Why 2025 saw a blepharoplasty boom - with Dr Elizabeth Hawkes

0:01Dr Sophie Shotter:Hi, I'm Sophie and this is Age Well with Dr Sophie Shotter, a space devoted to all things health, wellness and longevity. Because for me, ageing well is about looking and feeling like the best possible version of ourselves, inside as well as out. So together with my producer Fee, I'll be deep diving into the latest research, sifting fact from fiction. I'll also be talking to all kinds of trusted experts, tapping into their knowledge, along with bringing you conversations from a range of interesting women, and men finding out how they age well. So this is my show, welcome along and as always thank you so much for listening.

0:45Dr Sophie Shotter:Elizabeth thank you so much for joining us. You're one of the UK's most celebrated and respected eye surgeons and your credentials very much speak for themselves from your training to your professional appointments and memberships including several advisory and regulatory roles which for listeners is a huge green flag. It also seems that you're on the speed dial of half of London's beauty editors which we'll get into in a moment and since you and I both know that this is a highly discerning subset of people bravo for all the plaudits and accolades you've had there. What I hadn't realised is that you're from a highly prestigious medical family, your mother is a consultant ophthalmologist, your father is a world-renowned professor of neurology and you're married to an ophthalmologist.

1:28Dr Sophie Shotter:I may well return to that shortly but first I know your work straddles both eye health and ocular surgery as well as aesthetics. Shall we start with some of the most prevalent areas of discussion around aesthetics and that's bags under the eyes. Can you give a brief layperson's explainer on what causes these and if there's anything that can be done to mitigate the risk and if you can then kind of move into non-surgical treatments and possible solutions, whether that's in-clinic or DIY interventions like massage or gua sha or anything else that you rate?

2:01Dr Elizabeth Hawkes:Yeah, definitely. So thank you so much for having me today. And that's a really kind introduction. So yes, as he said, eye bags are a big problem and a common concern for many of my patients. So firstly, the cause. So your eyeball is in a bony socket, which is called the orbit, and it's actually cushioned in fat. And this is orbital fat, and it's different to fat around the rest of the face or the body. And what happens is it's held back by a very thin membrane. It's microns thin and it's see-through and it's called the septum. And that structure keeps your orbital fat in place. And over time, that structure can weaken and you get prolapse.

2:42Dr Elizabeth Hawkes:So the orbital fat starts to come forward and that causes puffiness and the appearance of eye bags. so it can happen over time age related and it can also happen due to genetics so if you have a family history of eye bags you may have a genetic predisposition to get developing them a little bit earlier and it's also associated with medical conditions such as thyroid eye disease so it's really important if you do start to notice puffiness around the eye before thinking about any type of cosmetic surgery or any intervention you want to get your thyroid function tested and the reason why that happens is thyroid eye disease is an autoimmune condition and it actually causes thickening of the orbital fat pads which is one of the reasons why we know that orbital fat is different to fat around the rest of the face and the body so essentially what it is it's eye fat that's prolapsed forward so treatments really the gold standard treatment would be a surgical blepharoplasty which is an operation where the fat pads are most commonly repositioned so moved around the eye area to give a smooth result or the fat pads are actually removed if there's excess hypertrophy.

3:48Dr Elizabeth Hawkes:And then there's lots of non-surgical options as well to rejuvenate the under eye area. So there's no real non-surgical treatment that will dissolve the fat around the eye. It has been tried but it didn't take off. So non-surgical treatments are usually aimed around improving the quality of the skin around the eye and ways to camouflage the bags or the puffiness and they can be tailored according to patients anatomy really and it's usually a combination of skin boosters energy-based devices and carefully placed tear trough filler and then DIY like you said I love DIY treatments actually it's really important to do treatments at home but as most people would be aware that or can relate to the eyes are very prone to becoming puffy people say you wake up in the morning and your eyes are puffy and it gets better at the end of the day that's because the eyelid area is prone to water retention mainly because there's lots of space and it has loose attachments to its bone that's why the eyes puff and swell up more than say other parts of the face it also has a very complex lymphatic drainage system so yes massage and of course eye creams are really important i know we'll touch on that later so they're the sort of

4:57Dr Sophie Shotter:treatments i'd recommend you could do at home thank you so much elizabeth i'm so glad we started sophie with eye bags because the older i get the more it's something i'm thinking of another one is dark circles again is there anything that can be done aesthetically beyond like really good makeup although we'd love to hear about any concealers that you'd recommend and again does lifestyle play a part both in terms of cause and prevention and a final question on dark circles what do dark circles say about our health apart from maybe you're very tired yes so dark circles

5:31Dr Elizabeth Hawkes:another very common concern. So this is when the skin underneath the eyelid, so underneath the lower eyelid, starts to look more pigmented and is a really common concern. So this can be genetics. Again, you're genetically predisposed to having darker skin under the eye, but also quite a few medical causes that can make the under eyes appear more dark. And the reason is the eyelid skin is very thin, some of the thinnest skin on our body. And directly underneath our eyelid, we have a muscle called the obicularis oculine muscle which is responsible for blinking and it's going about sort of we're blinking around 15 ,000 times a day and what's unique about the eyelid skin compared to skin on the cheek is the cheek you have a layer of fat immediately underneath the eyelid skin whereas in the eyelid skin it's skin and then muscle you don't have that layer of fat so therefore the blood vessels around the eyelid it's also very vascular area are very visible and that's why it can be linked to medical conditions and the most commonly known one that people associate dark circles with is iron deficiency and that's when the blood vessels can become thicker and you have a reduced blood circulation and it could cause the appearance of dark circles.

6:40Dr Elizabeth Hawkes:Tiredness is another one again it's related to your general health so that's the link. Also anatomical causes if you have volume loss you can get more shadowing from that bony socket I mentioned and that can worsen the appearance of dark circles.

6:54Dr Sophie Shotter:Shall we touch on menopause and some of the key changes that women find themselves dealing with and I think dry eyes is a really big one. I'd love to talk to you about eye drops too if you can and also as a colleague I'd be intrigued to hear your thoughts on the luminous IPL therapy for dry eye.

7:13Dr Elizabeth Hawkes:Many of my patients are menopausal and there's a few things that happen in the eye, two big ones. So the eye itself, dry eye like you mentioned. So in between our lashes, we have specialist glands. These are called meibomium glands. And you only have them in the eyelid. And they secrete the oily layer of your tear film. So in order to see in process light, you have to have a good tear film. And the most superficial layer is the oily layer, the meibomium glands. And this layer is very prone to hormonal changes. So often the hormonal changes that are experienced in perimenopause and the menopause can affect the quality of the secretions of the oil glands.

7:52Dr Elizabeth Hawkes:So for that reason, your tear film becomes unstable and you get the development of dry eye. So treatment for that, the mainstay of treatment in all patients with dry eye is artificial tears, so lubricating eye drops, and then lid hygiene as well, which is a term that ophthalmologists use to clean your eyelids as a specific way to clean your lids. And that is simply massaging down for the upper lids and up for the lower lids with a finger, because these glands run vertically. So in terms of drops, you want to look for drops over the counter that are preservative-free, phosphate-free, and essentially contain hyaluronic acid because these drops are hydrating.

8:29Dr Elizabeth Hawkes:And Optase is a great brand, Hycosan Red and Hycosan Blue, and they're okay for contact lens wear. You also want to clean your eyelids so you can use water, but you can also by either medicated wipes or a specialized gel. I like to use the tea tree oil gel by Optase and that's because it also has some antimicrobial properties and also in between these glands you can get the presence of demodex which is a bacteria that can form around the eyelids and can also alter the secretions in the glands and that condition when you start to get clogging of the glands and inflammation around the eyelid is called blepharitis.

9:07Dr Elizabeth Hawkes:So blepharone just means eyelid and itis means inflames the inflammation of the eyelid so the luminous IPL is great so IPL actually from an ophthalmic point of view was pioneered by a very clever ophthalmologist Rolando Toys in America and he was treating patients with rosacea and one of the hallmarks of rosacea is you get broken blood vessels telangiectasia on the cheek and IPL works to constrict those abnormal blood vessels. So what he noticed is that his patients, their eye symptoms and the symptoms of dry eye also got better. And one of the hallmarks of blepharitis is you actually get those telangiectasia on the lid margin.

9:46Dr Elizabeth Hawkes:So IPL, luminous IPL, was probably the first one used for the eye and it's brilliant. I think it's a great treatment, lots of evidence to support its use. The second thing that happens with menopause is the lack of collagen. So your collagen levels decline and the eyelid skin is particularly prone to this so that's often why many women say they feel they've aged overnight because of this gradual decline in collagen and that looks like hooded eyes and excess folds of upper eyelid skin because the eyelid skin is so thin when you lose the collagen it's more prone to accelerate in the aging process we get redundant folds of skin and it can feel like it happens overnight but it never normally does it's normally a slow process really interesting

10:31Dr Sophie Shotter:Thank you for that, Elizabeth. A lot of that sounds actually very familiar for me, certainly the dry eyes, as Sophie mentioned. But before we get into the more invasive and surgical side of what it is that you do, should we talk products? And I would love to bring you in on this question too, Sophie. What products, Elizabeth, are your personal go-tos? And Sophie, I know that you've previously mentioned, I've got a list here, Revisions, Revox Line Relaxer, Media Beauty's Myofix and Skin Better's IMAX Alpharet. so so please do tag on to the back of Elizabeth's answer with any newer products or finds that you've got but Elizabeth first of all what's on the bathroom shelf for you in terms of eye creams

11:09Dr Elizabeth Hawkes:or serums well I love eye cream obviously I'm a big advocate for using eye cream I have loads of eye creams I'm in a really lucky position that I get to test so many different ones because of my job and I do judging so I have loads of eye creams and it's hard to say what my go-to is because it depends on what your concerns are and there's a huge range of eye creams I don't think there's one eye cream for every concern or every sort of decade of life so if you have sensitive eyes you're going to want to choose an eye cream that is fragrance free if you have fine lines and hydration you want more of a hydrating cream but you don't want to have too thick of an eye cream because that can cause milia which are white bumps that often develop around the eyelid skin and that's because the eyelid skin has a slower turnover rate to the rest of the skin so it's common for some of the superficial skin cells to get clogged up with a protein called keratin so that's why you have to be careful with thick heavy creams if you have dark circles you may want to choose a different cream and puffiness so I really think it depends on your concerns but I definitely always I like to wear eye makeup so I always use eye makeup remover there's the eye drops that we spoke about they also have a specific eye makeup remover for sensitive eyes the Optave Life Sensify Makeup Remover I don't use micellar water so micellar water is quite harsh it uses surfactants to remove makeup so I'd recommend to not use that because you can actually strip the lipid layer around your eyes and as we spoke about these specific glands the meibomium glands you want to really look after that lipid layer on the eyelids because it's responsible for your the first layer of your tear film and ultimately if your tear film's disrupted it's not going to let light in as efficiently and it can lead to blurred vision so I use the Optase I've Sepsid Eye Makeup Remover it uses patented ionized water and it repulses the makeup particles from the eyelid skin without actually stripping the surface it also contains hyaluronic acid which is very soothing and it's good for sensitive eyes so that's always something I have there and then And it's a whole range from sort of affordable brands that I've been lucky to try and the more sort of luxury skincare.

13:22Dr Elizabeth Hawkes:So it's a huge range and it just depends how my eyes are feeling, really.

13:26Dr Sophie Shotter:Thank you. So are you still using those trusty three that we've just mentioned or do you have any new ones that you can add to the list? So I guess what I would say is both the Mead and Myofix and the Reevox line relaxer, they're not eye creams per se, but they're good if people have very fine crepey lines under the eyes. the IMAX is a great product I still rate that for a lot of people but yeah as Elizabeth said so much just depends on the concern if people have dark circles revisions C plus brightening eye is an amazing product I love clinical skins eye creams they have a really nice quite nourishing one but as Elizabeth said it really does depend on your concern as to what cream I would recommend so let's move into the surgical discussion specifically the blepharoplasty Inge van Lotringen who is an amazing beauty editor that I know you and I both know very well has talked quite a lot about having had this and I quote she says it set the clock back on my eyes by two decades she also went on to say that blepharoplasties are becoming more and more popular because while it's serious surgery as all surgery is it's also almost always undetectable with minimal downtime.

14:38Dr Sophie Shotter:Polly Vernon has written about more and more patients in their 40s seeking it as part of an overall trend towards more natural aesthetic interventions and how it's known in some circles as a quiet facelift and she's tracking her journey with you on Instagram if anyone wants to take a look and I know Alice Hart-Davis chose you as her surgeon to remove as she put it, lax skin from the upper eyelids, fat from her eye corners and to correct the ptosis in one eyelid. With all of that in mind, can you tell us everything we might need to know about the blepharoplasty, including what it can treat? Are we talking everything from under eye bags and droopy eyelids to lines and wrinkles, plus the difference between an upper and lower, and obviously the lower being the more complex of the two?

15:20Dr Sophie Shotter:Is there anything else we need to know? And then I know Fi has some questions on the more practical side.

15:26Dr Elizabeth Hawkes:Yeah, so upper eyelid blepharoplasty is definitely my most commonly performed surgical procedure. We're definitely going through a blepharoplasty boom. It's been widely talked about in the media and the stats back it up in the ASIC surgery societies. It's now one of the most popular cosmetic surgical procedure that's performed in men and women. So essentially blepharone meets eyelid as I said before and plasties to mould. So you're essentially moulding eyelid skin. There's an upper eyelid blepharoplasty which can address excess folds of upper eyelid skin or hooded eyes and often the patient starts to notice female patients that their makeup is smudging or male patients that they look more tired and with the lower eyelid a lower eyelid blepharoplasty commonly addresses the under eye concerns such as puffiness loose skin or a lax eyelid which are all natural age-related changes that will happen over time specifically with the upper eyelids the excess skin can be so severe that actually starts to affect your vision.

16:29Dr Elizabeth Hawkes:If you have multiple folds of excess eyelid skin, it can affect your peripheral vision. So what you're able to see in the corner of your vision and that can be a medical reason to undergo the surgery. And essentially it's all done via natural incision. So we naturally have an eyelid crease. So when you close your eyes, the first line you should see is the upper eyelid skin crease. And in women, it's around 8 to 10 millimetres. And in men, it's around 10 millimetres. and you should just have one just but young eyes have just one fold of skin and then over time you can get multiple folds it is excess skin so surgically you essentially removing the excess folds of our pilot skin and on average you take around 15 to 16 millimeters the average age of my patients for an upper blepharoplasty is 45 there's actually once from that skin crease incision there's actually quite a lot you can do in an eyelid you can raise the eyebrow sometimes over time it's not just the excess skin that drops your eyebrow starts to drop as well and you can actually support the tail of the brow via the same skin crease incision which is great so it's just one one incision for the patient and you can sometimes it's not just excess folds of skin that cause a droopy eyelid you can have a condition called a ptosis which is when the eyelid actually sits lower than it should do and that can also cause the appearance of a tired eye it can also reduce the vision as well.

17:54Dr Elizabeth Hawkes:And it's mainly from ritosis point to view, it's mainly the asymmetry from eye to eye that most patients start to notice first. So that can all be done via the upper eyelid blepharoplasty incision. We were talking about orbital fat and eye bags. You also have two fat pads actually in the upper eyelid, three on the low lid, but two in the upper eyelid. And the one on the inner corner starts to prolapse forward as well over time. And that can be a common concern of patients as well. They notice puffiness on the inner corner and that's always addressed in blepharoplasty, that fat pad. So that's the upper eyelid.

18:25Dr Elizabeth Hawkes:And essentially, patients, it's day case surgery, no overnight stay. Your patient takes around 45 minutes to an hour. And it's usually done, an upper eyelid blepharoplasty can be done under local anaesthetic, or it can be done with light sedation, or you could be fully asleep if you're naturally a little bit anxious about having your eyes operated on eyelids. the lower blepharoplasty is a lot more complex so the eye bag so if there's the layers around an eye you have skin fat and muscles so the orbital fat is it's older school techniques used to remove all the fat and chuck it away and what we found over time is that can need sort of a hollowing look around the eye as you get older and actually isn't not aesthetically favorable so often the orbital fat is now moved and repositioned to give a small result but as I said in some patients when there is excess fat you do have to remove it in a conservative way and the eye bags can be addressed either via internal so no external skin incision like through the conductive of the white part of the eye or they can be addressed externally.

19:28Dr Elizabeth Hawkes:Often some patients have an element of laxity so the eyelid itself is quite loose so if you were to just simply reposition the fat you wouldn't get a great result because the eyelid itself is quite loose. So in that case, you'd often have to take an external approach or do an additional procedure to support the muscle and the lower lid, and that gives you a smooth result. But the key thing with an upper or lower lip blepharoplasty is to not take too much skin because that's when you get complications. It's not really about skin removal, it's about what you leave behind and just tightening muscles and repositioning tissues to give you the most natural result.

20:08Dr Elizabeth Hawkes:Lower eyelid surgery takes a bit longer, takes around an hour and a half and is often done under general anaesthetic or with some sedation. You can have all your eyelids operated on at once. You can even support the midface at the same time if required in a lower eyelid bepharoplasty.

20:24Dr Sophie Shotter:I mean, you've mentioned how long both upper and or lower would take and you've mentioned sedation and options there. But is there anything else that you can explain to us on a practical basis in terms of the day of surgery and what recovery is like and how soon somebody could realistically face the world I mean Sophie mentioned that some of these journalists are calling it the quiet facelift I mean how long could you face the world ideally without people knowing that you've had either one of these surgeries yeah so the it's all day case surgery

20:56Dr Elizabeth Hawkes:so you'd either come in the morning or the afternoon you'd go home that day so immediately after surgery you have an ice mask on so I usually keep the ice mask on for about an hour that just helps with the immediate bruising and swelling if you have a skin excision or an external approach lower lip lepharoplasty and obviously with an upper lip lepharoplasty you will have stitches in stitches that I use are black and they're not dissolvable so they come out seven days later so actually what patients find is when you immediately after surgery you're not that bruised or swollen and patients always say oh I don't look as bad as I was expecting but in that first week of recovery you always have the bruising and swelling will develop usually around day two day three and then it will start to settle so that first week I usually say to patients wear sunglasses work from home if you can light exercise is always encouraged but you don't want to do any vigorous exercise but you don't need to just be in bed resting you can be lightly active and then at day seven the stitches come out that first week as well you have a strict protocol of drops to use antibiotic ointment, antibiotic drops, and a lubricating eye drop as well to keep the eye comfortable.

22:00Dr Elizabeth Hawkes:I always give direct access to all my surgical patients to me. Eyes, most patients, they want to do their eyes, but they're often scared. They think, oh, it's my eye. What if something goes wrong? It's very safe surgery, actually. The risk to eyesight is 1 in 22 ,000, which is essentially zero. And to put that into content, the risk to your eyesight being content lens wear is more like 1 in 1 ,500 from a site-threatening infection. So So actually, ocular plastic surgery or blepharoplasty surgery specifically is very safe surgery. But I still think it's very reassuring to give my direct number to patients in case they're really worried.

22:31Dr Elizabeth Hawkes:It could quickly pacify concerns. So usually once you're through that first week, patients come at day seven and they're usually fine and ready to have the stitches out. They can start to feel a bit itchy. The stitches come out. And really by that day, you can face the world. Depending how private you want to keep the operation, if you really don't want anyone to know, then you want to give yourself two weeks off because of the bruising. But the bruising is still very subtle and it's contained around the eye. It doesn't extend on the whole face. And then once the stitches are out, the eye feels quite comfortable and you can start to wear makeup again around day 10.

23:05Dr Elizabeth Hawkes:I have a strict protocol of creams that I recommend to use after the surgery to encourage wound healing, specifically the SPF for the incision. So scars and where the incisions are they're usually red for around six weeks and they slowly start to fade to a white line which can take up to 18 months and luckily the eyelid skin here has a very good blood supply so it heals very well compared to the rest of the face so usually the incisions by the six-week check are barely noticeable. Exercise I usually say around three weeks and six weeks if patient's happy usually you're signed off.

23:41Dr Sophie Shotter:How long do the results last and how does a blepharoplasty pair with a deep plane facelift for example which is something we've spoken to mark pacifico about

23:50Dr Elizabeth Hawkes:yes so on average just resets the clock blepharoplasty surgery so on average you get about 10 years over that time it's not like the skin grows overnight over time the you will get excess fold of upper eyelid skin again and the brows will start to come down which can worsen that appearance and you may want to have it done again and you can it's completely safe to have two or three blepharoplasties in a lifetime if they're done safely each time. And how does it link in with a facelift? Well, they complement each other. A facelift and a blepharoplasty often go hand in hand. I usually find that my patients may want to have a facelift, but it's not their priority.

24:29Dr Elizabeth Hawkes:And therefore, they usually start with the eyes. And then often after they've done the eyes, naturally your eyes start to move to other parts of the face and the lower face. And then they she asks for recommendations for a facelift. But most patients sort of test the water with facial surgery with the eyes.

24:47Dr Sophie Shotter:What about threads? Is threads a thing that's done for the eyes or is that something that you would do or what are your views on threads or does that not work at all for the eyes?

24:58Dr Elizabeth Hawkes:No, I don't do threads. No, they, I mean, I think you can get some temporary good results, but they're often very precise. They don't last long and I think the risks outweigh the benefit.

25:08Dr Sophie Shotter:Which I think Sophie is what you've said before on Thread so that concurs thank you. Yeah just no. Yeah I'm not a fan at all. Risks for me when compared to the benefits and the longevity of benefits just doesn't tidy up. Moving into a more holistic eye health discussion what are your thoughts around eye health supplements and specifically lutein and zeaxanthin which I talked about a lot for macular degeneration and I'm also now hearing about things like magnesium which we know is amazing for pretty much everything and high dose vitamin k as well

25:42Dr Elizabeth Hawkes:yeah so supplements great for eye health so lutein and xianthin so that was all from a large multi-center international study looking benefits of diet vitamins on eye health so two things came out of that so the a red 2 study found that patients with age-related macrogeneration so the max so the back of the eye is called your retina and the central part of that is called the macula which is where you have your most finest vision and over time the macula will wear and tear with age and that's called age-related macgeneration so the a red 2 study looked at supplements and vitamins that you can take that can improve the health of the macula and lutein xanthine are always recommended.

26:29Dr Elizabeth Hawkes:In that study specifically, it looked at a specific subtype of MAC generation, but what I would recommend to patients is it's very difficult to get that from your diet alone. So if you have any family history of MAC generation, or if you have very early side, MAC generation can be picked up sort of 30 years, maybe not 30 years, maybe 20 years before you start to get the clinical signs of loss of vision. It's essential you go and see your competition, it's so easy just to scream for, I would say to that patient, there's no harm in taking lutein and xianthin. But there's loads of other vitamins that are great for eye health.