Lower Eyelid Surgery Explained
Lower Eyelid Blepharoplasty Before and After
What is lower lid blepharoplasty?
One of the first areas of cosmetic concern for many patients is the lower eyelid. As we age, the fat that is around the eyes can start to move forward in the lower lid, creating the “bags” that create a shadow and make us look like we have dark circles around the eyes. Depending on your anatomy, this can occur at a very young age, but is certainly more common as we get older.
There are only a couple of ways to help with the dark circles and fat pads. A great non-surgical option is to fill in the tear trough, just below the fat pad, with a hyaluronic acid filler. This adds volume to the tear trough and smooths out the transition from the cheek into the lid. This additional volume makes the dark circle less pronounced, and helps to mask the fat pad.
The other option is a lower lid blepharoplasty. In a traditional lower lid blepharoplasty, fat and excess skin (dermatochalasis) are removed. While results can be good with this technique, the removal of fat can lead to hollowing of the lower lid and a worsening of the dark circle. For this reason I prefer to do a fat repositioning blepharoplasty. With this technique the fat is not removed, but moved down into the tear trough. This maintains the volume of the lower lid, and filling in the tear trough will decrease the appearance of the dark circles.
Dr. Martin is one of the only surgeons in the South Florida area who does the fat repositioning surgery. In addition he performs the surgery with a laser to decrease the swelling and bruising.
Many of the patients seen in the office come in because of the puffiness of the fat pads in the lower lid. If someone is young, or does not have a lot of fat prolapse, fillers are usually the best option. A hyaluronic acid such as Restylane is used, and will usually last about 1-2 years here.
If someone has more significant amounts of fat and some loose, wrinkled skin, then surgery should be considered. A fat transposition blepharoplasty would be discussed, and this is done from a trans-conjunctival approach, which is on the inside of the eyelid. If there is excess skin, a strip of skin can be removed from just below the lashes in the lower eyelid crease. Laser resurfacing can also be done to tighten the skin and improve the skin texture.
To do a trans-conjunctival fat repositioning, the lid is pulled down so that inside of the lid is visible. Using a laser, an incision is made in the eyelid. The skin and muscle are elevated, and the fat pads are located. The fat is then moved down into the tear trough and sutured into position. The lid is then returned to its’ normal position. If the lid is very lax and loose, the tendon is tightened at the outer corner of the lid. A pinch of excess skin is then excised, and the skin is sutured closed. Laser resurfacing is then done to improve the skin texture in patients with lighter skin tones.
Lower eyelid blepharoplasty is done with local sedation anesthesia. Performing the surgery with only local anesthesia is not easy for the patient as the manipulation of the fat is uncomfortable. The patient will therefore have an IV placed to receive sedation. After surgery the patient will be in the recovery room for about one hour before going home.
General anesthesia is not necessary for this surgery.
After a lower eyelid blepharoplasty all patients will be bruised and swollen. This will last for at least 10 days and will vary from eyelid to eyelid and patient to patient. Ice compresses are used for the first 3 days, followed by warm compresses. An eye ointment is used 3x a day for a week. The sutures are removed in about 7-10 days. There is minimal discomfort for most patients post-op, and is usually controlled with Tylenol. The swelling can last for many weeks in some patients. If laser resurfacing has been performed, there may also be redness of the skin for several weeks.
The most troubling complication of lower eyelid surgery is ectropion. This is when the eyelid pulls down away from the eye, exposing the white sclera. This can cause redness, dryness and chronic irritation of the eye. If severe, a revision surgery will have to be performed. This usually occurs from excision of too much skin, or from not tightening a lax lid during the surgery. Other complications include chemosis which is a swelling of the conjunctiva, tearing, and dry eye. Prolonged swelling, especially of the malar fat pad can also occur.
A lower lid blepharoplasty can be combined with other cosmetic surgeries such as browlift, upper lid blepharoplasty, and face/neck lift. If a patient has a very hollow tear trough and does not have much fat in the lower lid, additional fat can be transferred from elsewhere on the body to the eyelid.