The T&C Know-It-All’s Guide to Blephs, Brow Lifts, and Everything Eyes
A quick visit to the plastic surgeon for an eye refresh is all the rage. But before you drop five figures and go under the knife, you need a serious primer.
“The beauty of a woman is not in the clothes she wears, the figure that she carries, or the way she combs her hair,” Audrey Hepburn famously said. “The beauty of a woman is seen in her eyes, because that is the doorway to her heart.” Hepburn was trying to argue against superficiality, and her point is well taken. That said, a person’s eyes are that much easier to appreciate when they aren’t framed by drooping skin or ghastly dark circles.
Such are the concerns that send nearly all of us, at some point, to seek cosmetic relief. Eyelid surgery is the most common cosmetic surgery worldwide, with rates skyrocketing in the last few years in the United States, notably among younger patients.
The good news is that satisfaction rates for eyelid surgeries are very high, and complications are low. Also good news: Many common eye-area concerns can be tackled, at least at first, with nonsurgical approaches. But the eye area is tricky, and it requires real expertise to determine the right approach.
“The overarching takeaway I give patients is this: The eye area does not tolerate excess, whether that’s too much filler or too much surgery,” says Manhattan dermatologist Shereene Idriss. “The best results come from restraint, precision, and knowing when not to intervene.”
Concern: Crow’s Feet
Congrats: This is an easy problem to fix, no scalpel required.
“Botox remains the gold standard for softening crow’s feet and preventing deeper etched-in lines, and results are both reliable and subtle when done well,” says New York dermatologist Dendy Engelman.
The only real caveat: You don’t actually want them completely gone.
“Overtreated crow’s feet will make a patient look disingenuous when smiling,” warns Nicola Lowrey, an expert and international educator in aesthetic injectables and skincare. The goal with crow’s feet, she says, “is to soften, not remove.”
This area will also benefit from treatments you might do for the whole face.
“Collagen-inducing treatments — lasers, microneedling, high-intensity focused ultrasound (HIFU) devices such as Sofwave — will also elicit dermal thickness and reduce the appearance of crow’s feet,” Lowrey says.
Concern: Dark Circles
We regret to tell you that here the opposite is true: Dark circles are a tough nut to crack.
“For many people it’s genetic. For others it’s vascular, meaning increased blood flow or visible vessels beneath very thin skin,” Idriss says. “I see this a lot in patients with allergies or chronic congestion.”
“If dark circles are caused by volume loss, fat grafting — harvesting fat from another part of the body and injecting it to add volume — works well,” says Beverly Hills plastic surgeon Catherine Chang. “However, if pigmentation is the issue, fat grafting won’t help. In those cases, topical brightening agents or laser treatments are more appropriate.”
“Softening shadows by strategically using hyaluronic acid fillers for gentle volumization can minimize darker undereyes,” Lowrey says.
“In more youthful patients PRP and PRF — platelet-rich plasma and platelet-rich fibrin treatments — can improve undereye appearance. But no cream or laser or surgery can do much for this complaint if it’s truly from pigmentation. Often it’s best to invest in a good undereye concealer.”
Concern: Crepey Skin
“The delicate skin around the eyes has fewer oil glands and can quickly appear crepey without proper hydration,” Engelman says.
Which is why eye cream is a $5.3 billion industry.
“I would look for a product that is hydrating and has peptides that help reduce fine lines by strengthening the extracellular matrix of the cells,” says New York plastic surgeon Melissa Doft. “Also consider a retinol to increase the thickness of the dermis.”
Estrogen creams have recently become popular for the eye area as well.
“I’ve started using an estradiol cream around my eyes two or three times a week before bed,” Lowrey reports, “and have noticed some plumpness that is lovely.”
But if your eye cream is operating like a knife in a gun fight, you might need stronger weapons.
“It’s all about resurfacing,” says Beverly Hills plastic surgeon Jason Diamond. “A CO₂ laser or a good, strong chemical peel is going to give you the best result. There are less intense, minimally ablative or nonablative lasers, too, and those can keep somebody looking good in more of a preventive way. But at some point those won’t be enough, and then you have to graduate to a real resurfacing laser.”
Concern: Hollowness
“When eyes look tired from deep hollows, in a younger patient we try to start with a nonsurgical approach,” says dermatologist Morgan Rabach of LM Medical in NYC, a practice she shares with her sister, plastic surgeon Lesley Rabach.
“This includes small amounts of filler in the ‘tear trough’ as well as tightening of the skin, which can involve Ultherapy, RF microneedling, CO₂ laser, or a chemical peel.”
“Hyaluronic acid filler, when done well, can look beautiful and natural and be a long-term solution,” says Lowrey. But—and this is a big but—there are far fewer providers who are good at this than there are offering it. So patient beware.
“Most injectors get this area wrong, leading to terrible outcomes,” Lowrey says. “By adding volume here, you run the risk of creating convexity under the eye, which is non–human-looking. You also run the risk of lumps, bumps, and migration.”
The best outcomes, she says, involve not injecting the undereye in isolation.
“In my chair, volume restoration would most commonly happen at the temple, the anterior cheek (specifically in the deep medial cheek fat pad, which supports the tear trough ligament), and the lateral SOOF (the fat pad under the eye laterally). The final step of the actual tear trough is minor, utilizing the tiniest amount of HA delicately placed superficially to keep it out of the muscle.”
Due to the complicated nature of filling this area, there is a lot of debate about the pros and cons of transferring fat here in lieu of HA filler, with many plastic surgeons increasingly relying on fat transfer.
“Over the years I’ve gradually limited the amount of fillers I use, and the patients I use them on, and have replaced fillers with micrografting [fat] instead, as this doesn’t migrate or cause swelling under the eyes,” says plastic and reconstructive surgeon Yannis Alexandrides, founder of 111SKIN in London. “Furthermore, micrografting improves the quality of the skin.”
Concern: Bags
The opposite of hollowness—bulging in the undereye—is equally distressing.
When the bulging is minimal, “HA filler can be used to mask the convexity,” Lowrey says, but “this is a temporary solution. Typically, the herniation will worsen over time.”
“Nothing except surgery fixes bags under the eyes,” says Doft. “I transition from noninvasive measures to surgery when patients are looking for a permanent result. Usually patients have this surgery once and never again.”
The surgery she’s referring to is a lower blepharoplasty.
“The goal of the procedure is to reduce puffiness caused by herniated or bulging fat from the lower eyelids. It can also correct a deep tear trough by changing the position of the fat.”
In some cases doctors will do a “skin pinch” during the process, in which excess skin is also removed.
There are two different methods for lower bleph surgery, Doft explains. “One involves making an incision under the lashes, and one on the inside of the lower eyelid (transconjunctival). I usually make the incision transconjunctival, as it decreases the risk of changing the eye shape or poor scarring. If needed, the skin is tightened afterward using a laser or peel.”
Fellow NYC surgeon Adam Kolker notes that a bit of fat grafting is often useful as well.
“Aging lower lids are often characterized by hills and valleys. Puffiness or bags form immediately beneath the lash line and interface with the tear trough, which is the shadow immediately beneath them. The goal is to reduce the ‘hill,’ fill the ‘valley,’ and smooth the junction between the eyelid and the cheek. Fat grafting is a terrific adjunct. It can work as a standalone procedure for hollowing or in conjunction with a lower bleph to better smooth that junction.”
Downtime for the whole procedure is generally one to two weeks.
Concern: Upper Eye Droop
The key to addressing this is determining what anatomical issue you’re dealing with.
“Many times people’s idea of what they need is off,” Diamond says. “They think, ‘I need my upper eyelids done,’ when in fact it’s that their brow is too heavy—or vice versa.”
If a lifted brow is what you’re after, Botox might be enough.
“This is one of the most important and most misunderstood conversations I have with patients,” says Idriss. “If the brow is being pulled down by muscle activity, Botox can help. By relaxing the depressor muscles, you can get a subtle, temporary lift—aka a chemical brow lift. But if the brow has dropped because of skin laxity or structural aging, Botox won’t fix that. A surgical brow lift is the only way to reposition tissue in a meaningful, lasting way.”
The goal of a brow lift is “to elevate or reshape the brows,” Doft says. “It takes about one week to heal. The scars are placed along the hairline or within the hairline.”
If the issue is hooding of the upper eyelids, an upper blepharoplasty to remove excess skin—with the scar hidden in the eyelid crease—is the solution. This can be combined with a brow lift or a lower bleph, depending on a patient’s needs.
But while these are straightforward surgeries with relatively easy recoveries, the outcome is not always perfect.
“Aggressive eye surgery can be catastrophic,” Lowrey says. “It can change the shape of your eyes. You can also remove too much fat or skin, resulting in a hollowed-out appearance.”
“It’s extremely important to respect the patient’s natural architecture,” says Lesley Rabach. “Surgeons should look at photos of how a person initially looked so they don’t create an oversculpted, skeletonized appearance that makes patients look older.”
Make sure to do your due diligence during consultations. Even before that, Engelman points out there might be a simple fix worth trying: a prescription eye drop called Upneeq.
“As we age, there’s a phenomenon called acquired blepharoptosis where the muscle that controls the upper eyelid gets weakened. In addition to the natural drop in eyebrow positioning, this results in a smaller eye opening. Upneeq works by activating the Müller muscle in the eyelid, causing it to lift the lid and making eyes wider and more open. It’s a blessing for when every millimeter counts.”
In Conclusion
While your eyes might be the first area to show signs of aging, there are many effective solutions. But one thing every expert stresses is prevention. This includes eye creams with actives like retinols and peptides and—above all—sunscreen around the eye area, plus physical protection like sunglasses and hats.
