Eyelid Surgery (Blepharoplasty)
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Dr. Horton
Emily Sespaniak, MSN, FNP-C
Danielle Bautista, MSN, ANP
What Is Blepharoplasty?
Am I a Candidate for Eyelid Surgery?
Types of Eyelid Lifts
The Blepharoplasty Procedure
Recovery After Eyelid Surgery
What to Expect from Your Results
Combining Blepharoplasty with Other Procedures
Why Choose Dr. Karen Horton for Blepharoplasty
Frequently Asked Questions About Blepharoplasty
The eyes are often the first feature others notice — and frequently the first area to reveal the visible effects of aging. Loose or sagging upper eyelid skin, puffiness caused by excess fatty deposits, under-eye bags, dark circles, and fine or deep wrinkles can create a tired, sad, angry, or older appearance that no longer reflects how you feel inside.
For patients in San Francisco and the greater Bay Area, Board-Certified Plastic Surgeon Dr. Karen Horton offers customized blepharoplasty procedures designed to restore a brighter, more rested, and naturally youthful (but natural) look to the eyes. Known for her exceptional precision and deeply personalized approach, Dr. Horton brings artistry and clinical expertise to every eyelid surgery she performs.
Blepharoplasty, commonly called an eyelid lift, can address the upper eyelids, lower eyelids, or both, producing results that are subtle, beautiful, and entirely natural. The goal is never to look ‘done’ or ‘surprised’ — but simply to look like yourself, refreshed.
What Is Blepharoplasty?
Blepharoplasty is a facial rejuvenation procedure that corrects the visible signs of eyelid aging by removing or repositioning excess skin around the eyes. It can improve the appearance of drooping upper lids, under-eye bags, puffiness, and fine wrinkles, restoring a more alert and youthful eye area.
In some cases, excess upper eyelid skin becomes severe enough to fold over the lash line and impair peripheral vision, making blepharoplasty both a cosmetic and functional procedure. Advanced conditions such as festoons — puffy bags of skin in the lower lids that are often genetic in origin — and ectropion, an outward curving of the lower eyelid that exposes the white of the eye, can also be corrected through eyelid surgery.
According to the American Society of Plastic Surgeons, blepharoplasty consistently ranks among the top five most performed cosmetic surgical procedures in the United States each year, reflecting its broad appeal and high patient
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satisfaction.
As Dr. Horton has noted, her philosophy is that the best eyelid surgery is the kind no one can detect. Patients should look like themselves — only brighter and more rested.
Am I a Candidate for Eyelid Surgery?
Ideal candidates for blepharoplasty are healthy adult men and women who are physically well, emotionally balanced, non-smokers, and show signs of eyelid aging such as those described above. In some cases, brow ptosis — drooping of the forehead or brow — may also be present, and combining a brow lift with blepharoplasty can produce more complete results.
The following conditions may affect candidacy or increase surgical risk:
- Cardiovascular disease, uncontrolled high blood pressure, or poorly controlled diabetes, due to concerns with bleeding, infection, or poor healing
- Eye conditions such as dry eyes, glaucoma, or a history of detached retina
- Graves disease, an overactive thyroid, or exophthalmos (bulging of the eyes)
- A history of LASIK surgery or other vision disorders — please disclose this during your consultation
If you receive neuromodulator treatments such as BOTOX®, Dysport®, or other injectable wrinkle reducers to the forehead or crow’s feet area, the effects should be fully resolved before your blepharoplasty consultation. Waiting approximately three months since your last treatment allows Dr. Horton to evaluate your brow and eyelid anatomy in its most accurate, natural state — since many patients unconsciously elevate their brows to compensate for upper eyelid drooping.
For detailed pre-operative guidance, please visit our Preparing for Surgery section.
Before & After
Types of Eyelid Lifts
During your consultation, Dr. Horton will evaluate your eyelids and forehead both at rest and in motion, assessing the interplay of facial muscles, skin texture and elasticity, brow position, the degree of excess skin, the presence of under-eye bags or festoons, and the overall condition of the brow and forehead. Based on this assessment, she will recommend one or more of the following approaches.
Upper Lid “Pinch” Blepharoplasty
Upper eyelid surgery is performed through an incision placed within the natural fold of the upper eyelid crease, extending slightly past the outer corner to fall within an existing laugh line. Only excess skin that can be gently pinched together is removed — thus the term “pinch blepharoplasty”, which is a skin-only procedure. Because the incision follows the natural eyelid crease, it heals to be nearly invisible over time — particularly with makeup or when wearing glasses. Through this incision, loose skin is removed to restore a refreshed, more youthful upper lid contour, but maintenance of a normal appearance to the eyes.
Lower Lid Blepharoplasty
Lower eyelid surgery may be performed using one of two approaches, depending on anatomy and the degree of skin laxity:
- Subciliary Lower Lid Lift: An incision is placed just below the lower lash line, allowing removal of excess skin and/or repositioning or removal of underlying fat. The incision heals nearly imperceptibly beneath the lashes. This is the technique most commonly performed by Dr. Horton.
- Transconjunctival Lower Lid Lift: An incision is made inside the lower eyelid, hidden within the conjunctiva — the thin membrane lining the lower lid. This approach redistributes or removes excess lower lid fat without removing skin, and is ideal for patients with good skin elasticity.
Four-Lid "Quad" Blepharoplasty
Surgery of all four eyelids — commonly called a “quad” blepharoplasty — addresses both the upper and lower lids in a single procedure. The lower lids may be approached via either the subciliary or transconjunctival method, depending on individual anatomy.
Nonsurgical "Liquid Eye Lift"
For patients who prefer a non-surgical option, modest rejuvenation of the eye area can be achieved using neuromodulator injectables such as BOTOX Cosmetic and/or dermal fillers to soften depressions, deep creases, or hollows above or below the eyes. Selective muscle relaxation can also gently elevate the outer brow, also known as a “Botox brow lift”. This can subtly open the eyes, giving them an overall refreshed appearance. Non-surgical treatments improve the eye area both at rest and with animation and can last from several months to a year or more.
Other non-surgical treatment options for the eye area include microneedling and laser resurfacing of the skin around the eyes, which can stimulate collagen and improve fine lines and wrinkles.
Non-surgical injectable and aesthetic treatments at our practice are performed by our skilled Nurse Practitioner Emily Sespaniak, NP, Please visit our Minimally Invasive Procedures section to learn more.
The Blepharoplasty Procedure
For detailed information about what to expect on the day of surgery, please visit our Preparing for Surgery section.
Blepharoplasty is performed in the operating room under local anesthesia with an oral anti-anxiety medication and inhaled laughing gas, or under general anesthesia combined with local anesthesia — particularly when eyelid surgery is combined with other procedures. As with all aesthetic Plastic Surgery procedures of the face, Dr. Horton performs blepharoplasty under surgical loupe magnification to ensure exceptional precision and careful attention to detail.
After administering local anesthesia with epinephrine to minimize bruising, the delicate eyelid skin is gently separated from the underlying tissue. Excess eyelid skin is surgically excised as needed, small blood vessels are carefully sealed using low-energy pinpoint electrocautery, and eyelid skin is precisely trimmed and smoothly redraped without tension. Fine sutures are placed beneath the eyelid skin and are typically removed within one week to prevent visible suture marks.
Eyelid surgery is performed on an outpatient basis and takes approximately one to two hours, depending on the complexity of the procedure. Most patients find the experience comfortable, with minimal pain. Prescription pain medication is provided for post-surgical discomfort, though many patients do not require it.
Recovery After Eyelid Surgery
Initial healing after blepharoplasty may include eyelid swelling, bruising, tearing, eye irritation, light sensitivity, or dry eyes — all of which are managed with medication, cold compresses, and lubricating ointment or drops. Some initial asymmetry from uneven swelling is normal and resolves as healing progresses.
Key recovery milestones include:
- Week 1: Sutures are removed in the office. Cool compresses — not ice (keep cool packs in the fridge rather than the freezer) are applied directly to the eyelids — to help manage swelling. Large sunglasses can conceal bruising while healing.
- Weeks 1–2: Concealing makeup may be applied. Bruising tends to follow gravity and may descend to the lower lids and cheeks, even when only the upper lids are treated. Some patients wear glasses or get eyelash extensions to draw attention away from healing incisions.
- Months 1–6: Full results develop gradually as swelling resolves and incision lines continue to fade. Blepharoplasty incisions typically heal with virtually undetectable scars, owing to the delicate nature of eyelid skin and the robust blood supply of the face.
Sleeping with the head elevated (2-3 extra pillows) helps speed the resolution of post-operative swelling. To prevent hyperpigmentation and sun damage, strict sun avoidance and consistent use of a broad-spectrum SPF 30 or higher sunscreen are essential. Makeup may be applied over sunscreen beginning one week after surgery.
For complete recovery guidance, please review our Postoperative Instructions and Special Instructions for Facial Plastic Surgery sections.
Dr. Horton’s Scar Therapy Protocol
Dr. Horton’s comprehensive Scar Therapy Protocol emphasizes protecting the delicate skin around the eyes from sun exposure during healing and as an ongoing habit. Wearing dark sunglasses after surgery shields healing skin, enhances comfort, and helps preserve long-term results. Medical-grade skincare products recommended for post-operative skin protection are available through our practice as part of our Medical-Grade Skin Care regimen.
What to Expect from Your Results
Blepharoplasty results reveal smoother, more contoured eyelids and a rejuvenated eye area, contributing to a brighter and more youthful appearance. While early improvements are visible relatively soon after surgery, full results develop gradually over several months to a year as healing completes and incision lines continue to fade.
The results of blepharoplasty are long-lasting. While the natural aging process continues following any facial Plastic Surgery procedure, your eyes will always look younger than they would have without surgery. The outcome is designed to appear natural — never tight, overdone, or artificial.
To extend the benefits of your blepharoplasty, maintaining a consistent skincare routine, practicing diligent sun protection, and incorporating non-surgical rejuvenation treatments can be highly effective. Regular follow-up appointments with Dr. Horton ensure your results are monitored and optimized over time.
Before and After Photos
Before and after eyelid surgery results will be reviewed during your consultation. Your own preoperative and postoperative photos will be reviewed with you during follow-up visits and can be shared with you securely through the Symplast patient App, our secure digital platform for sharing your surgical journey privately and conveniently.
Combining Blepharoplasty with Other Procedures
While blepharoplasty focuses on rejuvenating the eyelid area, it does not address concerns in other regions such as the brow, mid-face, cheeks, neck, or jawline. A thorough facial assessment during your consultation will help determine which additional procedures may complement your goals.
Blepharoplasty results are often enhanced by combining it with:
- Facelift: Targets aging in the mid-face, smoothing wrinkles and lifting sagging cheeks for a rejuvenated appearance.
- Neck Lift: Restores definition to the jawline, eliminates jowls, and tightens loose neck skin for a youthful contour.
- Earlobe Repair: Rejuvenates or repairs stretched or aging earlobes, contributing to overall facial balance.
- Non-surgical options including BOTOX Cosmetic, dermal fillers, laser resurfacing, IPL photofacials, microneedling, medical-grade peels, and medical-grade skincare can also be incorporated before or after surgery to enhance and extend your results. These treatments are performed by our Aesthetic Nurse Practitioner, Emily Sespaniak, NP.
Why Choose Dr. Karen Horton for Blepharoplasty in San Francisco
Dr. Karen Horton, MD, MSc, FACS, is a Board-Certified Plastic Surgeon certified by both the American Board of Plastic Surgery (ABPS) and the Royal College of Physicians and Surgeons of Canada (RCPSC) — making her one of a select group of surgeons to hold dual international board certification in Plastic Surgery. She has been in private Plastic Surgery practice in San Francisco since 2006.
Dr. Horton completed her medical degree at the University of Toronto, followed by a competitive five-year Integrated Residency in Plastic Surgery, and additional Fellowship training in Reconstructive Microsurgery at The Buncke Clinic — one of the world’s premier Microsurgery centers, located in San Francisco. This advanced training in precision tissue handling directly informs her meticulous approach to blepharoplasty, where every incision is placed under surgical loupe magnification and every result is designed to look naturally refreshed.
Her recognition and professional affiliations include:
- SFGATE Best of the Bay 2025 & 2026 — Voted Best Cosmetic/Plastic Surgeon in the Bay Area; also awarded Best Medical Spa 2025
- Castle Connolly Top Doctor since 2019
- Marin Magazine Top Doctor
- Active Member, American Society of Plastic Surgeons (ASPS)
- Active Member, The Aesthetic Society
- Fellow, American College of Surgeons (FACS)
Frequently Asked Questions About Blepharoplasty
The results of blepharoplasty are long-lasting. While the natural aging process continues, your eyes will always look younger and better than they would have without the procedure. Maintaining a good skin care routine, practicing diligent sun protection, and incorporating non-surgical rejuvenation treatments can extend your results significantly. Regular follow-up appointments with Dr. Horton ensure your results are monitored and optimized in the short and long term.
Yes. While blepharoplasty focuses on the eyelid area, it is commonly combined with a Brow Lift, Facelift, Neck Lift, or other facial procedures to address concerns beyond the eyes. During your consultation, a thorough facial assessment will help determine which additional procedures may complement your goals. Please see the Combining Blepharoplasty with Other Procedures section above.
Non-surgical cosmetic treatments are often combined with blepharoplasty to enhance and extend its results. Common options include BOTOX Cosmetic, dermal fillers, laser resurfacing, IPL photofacials, microneedling, medical-grade peels, and medical-grade skin care — all of which can address fine lines, volume loss, and skin texture. Please visit our Minimally Invasive Cosmetic Enhancements and Medical-Grade Skin Care sections to learn more.
As with any surgical procedure, blepharoplasty carries potential risks, including temporary swelling, bruising, dry eyes, light sensitivity, and asymmetry during healing. Rare but serious complications can include changes in
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vision.
Before undergoing surgery, it is essential to be well-informed. For a detailed overview, please visit our Preparing for Surgery section, which includes information on general surgical risks, Special Considerations for Facial Plastic Surgery, and Postoperative Instructions tailored to blepharoplasty.
Dr. Horton takes a personalized approach to blepharoplasty, focusing on the connection between appearance and self-confidence. During your consultation, she will review your medical history, assess your concerns, and evaluate factors such as eyelid skin texture, elasticity or bagginess, brow position, facial bone structure, and depth and degree of facial wrinkles. Based on this assessment, she will design a customized treatment plan and recommend the most effective surgical technique.
It is important to note that blepharoplasty does not address dark circles, fine lines, or crow’s feet — which are better treated with non-surgical options such as dermal fillers, BOTOX, and advanced skin care. An upper eyelid lift also does not correct drooping brows or forehead sagging caused by brow ptosis (droop). If these issues are present, a brow lift may be recommended alongside or instead of blepharoplasty. Please explore our Minimally Invasive Cosmetic Enhancements and Medical-Grade Skin Care sections for non-surgical options.
This is one of the most common points of confusion for patients exploring eyelid rejuvenation. While both procedures can improve the appearance of a heavy or tired upper eye area, they address different anatomical concerns. Blepharoplasty removes excess skin from the eyelids themselves, whereas a brow lift repositions a descended brow that may be pushing skin downward onto the upper lid. In some cases, what appears to be excess eyelid skin is actually the result of brow ptosis — and treating the eyelid alone would not fully address the concern. During your consultation, Dr. Horton carefully evaluates both the eyelids and the brow together to determine the true source of the heaviness and recommend the most appropriate treatment, whether that is blepharoplasty, a brow lift, or a combination of both.
Mild eyelid asymmetry is extremely common and entirely normal — virtually no one has perfectly symmetrical eyes. In many cases, blepharoplasty can improve the appearance of unevenness caused by differences in skin laxity, fat distribution, or muscle tone between the two eyelids. However, it is important to understand that blepharoplasty is not designed to create perfect symmetry, and some degree of natural variation will always remain.
On occasion, eyelid asymmetry is actually due to an anatomical issue: levator muscle stretch or dehiscence from the tarsal plate in the upper eyelid — in this case, you will be referred to an Ophthalmological surgeon for a formal assessment, as skin-only blepharoplasty does not correct functional aponeurotic ptosis. Dr. Horton will thoroughly assess your eyelid anatomy during your consultation and set realistic expectations for what surgical correction can achieve in your specific case.
A well-performed blepharoplasty should have no negative impact on your natural facial expressions. Because the procedure is carefully designed to remove only the appropriate amount of skin and tissue — never too much — the eyelids retain their full range of motion and expressiveness. Patients frequently report that their eyes actually appear more expressive (and makeup application becomes fun again!) after surgery, as the overhang of excess skin no longer obscures the natural lid contour. The goal is always a result that moves naturally with your face.
Non-surgical treatments such as laser resurfacing, radiofrequency, and injectable fillers can address certain concerns around the eye area — including fine lines, skin texture, and mild volume loss — but they cannot replicate the structural correction that surgery provides. Excess skin cannot be tightened away with energy-based devices alone, and fat herniation causing under-eye bags cannot be corrected with filler. Surgical blepharoplasty remains the gold standard for addressing significant skin laxity and persistent under-eye bags. That said, non-surgical treatments are excellent complements to surgery and are often incorporated into a comprehensive treatment plan before or after your procedure. Dr. Horton and her team will help you determine which approach — or combination of approaches — is right for your goals.
The cost of blepharoplasty varies depending on the complexity of your procedure, whether upper lids, lower lids, or all four lids are being addressed, and whether it is being combined with additional surgical or non-surgical treatments. A personalized quote will be provided following your consultation, once Dr. Horton has evaluated your anatomy and recommended a treatment plan tailored to your needs.
Contact Us
Ready to take the next step toward brighter, more refreshed eyes? Dr. Karen Horton and her team welcome patients from San Francisco, the Bay Area, Marin County, and throughout Northern California. Schedule your personalized blepharoplasty consultation today and discover what a difference natural, beautifully refined eyelid surgery can make.
