First author:Abstract
Purpose:
To assess the impact of upper eyelid blepharoplasty on patient-reported outcomes related to functional vision, esthetics, and psychosocial wellbeing in a large patient cohort and to contribute comprehensive PROM (Patient-Reported Outcome Measure)-based data to the literature.
Design:
Retrospective, observational case series.
Methods:
This retrospective observational study included 970 patients who underwent upper eyelid blepharoplasty at a single tertiary care center between 2017 and 2023. Inclusion criteria were dermatochalasis with visual or psychosocial complaints. Patients with prior periocular surgery or incomplete follow-up were excluded.
Intervention or Observation Procedure(s):
All procedures were performed by the same experienced oculoplastic surgeon using a standardized upper blepharoplasty technique.
Main Outcome Measure(s):
Patient-reported outcomes were collected via a structured postoperative questionnaire evaluating daily visual function, mirror appearance satisfaction, social confidence, and overall wellbeing.
Results:
Of 970 patients (82.9% female, mean age 54.7 ± 9.8 years), 93.3% reported “Good” to “Very Good” improvement in functional vision and daily activity performance. High satisfaction was reported with mirror appearance (96.9%), social confidence (94.7%), and general quality of life. Notably, 96.8% of participants indicated they would recommend the procedure. These results were consistent across age and gender subgroups.
Conclusions:
Upper eyelid blepharoplasty significantly improves not only esthetic satisfaction but also functional vision and psychosocial wellbeing. These findings, based on a large sample and structured PROMs, reinforce the classification of blepharoplasty as a procedure with therapeutic, not merely cosmetic, benefits. Further prospective studies may strengthen these findings.
Keywords: Esthetic satisfaction, functional improvement, patient-reported outcome, quality of life, upper eyelid blepharoplasty, visual function
Upper eyelid dermatochalasis is a common age-related condition characterized by excessive skin laxity and protrusion of orbital fat, often resulting in cosmetic and functional disturbances. In addition to contributing to facial aging, dermatochalasis may cause narrowing of the superior visual field, subjective eyelid heaviness, compensatory frontalis overuse, and tension-type headaches due to compensatory frontalis muscle activation.[1,2,3]
Upper eyelid blepharoplasty is one of the most frequently performed esthetic surgeries worldwide and is increasingly indicated for both cosmetic and reconstructive purposes.[4,5] While it has been shown to improve objective parameters, such as visual fields, contrast sensitivity, and astigmatism, patient-reported outcomes, including satisfaction and quality of life, have become increasingly recognized as essential metrics of surgical success.[2,3]
Several studies have demonstrated that upper blepharoplasty significantly enhances not only physical function but also patients’ self-perception and psychosocial wellbeing.[4,5] In particular, the FACE-Q[6] and other patient-reported outcome measures (PROMs) have been instrumental in documenting the multidimensional benefits of this procedure,[7] regardless of the severity.[4] Furthermore, utility-based cost-effectiveness analyses have supported blepharoplasty as a value-based intervention in appropriately selected patients.[1]
Despite these findings, the majority of prior studies were limited by small sample sizes and short follow-up durations, often ranging from 30 to 150 patients.[8,9] Large-scale, real-world patient-reported outcome data are needed to better characterize the subjective impact of upper eyelid blepharoplasty on daily life and satisfaction.
The present study aimed to fill this gap by evaluating the quality-of-life outcomes in a large cohort of 970 patients who underwent upper blepharoplasty using a structured 7-item patient-reported outcome questionnaire developed thematically in line with established PROM domains. By focusing on functional improvement, cosmetic satisfaction, and psychosocial impact, this study offers robust insight into the patient experience following upper eyelid surgery.
Methods
This descriptive cross-sectional study included 970 patients who underwent upper eyelid blepharoplasty at our tertiary care center between 2017 and 2023. All procedures were performed by a single experienced oculoplastic surgeon, which ensured technical standardization and uniform postoperative follow-up. The study was approved by the local ethics committee and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all the participants, and signed consent forms are on file. All participants were of self-identified Caucasian ethnicity, representative of the regional demographic profile in a tertiary care center. There was no ethnic heterogeneity in the study sample.
Patients were eligible if they underwent upper blepharoplasty for either esthetic or functional indications and were able to complete the postoperative questionnaire. Exclusion criteria included concomitant periocular procedures (e.g., ptosis repair, brow lift), congenital eyelid anomalies, prior eyelid surgery, or incomplete data. Patients with untreated acquired ptosis and those with a history of prior nonsurgical periocular procedures, including botulinum toxin injections or dermal fillers, were excluded from the study. Completion of the postoperative patient-reported outcome questionnaire was part of the routine clinical follow-up protocol for all patients undergoing upper eyelid blepharoplasty at our institution.
All procedures were performed under local anesthesia (2% lidocaine with epinephrine), with the patient initially in a seated position for preoperative marking, followed by supine positioning for surgery. Preoperative markings were made while the patient was seated based on the desired crease height (typically 6–8 mm), and the degree of dermatochalasis was measured using a pinch test and smooth forceps.
The incision line was marked with an ultrafine surgical skin marker (1 mm). After aseptic preparation, an incision was made along a marked line through the skin and subcutaneous tissue. To define the pretarsal crease, the orbicularis oculi muscle was preserved, and limited superficial cauterization was applied only when necessary to enhance crease visibility. When indicated, redundant nasal fat pads were accessed via the orbital septum and conservatively excised.
Layered closure was performed using 6-0 monofilament sutures. In selected cases requiring additional crease support, limited involvement of the levator aponeurosis was performed for crease definition; however, no formal levator strengthening procedures, such as levator plication or ptosis repair, were undertaken. Continuous skin sutures were then placed, and the patient was moved into a seated position to verify crease symmetry and esthetic outcome.
Postoperative instructions included the application of cold compresses for 48 hours (10 minutes per hour), topical fusidic acid ointment twice daily for 5 days, lubricating eye drops as needed, and oral analgesics. Sutures were removed on postoperative day 7.
The patient-reported outcome questionnaire used in this study was independently developed to assess functional, esthetic, and psychosocial changes following upper eyelid blepharoplasty. Its conceptual structure was informed by established domains from validated PROMs, particularly those assessed by the FACE-Q framework,[6] such as Appraisal of Upper Eyelids, Satisfaction with Eyes, Psychological Function, and Social Function. Importantly, the questionnaire was not adapted or modified from the original FACE-Q instrument and was not intended to replicate its psychometric properties. No items were reproduced, adapted, or modified from the original FACE-Q instrument, and therefore, no permission from the FACE-Q developers was required. Surgical success was defined as patient-reported improvement in functional vision and/or esthetic satisfaction without the need for revision surgery during the follow-up period.
To enhance its relevance in routine clinical practice, one additional item assessing patients’ willingness to recommend the procedure was included, an element not captured in FACE-Q. Thus, the instrument used in this study represents a simplified, face-specific PROM inspired by the thematic scope of FACE-Q.[6]
Patients completed a structured seven-item questionnaire postoperatively, covering the following domains:
Ability to perform daily activities
Overall quality of life
Visual field improvement
Satisfaction with appearance in the mirror
Social confidence
Changes in makeup use
Willingness to recommend the surgery
Responses were rated using a 4-point Likert scale (Very Good, Good, Neutral, Poor), except for makeup usage (Very Good, Good, Not Applicable) and recommendation (yes/no).
All questionnaires were completed between 4 and 6 weeks postoperatively, during routine clinical visits, to ensure early stabilization of both surgical outcome and patient perception.
Statistical analysis
Data analysis was performed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). Categorical variables are presented as numbers and percentages (n [%]), while continuous variables are expressed as mean ± standard deviation (SD) and median (minimum–maximum). A P value of <0.05 was considered significant.
Results
A total of 970 patients were included in the study, of which 804 (82.9%) were female and 166 (17.1%) were male. The mean age was 54.69 ± 9.83 years (range: 26–85).
Postoperative outcomes
Ability to perform daily activities
Following surgery, 680 patients (70.1%) reported a “Very Good” improvement in their ability to perform daily tasks, while 225 (23.2%) stated it was “Good.” Only 55 (5.7%) patients reported no change, and 10 (1.0%) reported a negative outcome.
Change in overall quality of life
A total of 665 patients (68.6%) showed “Very Good” improvement in their overall quality of life. 173 (17.8%) reported a “Good” outcome, while 122 (12.6%) noted no significant change. Only 10 patients (1.0%) experienced decline.
Improvement in visual field quality
Postoperative visual field perception was rated as “Very Good” by 692 patients (71.3%) and “Good” by 194 (20.0%). A total of 84 patients (8.7%) reported no significant differences.
Satisfaction with mirror appearance
A total of 631 participants (65.1%) expressed being “Very Satisfied” with their postoperative mirror appearance, and 308 (31.8%) reported being “Satisfied.” Only 20 patients (2.1%) were dissatisfied, whereas 11 (1.1%) reported no change.
Confidence in social environments
648 patients (66.8%) felt “Very Confident” in social settings after the procedure, and 271 (27.9%) stated they felt “More Confident.” Neutral and negative responses were reported by 41 (4.2%) and 10 (1.0%) patients, respectively.
Change in makeup habits
Among the participants who used makeup, 451 (46.5%) reported increased satisfaction postoperatively, while 145 (14.9%) reported some improvement. Notably, 374 patients (38.6%) reported that they did not use makeup.
Willingness to recommend the surgery
A strong majority of 939 patients (96.8%) stated that they would recommend upper eyelid blepharoplasty to others, indicating a high level of satisfaction with the surgical outcome.
Table 1 summarizes the distribution of patient-reported outcomes across various domains such as daily activity, visual function, appearance satisfaction, and social confidence. A significant majority reported either “Very Good” or “Good” improvement in all the evaluated parameters. Notably, 96.8% of the patients stated that they would recommend surgery to others.
Table 1.
Distribution of postoperative patient-reported outcomes. All parameters were assessed using a structured 7-item questionnaire aligned with FACE-Q subdomains
| Postoperative Outcome | Very Good n (%) | Good n (%) | Neutral n (%) | Poor n (%) | ||||
|---|---|---|---|---|---|---|---|---|
| Improved ability in daily activities | 680 (70.1%) | 225 (23.2%) | 55 (5.7%) | 10 (1.0%) | ||||
| Improved overall quality of life | 665 (68.6%) | 173 (17.8%) | 122 (12.6%) | 10 (1.0%) | ||||
| Improved visual field quality | 692 (71.3%) | 194 (20.0%) | 84 (8.7%) | – | ||||
| Satisfied with mirror appearance | 631 (65.1%) | 308 (31.8%) | 11 (1.1%) | 20 (2.1%) | ||||
| Improved social confidence | 648 (66.8%) | 271 (27.9%) | 41 (4.2%) | 10 (1.0%) | ||||
| Improved makeup habits | 451 (46.5%) | 145 (14.9%) | – | – | ||||
| Would recommend surgery | 939 (96.8%) | – | – | 31 (3.2%) |
Patient-reported outcomes following upper eyelid blepharoplasty (n=970). Values represent the number and percentage of patients reporting each level of change in the respective domains. “Very Good” and “Good” responses together accounted for the majority of outcomes across all items. For the makeup-related item, only applicable responses from patients who used makeup were included. The final item reflects patients’ willingness to recommend the procedure (Yes/No format)
Fig. 1 illustrates representative preoperative and postoperative photographs of selected patients, visually demonstrating the esthetic improvements achieved through upper eyelid blepharoplasty. These images complement the subjective outcomes reported and provide objective context to the functional and cosmetic changes described.
Figure 1.
Representative preoperative (top row) and postoperative (bottom row) images of three female patients who underwent upper eyelid blepharoplasty. (a) A 44-year-old patient with marked improvement in eyelid contour and upper lid redundancy. (b) A 61-year-old patient demonstrating significant reduction in dermatochalasis and periorbital heaviness. (c) A 46-year-old patient showing enhanced upper eyelid definition and symmetry postoperatively. All patients reported high levels of satisfaction with both functional and esthetic outcomes
Discussion
This large-scale study involving 970 patients adds to the growing body of evidence that upper eyelid blepharoplasty significantly enhances quality of life across multiple domains, including functional capacity, esthetic satisfaction, and psychosocial wellbeing. Our findings align with those of numerous prior studies and provide additional insights due to the sample size and standardized surgical approach used.
Our results are in agreement with those of Vasović et al.,[8] who used the FACE-Q to demonstrate significant improvements in psychological function and appearance satis-faction after upper eyelid blepharoplasty. Similarly, Domela Nieuwenhuis et al.[9] observed notable enhancements in psychosocial wellbeing, facial appearance, and perceived youthfulness. These results are mirrored in our cohort, where patients reported increased daily functionality, self-confidence, and satisfaction with their image despite the use of a different, nonvalidated questionnaire.
The functional improvements observed in our study are consistent with those reported by Marangi et al.,[4] who found substantial clinical and visual field improvements, particularly in patients with moderate to severe dermatochalasis, highlighting that even advanced cases can benefit from blepharoplasty. Our results echo these findings, showing functional gains reported by the majority of patients independent of the initial severity.
Moreover, Ekin and Ugurlu demonstrated significant visual field expansion post-blepharoplasty, supporting the functional justification of the procedure.[2] These findings complement the visual comfort and ease of daily activities reported by our patients, who often reported reductions in ocular fatigue and improved visual awareness.
Lee et al.[1] added a new dimension by showing that upper eyelid blepharoplasty is a cost-effective intervention, with favorable utility values and quality-adjusted life years (QALYs). Although our study did not perform a cost-effectiveness analysis, the high level of patient satisfaction and functional improvement observed here further supports the value of the procedure in broader health and economic terms.
Liu et al.[5] highlighted the importance of patient education, clear communication of expectations, and minimization of postoperative asymmetry and scarring as key factors for satisfaction in Asian populations undergoing double eyelid surgery. While our population demographics differed, the universal themes of patient trust, perceived symmetry, and surgical precision were indirectly supported by our findings, given the high recommendation rate (96.8%) and the uniform surgical technique used by a single experienced surgeon.
Rodrigues et al.,[3] who conducted a systematic review, emphasized that the benefits of blepharoplasty extend well beyond esthetics and are better understood when evaluated with validated patient-reported outcomes. Although our questionnaire was not formally validated like the FACE-Q,[6] it was independently developed to reflect similar domains and proved to be practical in a high-volume, real-world clinical setting. Similarly, Hollander et al.[10] emphasized in their systematic review that upper eyelid blepharoplasty improves both functional and esthetic outcomes, especially when patient satisfaction and visual field improvements are considered together. Their findings further reinforce the dual nature of the procedure and support our conclusion that its impact extends beyond cosmetic improvements.
Additionally, Leivo[11] found that blepharoplasty can reduce medication use for headache and eyelid skin disease, hinting at systemic benefits beyond local outcomes. Although medication use was not evaluated in our study, patient feedback often included decreased eyelid discomfort and strain, suggesting potential systemic improvements.
Our observations also align with findings from Jacobsen et al.,[12] who showed mean improvements in superior visual fields of 31.3% and 28.3% for the right and left eyes, respectively, using octopus perimetry. Federici et al.[13] also reported a mean 30-point gain in functional visual score following blepharoplasty. These objective improvements add validity to the subjective outcomes of our study. To our knowledge, no previous study has evaluated patient-reported outcomes in such a large and demographically homogeneous cohort using a standardized surgical approach over an extended period. This scale and consistency allow for a more nuanced understanding of the procedure’s impact on everyday life. In this context, although dermatochalasis is typically age-related, younger patients may present with early dermatochalasis due to genetic predisposition, eyelid anatomy, or individual anatomical variations.
Further supporting these results, the American Academy of Ophthalmology outlined functional indications for upper eyelid surgery in their technological assessment, including reduced MRD1, compensatory head posturing, and ocular fatigue.[14] These criteria were reflected in the symptomatic profiles of the patient population.
Battu et al.[15] emphasized that both unilateral and bilateral blepharoptosis repairs led to substantial gains in vision-related tasks such as reading, driving, and personal care, consistent with our patients’ reports of improved daily functioning.
A major strength of this study is its unprecedented sample size of 970 patients—the largest cohort to date—to our knowledge, assessing patient-reported outcomes after upper eyelid blepharoplasty. This scale enhances the statistical power and generalizability of our findings. Moreover, all surgical procedures were performed by a single, highly experienced oculoplastic surgeon over a 6-year period using a standardized and reproducible technique. This methodological uniformity minimized surgeon-related variability and contributed to the study’s high internal validity. The combination of scale, surgical consistency, and real world settings provides a robust foundation for interpreting the multidimensional benefits of upper eyelid blepharoplasty. However, this study has some limitations. Our reliance on subjective, self-reported outcomes, absence of a control group, and lack of objective measures, such as visual field testing, limit causal inference. Another limitation is that all surgeries were performed by a single surgeon. While this ensured consistency in technique and minimized inter-surgeon variability, it may limit the generalizability of the findings to surgical settings with varying levels of expertise. Furthermore, female predominance among respondents could influence generalizability. Preoperative severity grading, objective visual field testing, and systematic assessment of postoperative residual dermatochalasis were not available in this retrospective cohort and therefore could not be analyzed. However, the study was designed to capture patient-centered outcomes, reflecting real-world perceptions of functional and psychosocial benefits. While these limitations restrict causal inference, the large sample size and uniform methodology support the general relevance of our observations, especially for clinical settings where validated tools may not be feasible. This marked predominance of female participants may reflect a sociocultural predisposition toward seeking cosmetic or functional facial enhancement procedures, particularly in the periocular region. Such demographic trends should be considered when interpreting patient-reported outcomes and their generalizability. Although we did not use a formally validated patient-reported outcome measure such as the FACE-Q,[6] our questionnaire was conceptually aligned with several FACE-Q subscales, including ‘Appraisal of Upper Eyelids,’ ‘Satisfaction with Eyes,’ ‘Psychological Function,’ and ‘Social Function.’ While the questionnaire was not a formally validated patient-reported outcome, the conceptual overlap with the FACE-Q subdomains supports its content validity and clinical interpretability. Importantly, no items from the FACE-Q instrument were reproduced or adapted, and the questionnaire was independently developed, eliminating the need for formal permission for its use. Future research should incorporate validated patient-reported outcomes, such as the FACE-Q, objective functional assessments, and long term follow-up, to evaluate the durability of these improvements.
Conclusion
In this single-center study comprising 970 patients, we demonstrated that upper eyelid blepharoplasty significantly enhances quality of life across functional, esthetic, and psychosocial domains. To our knowledge, this is the most comprehensive quality-of-life study based on patient-reported outcomes in the blepharoplasty literature. Our findings confirm the established benefits of this procedure and provide robust evidence for its therapeutic role beyond cosmetic enhancement. By addressing a notable gap in the existing literature, this study highlights the need to reconsider the classification of upper eyelid blepharoplasty as purely esthetic. Further studies incorporating objective functional testing, validated PROMs, and long-term follow-up are warranted to better delineate their multidimensional benefits.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors have reviewed and edited all outputs and take full responsibility for the content of this publication.
Funding Statement
Nil.
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