Lower Blepharoplasty Dallas

The problem

The reason why lower lids look puffy with age is not due to excess fat beneath the lids. In youth, the fat around the lower lid merges imperceptibly with the fat of the upper cheek to produce a smooth transition from the lower lid to the cheek (lid cheek junction). With advancing age, there is loss of fat from the cheeks with relatively less loss from around the eyes. Besides, there is a ligament that keeps the fat around the eye from moving down to fill the fat lost from the upper cheeks. This causes disproportion between the fat beneath the lower eyelid and the cheek, causing the appearance of excess fat around the lower lids.

Fat removal versus redistribution

Traditionally, puffy lower lid fat was removed during blepharoplasty to smoothen contours around the eye. However, it was noticed that although the protruding fat was removed and the eyelid contour appeared much improved, there was an aged appearance as the removal of fat around the eye gave it a hollow/sunken appearance. For this reason, modern blepharoplasty techniques involve releasing this retaining ligament and moving some of the fat from beneath the eyelid to a lower position to fill in the lost fat over the upper cheek (lid cheek junction). This equalizes the fat at the lid cheek junction and avoids the hollow appearance caused by traditional techniques involving fat removal. This procedure can be done through an external eyelid incision or from the inside of the lid using a transconjunctival approach.

Eyelid structure

The lower eyelid has three layers of structures covering the protruding fat. These layers from the surface to deep are:

  1. Skin
  2. Orbicularis muscle
  3. Orbital septum

There is a natural glide plane (non attached loose space) between the orbicularis muscle and orbital septum.

Put the tip of a finger just below the lash line of the lower eyelid and notice how the lower lid pulls down even with very minimal downward traction. By using an external skin incision to do a blepharoplasty, one is cutting through the skin, orbicularis muscle and orbital septum to approach the fat pads, thereby violating all three of these delicate layers. Scarring between the skin and muscle, muscle and orbital septum, or all three layers can cause the lower lid to move down just as minimal traction with a finger pulls it down. This can cause a visible abnormality with difficulty in closing the eyelid.

However, if the cut is made through the inside of the eye, one gets to the fat by going beneath the deepest layer covering the fat namely the orbital septum without actually damaging any of the three covering layers. Therefore the skin, muscle and orbital septum are now intact and the glide plane is maintained between the orbicularis muscle and septum. The chance of scar tissue pulling the lid down is negligible as normal lower lid anatomy is maintained. Imagine the following analogy: if one has to reach for an object behind a wall, would it be better to break a part of the wall, weaken it and fix the hole in the wall or go over the top of the wall leaving the wall itself intact?

Lower blepharoplasty techniques

Transconjunctival fat excision: An incision is made inside the lower lid and the excess fat is removed. No external scars are visible. This is probably the most commonly practiced lower lid blepharoplasty technique. Often, the ligament is not released; hence the fat is removed but not redistributed.

Removal of fat can cause a skeletonized appearance. Although the actual puffiness around the lower lid is corrected, the tissues around the lid can appear sunken which can result in an aged appearance. However in younger patients, a little fat removal using this technique may be all that is required (although fat redistribution rather than removal is the best solution).

Skin muscle flap procedure: An incision is made immediately under the eyelash and extends to just outside the outer corner of the eye. A similar cut is made in the underlying muscle followed by an incision in the orbital septum, and the lower lid fat pads are exposed. Fat is then removed; the ligament can also be released and fat can be repositioned instead. Excess skin can also be removed and the incision is closed.

All three layers of the lower lid are violated with this approach and there has been a lot of controversy with regards to possible muscle weakening resulting in altered function of the lower lid. Although it is of relatively little consideration in younger individuals, older people can develop dry eyes due to weakening of the muscle function of the lower lid. Besides, an external scar is more likely, especially when combined with skin removal to cause a dreaded lower lid blepharoplasty complication, namely ectropion or pulling down of the lower lid. Scarring that is often unpredictable, can also alter the shape of the eye with this approach.

My approach to lower blepharoplasty

I have personally performed every possible variation of lower lid blepharoplasty and my surgical technique has evolved through the years. I now perform what I believe is the best and safest technique for lower lid rejuvenation. The incision is made inside the eyelid (transconjunctival) so that there are no external scars. I then go beneath the orbital septum (deepest layer covering the eyelid fat) and release the ligament in a plane immediately adjacent to the orbital bone. This approach keeps all three layers of the eyelid intact unlike the approach when an incision is made through the lower lid skin. I then reposition the fat into the upper cheek such that there is a smooth blending of the lid cheek junction. The incision is then closed with very fine sutures and the procedure concluded. In patients with advanced aging and weak lower lids, a tacking suture is placed in the outer corner of the lower lid to keep the lid supported during the healing phase.

Although most surgeons remove excess lower lid skin using an incision placed below the lash line, I believe that what appears to be excess lower lid skin, is in most cases skin that has lost youthful texture secondary to aging and sun exposure. Rather than removing it, my preferred approach is to use a chemical peel done at the time of blepharoplasty or later to tighten the skin and improve the fine wrinkles. Skin removal does not change texture or remove fine wrinkles unlike chemical peel or laser resurfacing.

Limitations of lower blepharoplasty

Lower lid blepharoplasty will not address fine wrinkles over the lower lids, crow’s feet or lift sagging cheeks. Dark circles around the eye may be improved as fat redistributes across this area and affects the interplay of light and shadows. However, it will not eliminate them.

Post-operative recovery

Patients can go home after eyelid procedures. A cold pack is applied to the eyes for the first 24 to 36 hours to decrease bruising. Lubricant eye ointment is prescribed to help keep the eye moist till the eyelid swelling resolves. Bruising almost always happens and usually resolves by 2 to 3 weeks. Although by three weeks some patients look close to normal with make up, allow up to three months for residual swelling to resolve.

Questions to ask your surgeon before undergoing blepharoplasty

Is the incision made internally or externally? If it is external, what is the rationale for it in my case? As discussed above in detail, although I make the incision internally there are specific instances where I may decide to make the incision externally. This is more the exception than the rule. Unfortunately, it is not uncommon for surgeons to do this procedure exactly the same way in every patient independent of patient presentation. Does your surgeon make the incision externally in all patients, even in circumstances where it is not required because that is just the way he/she does it?

Is the fat removed or repositioned? Although removal of some of the fat is acceptable and often required, the bulk of it needs to be repositioned rather than removed

Is the retaining ligament taken down? As discussed above, fat cannot be repositioned without releasing the retaining ligament.

In upper blepharoplasty, is part of the orbicularis muscle removed along with the excess skin? In most patients this is not required. However, some by tradition remove this in all patients.

How are the skin texture changes over the eyelid addressed? Skin removal is the commonest technique to address this problem. However, as discussed above, skin removal can cause scarring and pull down the lower lid. Besides, it does nothing to improve skin quality. Skin can always be removed even in the office at a later date under local anesthetic, but removing too much can cause significant problems that can be difficult to correct.

Do I have brow descent or lid droop (ptosis)? If so, is there a plan to address these during the blepharoplasty.