my technique

Autologous fat (from the patient) has revolutionised periorbital surgery. I use two forms of processing, each with specific indications:

Microfat

Microfat is obtained through liposuction with fine cannulas, usually from the abdomen or thighs. After careful processing, I inject this graft into areas that have lost volume with ageing:

• Malar region: when the cheekbones are sunken, the dark circles appear deeper. Restoring malar volume is essential for a natural, balanced result;
• Sunken upper eyelids: in patients with "deep-set eyes", the microfat graft fills the depression above the eyeball, restoring a youthful appearance.

Nanofat for dark circles

Nanofat is an additional refinement: the fat is processed until it has an extremely fine, almost liquid consistency. This technique is especially valuable for treating deep dark circles, that dark depression just below the under-eye bags of the lower eyelids.

Why nanofat and not hyaluronic acid? The difference is significant. Hyaluronic acid, when injected into the dark circle area, often causes the so-called Tyndall effect: a bluish or purplish discolouration that appears under the thin skin of this area. It is a common problem that frustrates many patients. Nanofat does not cause this effect, as it is autologous tissue that integrates naturally into the site.

Moreover, fat carries adipose stem cells that promote real skin rejuvenation. Scientific studies show that these cells stimulate collagen production, improve vascularisation, and regenerate damaged tissues. The result is not just filling; it is regeneration.

Brow lifting: techniques that work

Often, what appears to be excess skin on the upper eyelid is, in fact, drooping of the eyebrow. In these cases, simply removing skin does not solve the problem and can even worsen the appearance.

I do not perform endoscopic brow lifts or the technique popularly known as "foxy eyes". Why? Because, in my experience, the results of these techniques do not last. The eyebrows tend to droop again in a short time, frustrating the patient.

For cases that truly require brow lifting, I use techniques with a small and discreet incision, positioned close to the upper part of the eyebrows, on the lateral third. Depending on each patient's anatomy, I apply variations such as:

• Minicastanhares Technique: subtle elevation with an almost invisible scar;
• Vinhas Technique: recommended for specific cases of lateral ptosis;
• Nike Technique: so named for the shape of the incision, provides elegant elevation of the tail of the eyebrow.

These techniques produce lasting results because they create a real structural fixation, not just a temporary suspension. The scar is hidden at the upper edge of the eyebrow and becomes imperceptible in a few weeks.

Are you a good candidate for blepharoplasty?

Blepharoplasty can benefit both young and mature patients, as long as the indications are correct. You may be a good candidate if:

• You have heavy or drooping upper eyelids;
• You have under-eye bags on the lower eyelids;
• You suffer from deep dark circles that do not improve with topical treatments;
• You notice that your eyes look constantly tired;
• You are in good overall health and have realistic expectations.

On the other hand, there are conditions that require special evaluation, such as severe dry eye, thyroid diseases (especially Graves' disease), glaucoma, or other ocular pathologies. In these cases, I work together with ophthalmologists to ensure the safety of the procedure.

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How I perform blepharoplasty

One of the most important advances I have incorporated into my blepharoplasty practice is fat grafting to treat dark circles. Traditional approaches used hyaluronic acid fillers to conceal the hollow groove beneath the eyes, but these fillers are temporary, lasting at most eighteen months, and can migrate or cause a bluish discolouration known as the Tyndall effect. The fat I harvest from the patient's own body and process into nanofat offers a stable long-term solution. This nanofat is rich in adipose-derived stem cells that regenerate the thin, darkened skin of the periorbital area from within, improving both the depression and the pigmentation simultaneously. When combined with blepharoplasty, the fat graft transforms the entire eye region, restoring a youthful fullness that skin removal alone cannot achieve. At my clinic in Brazil, I offer this combined approach as the gold standard for periorbital rejuvenation, drawing patients from across the country and internationally.

The technique varies according to the needs of each patient, but I can describe the general principles that guide my approach:

Upper eyelids

I start with precise marking of the skin to be removed. This marking is done with you sitting, as the lying position alters the distribution of tissues. The incision follows the natural crease of the eyelid, becoming practically invisible after healing.

I remove the marked strip of skin and, when needed, a small portion of the orbicular muscle. If there is medial fat herniation, I can remove it or reposition it to fill depressions. In cases of sunken eyes, I perform micro-fat grafting to restore the lost volume.

If there is an indication for eyebrow elevation, I perform an additional incision in the lateral third, applying the most appropriate technique for each case (mini-lifts, vines, or Nike). This step is fundamental for patients with eyebrow ptosis, as simply removing skin does not adequately correct the problem.

Lower eyelids

For the lower eyelids, I preferably use the transconjunctival approach: the incision is made from inside the eyelid, with no visible external cut. This approach allows for direct and safe access to the under-eye bags.

Depending on the case, I may remove, redistribute, or combine the fat from the bags with additional grafting. When there are deep dark circles, I perform nanofat grafting in this region, filling the depression and improving the dark colouration.

If there is significant excess skin on the lower eyelid (more common in older patients), I may combine a small incision just below the eyelashes to remove this excess. The scar remains extremely discreet.

Fat grafting

When the plan includes fat grafting, I start the procedure with liposuction from a donor area, usually the abdomen or inner thighs. The fat is carefully processed to separate the viable cells.

For the nanofat for dark circles, the processing is even more refined, filtering until achieving an almost liquid consistency, rich in adipose stem cells. This fraction is injected with special micro-cannulas, creating a smooth and natural filling.

The fat graft not only fills; it regenerates. The stem cells present in the fat stimulate collagen production, improve skin quality, and promote neovascularisation. Over time, the treated area shows progressive improvement that goes beyond simple filling.

Surgical time

A simple blepharoplasty, just of the upper eyelids, lasts approximately one hour. When I combine lower eyelids, eyebrow elevation, and fat grafting, the procedure can last between two and three hours. I prefer not to rush; each step deserves meticulous attention.

About complications

In over twenty years performing blepharoplasties, I have developed a technique that prioritises safety above all. The complications described in the literature, such as retrobulbar haematoma, ectropion, or significant asymmetry, are extremely rare when the procedure is performed by an experienced surgeon with the appropriate technique.

My history reflects this commitment to safety. I attribute my consistent results to the combination of careful indication, detailed planning, refined technique, and rigorous post-operative follow-up.

Scars

The scars from blepharoplasty are remarkably discreet:

• Upper eyelid: the scar is hidden in the natural crease, becoming practically invisible in a few weeks;
• Transconjunctival lower eyelid: there is no external scar;
• Eyebrow elevation: the scar is at the upper edge of the eyebrow, concealed by the brow hairs;
• Fat donor area: small incisions of three to four millimetres that heal without leaving a visible mark.

Blepharoplasty Combined with Other Procedures

Frequently, blepharoplasty is performed alongside other facial surgeries for a more complete and naturally balanced result:

Blepharoplasty + Facelift

The most common combination. While blepharoplasty rejuvenates the eye area, the deep plane facelift addresses the sagging of the middle and lower thirds of the face. The result is a global and balanced rejuvenation. For those seeking a less invasive option, the mini facelift can also be combined with blepharoplasty.

Blepharoplasty + Rhinoplasty

In some patients, a large or disproportionate nose diverts attention from the eyes. Correcting both in the same surgery creates a natural facial balance superior to isolated treatment.

Blepharoplasty + Non-Surgical Treatments

Botulinum toxin for expression wrinkles and facial fillers with hyaluronic acid can complement the results of blepharoplasty, treating areas that the surgery does not directly address.

Correction of Failed Blepharoplasty

I receive patients who have undergone blepharoplasty with other professionals and are not satisfied. The most common problems are:

• “Rounded” or startled eyes: usually due to excessive skin removal;
• Ectropion: lower eyelid turned outward;
• Sunken eyes: excessive fat removal;
• Asymmetry: one eye different from the other;
• Visible scars: poor suture technique or healing complications.

The correction of failed blepharoplasties is one of the most challenging procedures in facial plastic surgery. Each case requires careful evaluation and individualised planning. Frequently, fat grafting is essential to restore lost volume and improve the quality of damaged skin.

If you are not satisfied with a previous blepharoplasty, book a consultation. I will conduct a complete evaluation and honestly present the possibilities for improvement for your specific case.

What do the eyes look like after blepharoplasty?

An honest description of what to expect helps align expectations. Out of respect for CFM Resolution 2.336/2023, which regulates the use of comparative images in medical advertising in Brazil, I do not display real patient before/after photographs on this page. What I describe below is what my clinical experience shows consistently.

What changes visually

The upper eyelid stops weighing down on the eye. The lower fat bags disappear or are significantly reduced. When nanofat grafting is associated, the tear trough softens and the eyelid-cheek transition becomes harmonious again. The general impression is of a more rested, more open, less "heavy" gaze. The patient remains recognisable — the expression does not change; freshness is restored.

What patients report

The most common descriptions: "My eyes looked tired all day long — now they look rested", "I recognise myself in the mirror again in the morning", "People say I look different but they cannot tell what changed", "I can wear make-up again with a beautiful result". Patients rarely describe the result as "prettier" — they describe it as "more like me".

When the result becomes apparent

At 7 days, most sutures are removed. At 10-14 days, the purple bruising and the main swelling have subsided and the patient is socially presentable with light make-up. At 30 days, about 70% of the result is visible. At 3 months, 90% — the scar is already discreet and the area has stabilised. Final refinement occurs between 6 and 12 months, when the scars mature fully and any residual swelling of the tear trough (especially when fat grafting was performed) resolves.

How many years does blepharoplasty rejuvenate the gaze?

In the facial plastic surgery literature and in my clinical observation, blepharoplasty produces a visual perception of rejuvenation of 8 to 12 years on average for the gaze — some patients perceive more, others less, depending on facial structure, skin quality and accumulated ageing. The upper eyelid result tends to remain stable for 8 to 12 years; the lower eyelid, for 10 to 15 years. Natural ageing continues from the new baseline.

Why I do not publish before/after photos

As a plastic surgeon registered with the Regional Council of Medicine of Parana (CRM-PR 17.388), I follow CFM Resolution 2.336/2023 regarding medical advertising. This resolution prohibits the use of before/after images on publicly accessible online platforms to avoid inducing unrealistic expectations in the general public. During in-person consultation, I can share educational material and discuss expected outcomes individually and ethically, within the Brazilian regulatory framework.

Common blepharoplasty regrets

This is one of the most searched queries on Google about blepharoplasty — and it deserves an honest answer. Post-blepharoplasty regret, when it exists, is almost never a consequence of the decision to operate itself. In my clinical experience and in the facial plastic surgery literature, regrets follow four identifiable patterns — and all of them are largely avoidable with proper planning.

1. Expectation misaligned with what the surgery actually solves

The most common complaint: "I had eyelid surgery expecting the dark circles to disappear, but the dark circles are still there." Isolated blepharoplasty treats excess skin and fat bags — but does not resolve dark circles caused by loss of bony or fatty volume in the tear trough. Without treating the lost volume, the eye may even look more hollow after surgery. That is why, in my practice, I assess the tear trough individually and frequently combine blepharoplasty with nanofat grafting in the area to correct the root of the problem.

2. Excess skin removal on the upper eyelid

Less experienced surgeons, trying to offer a "dramatic result", remove too much skin. The result is eyes that always look open, with difficulty closing fully (lagophthalmos), chronic irritation and an artificial appearance. Once removed, skin does not come back. The safety rule is simple: it is better to leave a little extra — which the patient finds discreet — than to take too much. Retouches are possible when needed, but the reverse is not.

3. Excess fat removal on the lower eyelid

In the past, the standard technique was to remove the fat from the lower bags. This approach ages the face: the patient ends up looking skeletal, the eyes appear hollow, and the eyelid-cheek transition becomes sharp. The modern approach — which I use — is to reposition the fat (septal transposition technique) or even add fat to the points where the patient has already lost it. Instead of emptying, I redistribute and enrich.

4. Not treating the midface when it needs treatment

Some patients arrive thinking that the only surgery they need is blepharoplasty, when in fact the main problem is descent of the malar region (cheekbone). In these cases, isolated blepharoplasty does not solve the issue — the eye continues to look tired even with the eyelid redone. Honest assessment in the consultation avoids this mistake: when the midface needs attention, either I add malar fat grafting in the same surgery, or I discuss combining with a more complete facelift.

How to avoid regret: an experienced surgeon, individualised assessment of the tear trough and midface, conservative philosophy on tissue removal, and combination with fat grafting when indicated. A frank conversation in the consultation is what separates a good result from a regret.

Non-surgical blepharoplasty, plasma pen, CO2 laser: what is the difference?

These three techniques appear frequently in searches by patients who want to avoid traditional surgery. I will explain what each one is, what it can and cannot do, and why I do not perform any of them in my practice.

"Non-surgical" blepharoplasty (plasma pen / plasma jet)

The plasma pen is a device that creates small points of controlled desquamation on the skin of the eyelid, inducing cutaneous retraction. It is an office-based procedure, without a scalpel, under topical anaesthesia. It can slightly improve excess skin in patients with very mild laxity. But it has important limitations: it does not treat fat bags, does not correct true ptosis, produces a modest result (20-30% of what classical blepharoplasty achieves) and carries a risk of superficial burns with dyschromia (hyperpigmented or hypopigmented spots) on the thin skin of the eyelid, which can be persistent. In my opinion, it does not justify the risk. I do not perform it.

Blepharoplasty with CO2 laser

CO2 laser can be used in two ways: as a scalpel to make the incision (replacing the cold scalpel) or as an ablative technique to rejuvenate the eyelid skin. The first does not substantially alter the surgical outcome — it is a technical choice between surgeons. The second produces cutaneous retraction and may improve fine wrinkles, but carries the same risks as the plasma pen: dyschromia, longer healing time, risk of ectropion from excessive retraction. I prefer the traditional cold scalpel combined with nanofat grafting to improve skin quality — it produces a more predictable result.

Why classical surgical blepharoplasty remains my standard

For true laxity, fat bags and dark circles caused by volume loss, there is no safe and effective substitute for a well-executed surgical blepharoplasty. The "non-surgical" methods have a limited place in very specific cases and in experienced hands, but they are marketed as a universal alternative — which does not match the clinical reality. When a patient insists on a non-surgical procedure because they fear the scalpel, I explain that postponing is not the problem — the problem is confusing anxiety sedation with an actual solution to the anatomical issue.

Does insurance cover blepharoplasty?

Common question, and the answer depends on an important distinction between cosmetic blepharoplasty (performed to rejuvenate the gaze) and correction of functional eyelid ptosis (performed when a drooping eyelid impairs the visual field).

Cosmetic blepharoplasty: not covered

Blepharoplasty performed for purely cosmetic purposes is not covered by public health systems or by most private health plans. In Brazil, this follows the general rule of the ANS (National Supplementary Health Agency), which does not include cosmetic procedures in its mandatory coverage list. In the United Kingdom, the NHS does not cover cosmetic blepharoplasty, and private health insurance policies rarely do unless there is a functional indication.

Functional eyelid ptosis: may be covered with clinical indication

When the upper eyelid drops to the point of impairing the visual field (obstruction of the upper visual field, difficulty driving at night, chronic visual fatigue), the correction is considered functional rather than cosmetic. In Brazil, this procedure is in the ANS list and, with documented medical indication, may be covered by private health plans such as Unimed. The public SUS system also performs functional ptosis correction in teaching hospitals and ophthalmology/plastic surgery units, based on an objective assessment of the visual field. In the United Kingdom, the NHS may cover upper-lid ptosis correction on functional grounds through referral via your GP, and some private insurance policies include similar clinical indications.

Documentation required

To obtain authorisation, what is usually required: ophthalmological examination with visual field measurement (demonstrating the obstruction caused by the ptosis), standardised photography of the patient in neutral gaze, a medical report describing the functional symptoms and, in some cases, prior assessment by the insurer's own ophthalmologist. The authorised procedure is usually the correction of structural ptosis; the cosmetic portion (lower fat bags, redundant skin without visual impact) remains private.

How it works in my practice for international patients

When a patient arrives with true functional ptosis, I assess during the consultation and advise on how to proceed with their insurance. For international and UK patients travelling to Brazil, the procedure is usually paid privately regardless of medical indication, but I can provide detailed medical reports for those who wish to seek reimbursement from their home-country insurer. Each insurer has specific criteria, and the in-person consultation clarifies the step-by-step process.

I had blepharoplasty and still have dark circles — why?

This complaint appears in hundreds of searches per month and deserves a clear explanation. When a patient has blepharoplasty and notices that the dark circles remain — or, worse, become more evident — the cause is almost always the same: the dark circle was never a fat-bag problem or an excess-skin problem; it was loss of volume in the tear trough.

There are three distinct types of dark circles, with completely different origins:

• Vascular dark circles — purple or reddish appearance caused by fragility of the superficial vessels. Blepharoplasty does not fix it. Treatment: vascular laser, specific peels, dermatological camouflage.
• Pigmentary dark circles — hyperpigmentation of the skin from melanin, common in darker skin types. Blepharoplasty does not fix it. Treatment: topical depigmenting agents, peels, pigment laser.
• Structural dark circles (tear trough) — depression just below the lower eyelid, caused by loss of bony or fatty volume with ageing. This is the only type that blepharoplasty combined with nanofat grafting resolves.

Honest preoperative assessment distinguishes these three types — and this is the critical point. If the patient has vascular or pigmentary dark circles and is taken to blepharoplasty without that distinction, the postoperative experience turns into frustration. In my practice, I only indicate blepharoplasty to treat dark circles when the structural component is dominant, and I always combine with nanofat grafting to restore the lost volume. When the component is vascular or pigmentary, I advise the patient to seek aesthetic dermatology first.

Who is qualified to perform blepharoplasty?

Blepharoplasty is a surgery that involves delicate ocular structures — the globe, oculomotor muscles, lacrimal pathways, eyelid ligaments — whose safe management in case of complication depends on complete medical training. For this reason, the qualified professional categories for eyelid surgery are all medical.

Plastic surgeon — in the United Kingdom, a surgeon on the GMC Specialist Register in Plastic Surgery, with membership of BAAPS (British Association of Aesthetic Plastic Surgeons) or BAPRAS (British Association of Plastic, Reconstructive and Aesthetic Surgeons). In Brazil, a plastic surgeon with the specialist title (RQE) in Plastic Surgery, obtained through medical residency recognised by the Ministry of Education and by the Brazilian Society of Plastic Surgery (SBCP). This is my own training — medical degree, General Surgery residency, Plastic Surgery residency, more than 20 years of practice, and the Ivo Pitanguy School.

Ophthalmologist with oculoplastic sub-specialisation — in the United Kingdom, a consultant ophthalmologist with fellowship training in oculoplastics and membership of BOPSS (British Oculoplastic Surgery Society). In Brazil, recognition is granted by the Brazilian Council of Ophthalmology. These professionals have in-depth training in the anatomy of the eye globe and its annexes, which is particularly relevant in complex cases such as severe eyelid ptosis, ectropion, entropion and lacrimal-pathway surgery.

ENT surgeon with specific eyelid surgery training — less common, but legitimate when the professional has advanced training in the periorbital region.

The Brazilian Law 12.842/2013 (Medical Act Law) establishes, in Article 4, section III, that the indication and execution of invasive aesthetic procedures are privative to medical doctors. Aestheticians, biomedical practitioners, physiotherapists and other non-medical health professionals do not have legal backing to perform surgical blepharoplasty, nor the "non-surgical" plasma pen version on the eyelid, because it involves risk to the skin and to ocular structures.

How to choose your surgeon: in the United Kingdom, confirm GMC registration via the Medical Register, verify inclusion on the Specialist Register in Plastic Surgery or Ophthalmology, look for BAAPS, BAPRAS or BOPSS membership, and ask about blepharoplasty case volume. In Brazil, check the CFM portal to confirm the surgeon's CRM is active, verify the RQE in Plastic Surgery or Ophthalmology, look for SBCP or Brazilian Society of Ocular Plastic Surgery (SBCPO) membership. Regardless of country, check surgical case volume and ensure the operation takes place in a proper hospital environment with a dedicated anaesthetic team — the remote but real possibility of retrobulbar haematoma, a very grave complication, demands an immediate emergency response. My credentials: CRM-PR 17.388 · RQE 15.688 · Full Member SBCP and ASPS, trained at the Ivo Pitanguy Institute. I operate exclusively at Hospital do Coracao — Unidade Bela Suica, Londrina-PR, Brazil.

What can go wrong in blepharoplasty?

An honest answer: like any surgery, blepharoplasty has specific risks. Knowing them is part of the informed decision-making process. Possible complications, with approximate probabilities from the literature and from my own experience, are:

• Prolonged swelling and bruising — the most common and expected, usually resolving within 2-3 weeks.
• Discreet residual asymmetry — small asymmetries are frequent and usually acceptable; larger asymmetries may require a touch-up after 6 months.
• Hypertrophic or widened scar — uncommon on the eyelid because the skin is thin, more frequent in smokers. May require topical treatment or corticosteroid injection.
• Ectropion (lower eyelid turned outward) — rare when the surgical plan is well indicated; more frequent in patients with lax eyelid ligaments that were not reinforced during surgery.
• Lagophthalmos (difficulty closing the eye completely) — transient in the first days is normal; persistent is a sign of excess skin removal.
• Temporary dry eye — common in the first weeks, treated with lubricating eye drops.
• Diplopia (double vision) — very rare, may occur due to oedema close to the oculomotor muscles; usually resolves spontaneously.
• Retrobulbar haematoma — a very grave and fortunately very rare complication (estimated at less than 1 in 25,000 cases in the literature); real risk of vision loss if not treated as an immediate emergency. This is the reason I always operate in a hospital environment with a dedicated anaesthetic team.
• Infection — rare (<1%) in a hospital environment with adequate antibiotic prophylaxis.
• Result below expectation — the most subjective risk, linked to misalignment of expectations at the consultation.

Prevention: an experienced surgeon, conservative technique, hospital environment, adequate preoperative assessment, smoking cessation and close follow-up. The risk of death in elective blepharoplasty in a healthy patient is extremely low — comparable to that of any minor surgery under safe anaesthesia.

Contraindications: who should not have blepharoplasty

Not every patient is a candidate, and some conditions require detailed assessment before the surgical decision. These are the situations that research and assessment during the consultation need to consider:

• Glaucoma — not an absolute contraindication, but requires an ophthalmologist's opinion and strict control of perioperative intraocular pressure.
• Graves' disease / thyroid orbitopathy — may contraindicate surgery until stabilisation, because proptosis alters eyelid dynamics.
• Severe dry eye (significant keratoconjunctivitis sicca) — blepharoplasty may worsen it; ophthalmological assessment is mandatory beforehand.
• Uncontrolled diabetes — increases the risk of infection and delayed healing; requires glycaemic control before surgery.
• Uncontrolled hypertension — risk of haematoma and retrobulbar haematoma; requires prior control.
• Coagulopathies or use of anticoagulants — requires supervised suspension by a cardiologist whenever possible.
• Active smoking — does not contraindicate, but significantly increases the risk of scar-healing complications; I require cessation 30 days before and 30 days after surgery.
• Unrealistic expectations — the most subjective factor, but critical. A patient seeking absolute perfection or the resolution of psychological issues through surgery is not a good candidate.

Scarring: what to expect and how to care for the scars

The blepharoplasty scar sits in a privileged location — in the natural fold of the upper eyelid or just below the lashes on the lower eyelid (or transconjunctival, with no external scar). When well executed, it becomes practically invisible by 3-6 months. But there are important care steps for this to happen.

Hypertrophic scars and small inclusion cysts

Small nodules or inclusion cysts (small white spots) along the line of the scar are relatively common in the first weeks. Treatment: gentle massage with a recommended ointment (usually silicone-based) from day 14 onwards, avoidance of direct sun exposure, and office removal when they persist. True hypertrophic scarring (raised, red, itchy scar) is rarer on the eyelid than in other areas, and responds well to intralesional corticosteroid infiltration when it does occur.

Post-operative orientations I give to my patients

• Cold compresses during the first 48 hours (15 minutes every hour)
• Sleeping with the head elevated for 1-2 weeks
• Avoiding direct sun on the scar for 3 months
• High-factor sunscreen and sunglasses are mandatory
• Silicone-based ointments from day 14 onwards
• No make-up on the operated area for 10-14 days
• Avoiding intense physical activity for 3 weeks
• Follow-up appointments at 7 days, 30 days and 3 months

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To learn more about blepharoplasty and other types of plastic surgery that Dr. Walter Zamarian Jr. performs in Brazil, please contact the Zamarian Clinic and book a consultation.

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