Upper vs Lower Blepharoplasty: Which Eyelid Surgery Do You Actually Need?
By Dr. Rushapol Sdawat, MD — Thai Board-certified Plastic and Reconstructive Surgeon, Medical Licence No. 17689
Last reviewed: AUG 2026
You have started pulling the skin at the outer corner of your eye upwards with a finger to see what you would look like, probably in a car mirror at some point. Perhaps eyeshadow no longer stays where you put it. Perhaps someone at work asked whether you were tired on a day you had slept nine hours. Almost every eyelid consultation I do begins with one of those three observations.
What follows is a question you cannot answer on your own: is this an upper eyelid problem or a lower eyelid problem? They sound like two halves of one operation. They are not — different anatomy, different incisions, different anaesthetic, different recovery, and, most importantly, different complications. Confusing them is the commonest reason people arrive asking for the wrong surgery.
I am going to take these apart properly, give you tests you can do at a mirror before you speak to anybody, and tell you where the honest answer is that you should have this done in Australia rather than in Bangkok.
The two operations share a name and almost nothing else
Blepharoplasty means surgical modification of the eyelid. The word tells you nothing useful.
An upper blepharoplasty removes a measured ellipse of skin from the upper lid, sometimes with a strip of orbicularis oculi muscle and a small amount of medial fat. The incision sits inside the natural lid crease. It takes about an hour for both sides, is very often done under local anaesthetic with the patient awake, and the bruising is usually settled enough for normal life within two weeks.
A lower blepharoplasty is a different animal. The problem in the lower lid is almost never excess skin alone. It is usually herniation of the orbital fat pads forward through a weakening orbital septum, combined with descent of the cheek and hollowing at the tear trough — the groove running down and out from the inner corner. Correcting that means working at the orbital rim, either from behind the lid through the conjunctiva or through a fine incision just under the lashes. It is longer, usually needs general anaesthetic or sedation, swells far more, and carries the complication that genuinely frightens eyelid surgeons: pulling the lower lid down and out of position.
If you take nothing else from this article: an upper blepharoplasty is a skin operation; a lower blepharoplasty is a support operation.
What is actually causing your upper lid problem: skin, fat, muscle or brow?
Four things can produce a heavy upper lid, and they need different answers.
Dermatochalasis — genuine excess upper lid skin, sometimes resting on the lashes. This is what upper blepharoplasty is for.
Medial fat pad herniation — soft fullness at the inner third of the lid. Small volumes of fat can be reduced here, carefully.
Brow descent — the eyebrow has dropped, and the tissue crowding your lid is forehead skin that has migrated south. Cutting lid skin does not fix this and can make it worse.
Blepharoptosis — the lid margin sits low because the levator muscle or its aponeurosis has stretched. This is a lid-lifting problem, not a skin-removing one. Remove skin from a ptotic lid and you get a tidier eye that still cannot open properly.
These coexist constantly. Perhaps half the upper lids I assess have two of the four.
Four tests you can do at a mirror in the next five minutes
Do these in even, front-on light, face relaxed and forehead still. That last part is harder than it sounds — most people with heavy lids have been unconsciously lifting with the forehead for years.
The forehead-hold test. Press one palm flat and firmly across your forehead so the eyebrows cannot move, then open your eyes normally. This is your true starting position; everything below is judged from here.
The finger-lift test. Forehead still held, lift the tail of one eyebrow two or three millimetres with a fingertip. If the hooding largely disappears, a significant part of your problem is brow position. If the lid skin still hangs, it is lid skin.
The crease test. Can you see your upper lid crease at all? If skin drapes over and hides it, that is dermatochalasis. If the crease is visible but high and the lid margin covers more than the top edge of your iris, consider ptosis.
The lower lid pull test. Draw the lower lid down away from the eye and let go without blinking. It should snap straight back. If it drifts back slowly, your lower lid is lax — and operating on a lax lid without adding support is how eyelids get pulled out of shape.
None of this replaces an examination. It does mean you walk into a consultation able to say "I think this is brow, not lid" and see whether the surgeon agrees or talks past you.
What causes a lower lid bag — and why it is rarely skin
Look in a mirror, then lie down and look again. If your under-eye bags soften noticeably when you are flat, you are looking at fat that moves with gravity. If the shadow stays, you are largely looking at a hollow: volume loss and a visible bony rim, not a bag at all.
That distinction changes the whole operation. A protruding fat pad may need repositioning over the rim. A hollow needs volume added or the lid–cheek junction blended, and removing anything at all will make it worse. A great many people who ask for "eye bag removal" have hollowing, and the wrong operation on them produces a skeletonised lower lid that is extremely difficult to undo.
Excess lower lid skin does exist and can be conservatively trimmed, but the amount that can safely be removed is usually two or three millimetres. Beyond that you are borrowing tension from a structure with no spare.
Upper versus lower blepharoplasty compared
Upper blepharoplastyLower blepharoplastyMain targetExcess skin (dermatochalasis), sometimes medial fatHerniated orbital fat, tear-trough hollowing, lid–cheek junctionIncisionInside the upper lid creaseBehind the lid (transconjunctival) or just below the lashes (subciliary)AnaestheticUsually local, patient awakeUsually general or sedationOperating time45–60 minutes60–120 minutesBruising and oedemaModerate, mostly gone by 10–14 daysMore marked; 2–4 weeksBack at work10–14 days2–3 weeksDefining complicationOver-resection causing lagophthalmosEctropion or lid retractionReversing an over-correctionVery poorVery poor, and technically harderCan Medicare ever apply?Yes, MBS 45617, strict criteriaRarely — MBS 45620 is much narrowerUsually combined withBrow liftMidface support or fat grafting
Can Medicare pay for this? MBS item 45617 and what it actually requires
Yes — sometimes, for the upper lid, and it genuinely matters, because it may mean you should have this operation at home rather than overseas.
MBS item 45617 covers upper eyelid reduction where the reduction is for one of a defined list: a history of demonstrated visual impairment; intertriginous inflammation of the eyelid; herniation of orbital fat in exophthalmos; facial nerve palsy; post-traumatic scarring; or restoring symmetry with the other lid after one of those. It also requires that "photographic and/or diagnostic imaging evidence demonstrating the clinical need for this service is documented in the patient notes."
One point is routinely reported wrongly, including by clinics that should know better. The item used to require a visual field test confirmed by an optometrist or ophthalmologist. That requirement was removed on 1 November 2022 and replaced by documented history of demonstrated visual impairment, because patients were being unintentionally excluded from claiming. Formal visual fields are still commonly requested and are still good evidence — they are simply no longer the written gatekeeper.
The Schedule fee for item 45617 is A$281.40. Read that carefully: the Schedule fee is the government's benchmark, not the cost of the surgery and not what you will be charged. What the item number really unlocks is a possible private health insurance hospital benefit and rebates on the anaesthetic and theatre components, which is where the meaningful money sits.
The lower lid equivalent, MBS item 45620, has much narrower grounds — herniation of orbital fat in exophthalmos, facial nerve palsy, post-traumatic scarring, or symmetry with the other lid. Ordinary age-related lower lid bags do not qualify.
If your upper lids obstruct your vision and you are Australian, get assessed at home first. Medicare does not cover overseas medical treatment, and Australia has no reciprocal health agreement with Thailand. A functional upper blepharoplasty performed in Bangkok attracts no rebate at all, and you will have paid for something you may have been entitled to have subsidised.
The complications I make every patient repeat back to me
Dry eye is not a footnote. A ten-year single-surgeon review of 892 blepharoplasty cases published in JAMA Facial Plastic Surgery in 2013 found dry eye symptoms in 26.5% and chemosis — swelling of the conjunctiva — in 26.3%. Post-operative lagophthalmos raised the dry eye rate from 22.9% to 42.3%, and doing upper and lower lids in the same sitting was a risk factor for both. If you already have dry eye, tell your surgeon before you tell them anything else.
Also: prolonged oedema and bruising; a visible or thickened crease scar; asymmetry, which is extremely common early and usually settles by three months; suture cysts; wound infection; haematoma; lid margin numbness; and a change in crease height you did not ask for.
Then the ones that matter most. Over-resection of upper lid skin causes lagophthalmos — the lid will not fully close, particularly at night, and the eye dries, waters and can ulcerate. Skin removed from an eyelid cannot be replaced with anything that looks like eyelid skin. Ectropion and lid retraction with visible white sclera below the iris are the corresponding lower lid disasters, both far likelier if lid laxity was not recognised beforehand. One large transcutaneous series reported symptomatic lid malposition in 0.4% of 2,007 patients over 30 years — which tells you it is uncommon in careful hands and nothing about careless ones. Rarest and worst is orbital haemorrhage behind the eye, reported at roughly one in 2,000 cosmetic periocular operations, with permanent vision loss at roughly one in 22,000.
And one that never appears on consent forms: a result you are technically fine with but emotionally disappointed by. Eyes carry identity. A perfectly executed blepharoplasty can leave someone feeling they no longer look like themselves. I would rather under-correct and reoperate at six months than chase that.
What it costs at Intrarat Hospital, and who I decline
Our published prices, indicative in Australian dollars and Thai baht and confirmed at booking, are double eyelid surgery under local anaesthetic A$1,400 / ฿32,000 and upper and lower eyelid surgery under general anaesthetic A$4,800 / ฿110,000.For upper lids alone, a written quotation is given at consultation. All surgery carries risks. Individual results vary from person to person and are not guaranteed. A consultation and assessment with your surgeon is required before any procedure.
I decline eyelid surgery in several situations, and I would rather set them out here than in the room. Active thyroid eye disease not stable for at least six months. Significant untreated dry eye, or laser refractive surgery within six months. Unrecognised ptosis where the patient wants only skin removed. A lax lower lid where the patient refuses canthal support. Anyone whose reason for surgery is that a specific other person will find them more acceptable afterwards. And anyone flying home too soon — ASAPS advises that in Australia and New Zealand patients are told not to fly for six to eight weeks after surgery, and while eyelid surgery sits at the gentler end of that spectrum, a ten-hour flight at day four with fresh sutures and dry cabin air is not a plan.
When to seek care
Come back to whoever operated on you, or to an emergency department if you cannot, for any of the following.
Emergency — go to a hospital immediately, day or night. Sudden severe deep pain behind the eye. Rapidly increasing swelling with a tight, hard, forward-bulging eye. Loss of vision, a dark curtain, or new double vision. These suggest an orbital haematoma, and there is a short window in which pressure can be released. Do not wait for morning, do not wait for a flight, and do not message a coordinator and go back to bed.
Same-day review. Bleeding through dressings. Fever above 38 degrees. Spreading redness, heat and increasing pain after day three, when things should be improving. Pus at the incision. A lid that will not close over the eye at all. Asymmetry that appeared overnight.
Within a few days. A gritty, burning, watering eye not settling with lubricant drops. A lower lid margin starting to sit lower than it did last week. A scar becoming raised, red and itchy at week three to six.
In a Bangkok hotel, contact the hospital directly rather than the person who arranged your trip. Back in Australia or New Zealand, present locally and do not delay because your surgeon is overseas — bring your operation note and drug chart, and be aware that Australian private health insurance generally does not cover procedures performed overseas and may not cover the follow-up either.
How I would work through this if you were sitting in front of me
I would hold your forehead still, because everything else is unreliable until I do. I would check lid margin position against your iris, look for a crease, measure levator function, pull the lower lid and watch how fast it returns, and ask about dry eye, contact lenses and thyroid disease before looking at a photograph.
Then I would tell you which of the four upper lid problems you have and in what proportion, whether your lower lid issue is fat, hollow or descent, and whether the operation that would help you most is the one you came in asking for. Often it is not. Sometimes it is a brow. Occasionally it is nothing at all, and the consultation ends without a booking.
I am a Thai Board-certified plastic and reconstructive surgeon practising at Intrarat Hospital, Bangkok — Medical Licence No. 17689, verifiable on the Medical Council of Thailand register at checkmd.tmc.or.th. Diploma of the Medical Council of Thailand certifying proficiency in Plastic Surgery (13 July 2000); full member of The Society of Plastic and Reconstructive Surgeons of Thailand since 2001; ISAPS member since 2008. International training includes the AO Foundation course in advances in rhinoplasty and facial osteotomy, the International Plastic Surgery Training Center (malarplasty and angle reduction) and the safe use of laser-assisted lipolysis at Goldman Butterwick & Associates, San Diego. I hold Thai specialist certification and am not registered with Ahpra or the Medical Council of New Zealand.
This article is provided for general information and education. It is not medical advice and cannot substitute for individual assessment by a qualified practitioner who knows your history. Surgery carries risk, including risk of serious complications and of outcomes that do not meet expectations. Results vary between patients.
