Blepharoplasty firms up the eyelid area by snipping off excess folds of skin that have accumulated and by removing the fat pockets that have herniated above the muscles. Lax muscles can also be tightened by cutting off the excess.

Because de-aging the eyes can so remarkably youthenize the face, blepharoplasty is the cosmetic surgery procedure that can singly give you the most bang for your bucks.

You can either do it as a separate procedure or - if there is overall sagging of the facial skin - combine it with a face-lift.

• Blepharoplasty cannot get rid of wrinkles in the area of the eyes. The wrinkles in the snipped - off skin are, of course, gone for good, so that the eye area shows fewer lines overall; but the skin left behind will still show all the wrinkles that were originally there. To get rid of those calls for a light chemical peel, collagen injections or laser surgery that will level a wrinkle by removing the top layers of the skin around it.
• Blepharoplasty cannot get rid of dark circles under the eyes, or treat droopy eyelids (another feature of aging).
• Blepharoplasty cannot correct "cheek bags". These lie directly under the eyelids and over the cheekbones and are also a feature of aging. They must be excised in a separate surgical procedure performed some weeks after a blepharoplasty.

In general, as with all facial surgery, the earlier the better, if you wait till the time your upward vision is starting to get obstructed, the muscles around the eyelids may have become so overstretched as to cause extensive sagging of the skin. Then you are not only likely to require more surgical repair, but the results are also likely to be less successful than if you had carried out the correction earlier.

• You are young, but bagginess in your eyelids is not relieved by cosmetics, proper rest, controlling your intake of alcohol, salt and other fluid retainers; also, possible medical causes (mentioned earlier) should have been ruled out. In the case of such (inherited) bagginess, a blepharoplasty is best performed early - before the skin has stretched so much that it begins to sag and becomes more difficult to tackle.
• Excessive skin in your upper eyelids has weighed them down to the point that vision is being obstructed, even when you look straight.
• A habit of squinting in the sun or because of myopia has produced a horizontal bulge at the rim of the lower eyelid. (This bulge is caused by hypertrophy of the underlying muscle and is not a "fat pad").
• Due to the aging process, the skin of the eyelids has become loose and redundant; or fat bulges have become obviously visible.
• A combination of one or more of the above problems is present.

Pre-operatively, a thorough surgeon will check you out at various levels involving more than just the eye. The checks include:

• Weight
• Medical problems that may compromise the success of the surgery.
• Current medications. For instance, you may be advised to stop aspirin intake for some period of time before the surgery, because aspirin promotes bleeding.
• Allergies to drugs (such as antibiotics, and other medications that may need to be used post-operatively).

As far as the eyes they are concerned, the cosmetic surgeon will check out (and describe to you) several factors that can affect the quality of the result. Some of them:

• The amount of excess skin and/or bulging fat in the eyelids.
• The quality of the skin, including the extent of creepiness and loss of elasticity. Other things being equal, a person in the 50s can expect better results from any kind of facial cosmetic surgery than someone more advanced in years whose skin has lost tone and suffered more extensive sun damage.
• The presence of a skin lesion and whether or not it can be excised in the course of the blepharoplasty itself.
• Scars from previous surgery or accidents.
• A drooping of the eyebrows - which is a separate problem, also caused by aging but not correctable with a blepharoplasty. It will require another procedure, an eyebrow lift.
• The normalcy, or otherwise, of your vision. Sometimes, a person may have a non-seeing eye, for instance, and be unaware of it. Then, in the aftermath of the surgery, when he is subjecting the results to a hypercritical check, he may notice this defect and accuse the surgeon of making him blind. To safeguard himself, the careful surgeon will check his patient's vision pre-operatively to rule out blindness and other problems.
• Because the two halves of the face are asymmetrical, the surgeon will take photographs and indicate discrepancies or defects to the patient, explaining to him the results he can realistically expect from the surgery.

Although it's popularly known as an "eye-lift", there's really no lift involved but rather a removal of tissue: a snipping away of displaced and/or accumulated fat and a trimming of excess skin that forms wrinkles above and below the eye. As incisions are closed, the skin is gently tightened. Except for the crow's feet at the sides of the eyes, the entire area is smoothed. (The term 'blepharoplasty', derived from the Greek, means, "to mould the eyelids" and that precisely is what it does).

The extent of surgery depends on the depth of the wrinkles, the height of the puffs and whether top or bottom lids or both are affected. Though each operation is individualized, most surgeons follow this basic technique:

Prior to surgery, with the patient in a sitting position, the upper eyelids are carefully marked in such a way as to indicate the amount of skin that must be removed.

The operation is performed under either local or general anaesthesia, depending on the preferences of the surgeon and the patient. If local anaesthesia is used, it is combined with a light sedative.

Incisions are made along the natural creases of the upper and lower lids. The skin is separated from the underlying tissues and muscle, and the excess skin and exposed cushion of fat are removed. The incisions are closed with tiny sutures.

While the actual repair work is accomplished in about an hour, blepharoplasty is a precise and delicate operation. The surgeon needs to be particularly careful about not snipping off too much skin on the lower eyelid. Enough should be left to allow the eye to adjust to the upward gaze. Also, over - stretching the delicate skin in this area could cause a downward pull on the eye, giving it a "bulldog" look.

Similarly, just as removing too little fat can ruin an otherwise good result, removing too much can produce a hollow, cadaverous look.

Although it's popularly known as an "eye-lift", there's really no lift involved but rather a removal of tissue: a snipping away of displaced and/or accumulated fat and a trimming of excess skin that forms wrinkles above and below the eye. As incisions are closed, the skin is gently tightened. Except for the crow's feet at the sides of the eyes, the entire area is smoothed. (The term 'blepharoplasty', derived from the Greek, means, "to mould the eyelids" and that precisely is what it does).

The extent of surgery depends on the depth of the wrinkles, the height of the puffs and whether top or bottom lids or both are affected. Though each operation is individualized, most surgeons follow this basic technique:

Prior to surgery, with the patient in a sitting position, the upper eyelids are carefully marked in such a way as to indicate the amount of skin that must be removed.

The operation is performed under either local or general anaesthesia, depending on the preferences of the surgeon and the patient. If local anaesthesia is used, it is combined with a light sedative.

Incisions are made along the natural creases of the upper and lower lids. The skin is separated from the underlying tissues and muscle, and the excess skin and exposed cushion of fat are removed. The incisions are closed with tiny sutures.

While the actual repair work is accomplished in about an hour, blepharoplasty is a precise and delicate operation. The surgeon needs to be particularly careful about not snipping off too much skin on the lower eyelid. Enough should be left to allow the eye to adjust to the upward gaze. Also, over - stretching the delicate skin in this area could cause a downward pull on the eye, giving it a "bulldog" look.

Similarly, just as removing too little fat can ruin an otherwise good result, removing too much can produce a hollow, cadaverous look.

• Expect swelling and bruising. Ice packs are used to provide relief, and painkillers help to minimize discomfort. The swelling peaks in about 24 hours, but begins to subside in about 36 hours. The bruising takes somewhat longer to heal fully - about two weeks -- but in about a week, it has diminished to the point where it can be concealed with make-up (But make-up must be carefully removed).
• Any activity immediately after the surgery is likely to set off bleeding, so a 48- hour rest is advised.
• Aspirin must not be taken for a week to 10 days, as it would also provoke bleeding.
• With light make-up, the signs of surgery are unnoticeable in a week. By two weeks, even without make-up, you'd be hard-pressed to find the incisions. With time they will fade into the normal lines in the eye area. Once fatty tissue "bags" are removed, they generally do not return, although with the years there may be more wrinkling and sagging of the skin.

Transconjunctival Blepharoplasty is a variation on the conventional procedure used to reduce under eye puffiness. A small surgical incision is made in the conjunctiva (the mucus membrane inside the lower eyelid) and fat is removed via the opening. Bruising and swelling are minimal, and within four to seven days, no one's the wiser.

A refinement on this is using a laser through the conjunctiva (instead of the scalpel) to "melt away" the fat deposits.

But, since transconjunctival blepharoplasty does not remove or tighten excess skin, it works best for younger patients with good skin elasticity or for those with the hereditary type of bulging.

Mini Eye Lifts. Depending on your age and on how well your eyelids have resisted the ravages of Time, you may require not an all-inclusive blepharoplasty, but a scaled-down version, such as removal of only the protruding fat or a minor trim of the skin of the upper and lower eyelids.

The most common complaint from patients is that not enough skin was removed. Sometimes this is true, but most often the surgeon has used good judgment in not overdoing skin removal and putting the patient at risk.

If the surgeon removes too much skin from the lower lid, it can cause an unnatural downward pull on the lid, a condition known as ectropion. Ectropion can produce what is known as the "white eye syndrome", where too much of the white of the eye (known medically as sclera), becomes visible below the cornea. The condition is also described as excessive "scleral show".

Ectropion is one of the most serious complications of eyelid surgery. It is rare in the upper lid, more common in the lower lid. In thin persons, especially, it can result in a hollowed-out, "sunken eye" look. Expertise, caution and meticulous care by the surgeon are essential if the problem is to be avoided.

Ectropion is more likely to be a problem in advanced cases where there is poor muscle tone before the surgery. One way of preventing it is by making the skin incision in the lower lid at a lower level. This avoids the tension and leverage at the area of the rim that causes the ectropion. The lower incision would leave behind a scar, which in older patients would be inconspicuous.

Ectropion can sometimes be corrected post-surgery by carrying out squeezing exercises (repeatedly closing the eyelids tight), early and frequently in the post-operative period. If that is not done, or, if it does not work, a skin graft from the upper lid may be required.

In the immediate post-surgery period, one of the most common complications can be either excessive tearing or temporary lack of tears. The problem usually resolves spontaneously; or otherwise it can be dealt with by local means.

Discoloration can be a vexing problem, particularly in dark-complexioned patients or in those who've had dark under eye circles before the operation. Although it is a frequent problem, it is self-limited for the most part and disappears without any after-effects.

New scars can be produced by careless surgery. Thus, if the surgeon's incision has transgressed the natural boundary between the thin skin of the lower eyelid and the thicker skin of the nose, it will leave behind a fresh scar line that, in younger patients especially, is fairly conspicuous.

The careful surgeon will always ensure that his incisions are made within the natural folds and creases of the eye area itself.

Corneal abrasion or irritation of the conjunctiva sometimes occurs. It can result either from operative trauma, or from "dessication", i.e. redness of the cornea or the conjunctiva due to a foreign body, such as an eyelash or a piece of suture material which may have entered the eye during surgery, causing irritation. Or, because the local anaesthesia leaves the eyelids open during surgery, it exposes the cornea to dessication by the lights in the operation theatre. (The risk is greater during extended surgery such as when an eyelift is done in combination with a face-lift). Or, the patient may have been suffering from "dry eye syndrome" before the operation itself, and the surgery may have accentuated the symptoms.

The problem is best prevented by careful surgical technique and by the periodic use of saline solution to protect the cornea during the operation.

If the patient nevertheless complains of corneal irritation following the operation (scratchy feeling, "sand in the eye", pain), the surgeon will look into and treat the corneal abrasion with ophthalmic preparations.

Ptosis (drooping of the upper eyelid) can result from muscle injury/paralysis caused by poor surgical technique. It can be a major complication, compromising the success of the blepharoplasty and requiring secondary repair.

Haemorrhage (internal bleeding) can occur as an unpredictable and dramatic complication during blepharoplasty, either at the time of injection of the local anaesthesia into the fat pads or at the time of removal of the pads. The globe of the eye may suddenly prolapse and blood escape from a blood vessel. Although it is usually impossible to identify the bleeding vessel, the haemorrhaging generally stops spontaneously.

At times, however, pressure inside the eye may increase due to the prolapse and the bleeding, causing severe eye pain and making the globe stone hard. If untreated, the condition puts the patient at risk for blindness if the accumulated blood presses on the optic nerve. This loss of vision may be temporary or, in rare cases, permanent.

Loss of vision, following blepharoplasty, has also been reported, although its incidence is as low as 0.04 per cent. The causes may be varied, ranging from optic nerve injury to coagulation of blood in a retinal artery or vein (thrombosis).

This, again, underlines the need for a pre-surgery eye check-up to determine eye disease, which must be treated by an ophthalmologist before you can decide whether blepharoplasty is a safe option for you. Many cosmetic surgeons, unfortunately, do not carry out an eye-chart exam, but you, as the prospective patient, must insist upon it.

There is a slight risk of infection, which is no more than in any kind of surgery.

The removal of too much skin from the upper eyelid can also ruin the outcome, resulting in a wide-open, permanently surprised look.

The risks may seem daunting, but if you choose your cosmetic surgeon carefully, the chances of major complications are indeed quite low. Statistically, it would be fair to say that there are greater risks in a tonsillectomy than in a blepharoplasty. To date, surgical blepharoplasty remains the safest way to remove bags under the eyes and puffiness above.

All in all, the rate of patient satisfaction is high.

Despite a blepharoplasty being done, a certain degree of fullness may still be present in the upper eyelids if the eyebrows too have drooped with time. To correct this, and to remove that look of a permanent scowl that drooping eyebrows seem to contribute, requires an eyebrow lift.

An incision is made just behind the hairline, running across the top of the head, from ear to ear. Muscle and skin are then lifted away from the forehead and gently pulled up. Some muscle may be removed. The excess skin is cut away, and the free edges of scalp are sewn together.

The result : A smoother forehead (The procedure is, in fact, a combination eyebrow and forehead lift.)

The eyebrow lift can also be done at the same time as a blepharoplasty, by cutting away an ellipse of the skin and muscle above the eyebrow (following the natural curve of the eyebrow), and then suturing the eyebrow in place at a higher point in the forehead than it originally was. The scar left by the incision is minimal but permanent.

Sometimes the eyebrows can also be lifted in the course of a facelift without separate incisions being made, thus avoiding visible scars.