What are surgeons actually doing behind the drape when it comes to blepharoplasty? A recent review of over 3,000 cases from the ABPS continuous certification program gives us the clearest picture yet of this high-volume aesthetic procedure.
The 15-year data show how practice has evolved and where it still lags behind current evidence. If you’re still following old playbooks, this may be your cue to recalibrate. This week, Surgical Aesthetics 411 breaks down national practice patterns and evidence-backed techniques shaping modern blepharoplasty.
Office-Based Procedures Are the New Norm
Between 2005 and 2020, blepharoplasty moved firmly into the outpatient world. Office-based procedures jumped significantly, from 24% in the early cohort to 31% in the recent one, reflecting increased surgeon confidence in local anesthesia and streamlined surgical protocols. Hospital cases dropped, and surgical times shortened by 13 minutes on average.
Why does this matter? It’s a clear sign that minimalism is winning. Simpler procedures under local anesthesia are more efficient, cost-effective, and attractive to a growing subset of cosmetic patients who prefer in-and-out experiences.
Yet, this shift also means surgeons must sharpen their risk assessment skills. Office-based surgery demands stricter patient selection and precise intraoperative judgment. Patients with dry eye, poor lid tone, or asymmetries may not be ideal. And with less room for error, surgeons must be ready to adjust techniques on the fly, from resection depth to adding canthal support, all without the safety net of general anesthesia.
Upper Lid Blepharoplasty: More Skin, Less Fat
Upper blepharoplasty now favors preservation over excision. Skin-only resections are up (78% to 82%), while aggressive fat and muscle removal is down. Retro–orbicularis oculus fat (ROOF) resections remain rare (<4%), perhaps reflecting a growing awareness of the long-term aesthetic consequences of hollowing the upper orbit. Volume maintenance has finally become mainstream.
Interestingly, brow lifts remain underutilized despite clear evidence that lid ptosis and lateral hooding often coexist. Only 14–16% of blepharoplasty cases involved any form of brow elevation. This may reflect patient hesitancy but also may point to a broader trend among peers: Surgeons are increasingly relying on isolated blepharoplasty to deliver comprehensive rejuvenation, even when adjunctive procedures might yield superior results.
Lower Lid Blepharoplasty: Traditional Technique Still Dominates
Despite the literature’s growing endorsement of transconjunctival fat repositioning and septal reset techniques, the data show most surgeons haven’t made the leap. Use of skin–muscle flaps and transcutaneous fat removal has declined slightly in recent years, but both remain staple techniques in lower lid blepharoplasty.
This adherence to traditional methods, especially the Friedland skin–muscle flap approach without canthal support, likely reflects a cautious approach to lower lid surgery. Surgeons continue to avoid complex vector adjustments or volume manipulation unless strictly necessary. That said, this conservatism may miss opportunities to fully correct tear trough deformities or lid–cheek transition issues.
Where’s the Canthal Support?
Surprisingly, 82% of surgeons skip canthal tightening altogether, despite widespread consensus that any lower lid work should be accompanied by lid support when laxity is present. It’s unclear whether this is due to surgeon oversight, patient anatomy, or confidence in technique, but it does raise valid concerns about long-term lid positioning and the risk of scleral show.
Given that lid malposition was reported in only a small percentage of cases (ectropion in 0.4%), it’s possible that surgeons are accurately selecting low-risk patients. Still, a more routine use of suture canthopexy or lateral retinacular suspension might further mitigate complications, especially in older patients or those with a negative vector.
Concomitant Procedures Are Dwindling
Blepharoplasty is increasingly a standalone procedure. Concomitant face lifts, midface repositioning, and injectables were all significantly less common in the recent cohort. This likely reflects a combination of office-based workflow constraints and targeted patient desires. However, it may also represent a missed opportunity: Patients presenting for periorbital aging often benefit from a more holistic approach.
Surgeons should consider whether they’re defaulting to simplicity at the expense of synergy. Strategic use of injectables, resurfacing, or brow work, especially in select office-based cases, could significantly elevate outcomes with minimal added risk.
Less Antibiotics, Minimal DVT Prophylaxis
Antibiotic use dropped from 87% to 67%, signaling a trend toward antibiotic stewardship. The literature supports this move: Blepharoplasty is a clean case, and routine antibiotics offer limited benefit. However, topical agents are still advisable when mucosal incisions are involved.
DVT prophylaxis remains inconsistent. SCD use post-induction dropped significantly, with many surgeons skipping it entirely unless operating under general anesthesia. Given the short duration of most blepharoplasties (now averaging ~100 minutes), this risk-based approach seems reasonable, but vigilance is still warranted, especially for patients with known coagulopathies.
Complication Rates Stay Low, But Follow-Up Is Limited
Complications occurred in just 14% of cases, with serious adverse events like retrobulbar hematoma (0.04%) or visual loss (0.1%) being exceedingly rare. The most common minor issues included chemosis (3%), asymmetry (2%), and symptomatic dry eye (2%).
However, a key limitation of this dataset is that it doesn’t capture long-term follow-up for the recent cohort. Delayed complications and revisions likely go underreported, limiting the dataset’s full scope. Still, the numbers align with clinical expectations and underscore the overall safety of blepharoplasty when performed by certified surgeons.
What This Means for Your Practice
Let this review serve as a real-time benchmark for your own practice. The data show that national practice has evolved toward shorter, office-based, more conservative blepharoplasties, with a lag in adopting certain modern techniques supported by recent literature.
With that in mind, you might ask yourself:
- Are you balancing efficiency with thorough patient evaluation and individualized technique?
- Are you offering adjunctive treatments like fat repositioning or brow lift when indicated?
- Do you rely too heavily on traditional techniques when newer approaches might serve select patients better?
- Are you evaluating lid laxity consistently and modifying your technique based on that risk?
- Have you reexamined your antibiotic and DVT protocols in light of updated guidelines?
- Are your office-based workflows limiting the range of adjunctive procedures you might consider?
Staying current doesn’t mean chasing every trend, but it does mean revisiting your technique and decision-making regularly. Use this data to reflect, recalibrate, and refine. Treat every case as a decision tree. Trends like shorter procedures and office-based settings may change the landscape, but the core responsibility of getting it right, every time will never change.
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SOURCES: Plastic and Reconstructive Surgery, ASPS, Plastic and Reconstructive Surgery, Plastic and Reconstructive Surgery
