Lower Blepharoplasty Eyelid Surgery
Lower blepharoplasty is an operation of the soft tissue in and around the lower eyelids, it is a type of eyelid surgery. The operation aims to create a smooth contour to the skin immediately below the eyes. Common reasons that motivate patients to undergo lower blepharoplasty include under-eye wrinkles, puffiness, dark circles, or some combination of the above. These unsightly characteristics create an aged or tired appearance in many individuals.
As with any cosmetic surgical procedure, lower blepharoplasty aims to alter the anatomical causes of the problems in order to improve the appearance. For this operation there are two main ways in which a smoother contour is attained. First, uneven or wrinkled skin is treated to create smoother skin. This can be thought of as treatments to smooth out the surface. Second, unevenness of the deeper tissues of the under eye area can be altered in order to create a smoother contour. This can be conceptualized as smoothing out the infrastructure of the under-eye. Several options for treatment exist within these two categories of treatment and are discussed below.
SKIN TREATMENT
Historically, skin excess in the lower eyelids has been treated with surgical excision and closure. The incision is placed 1-2 millimeters below the margin of the lower eyelid so that it will be hidden below the lashes and within a crease that naturally forms there (termed the sub-ciliary incision). A parallel incision is then made some distance below the upper incision and the intervening skin is excised and removed. Care is taken to preserve much of the underlying muscle beneath the skin so no weakening of the lower eyelid ensues after surgery. The amount of skin removed depends on how loose and wrinkled the skin is prior to surgery. Over-aggressive excision can lead to retraction of the lower lid, in which the lid pulls downward causing a rounding of the eye from its normal almond shape. In severe cases, this retraction can cause dryness and eventual damage to the eye. Therefore surgeons tend to be conservative with the amount of skin excision. Through this skin incision, the fat in the lower eyelid can also be accessed and treated (see below).
In some cases in which the laxity of skin is mild or there is only early wrinkling of the skin, the skin may be resurfaced to enable tightening (see section on resurfacing—include link here). Chemical peels or laser resurfacing may be applied to the area to create tightening of the skin which can smooth fine lines in the area. In some cases, a conservative skin reduction is combined with post-operative resurfacing in order to get the benefit of combination therapy.
FAT REDUCTION
Traditionally, the most common target of lower blepharoplasty has been the bulging fat under the eyes. Fat normally resides under the eye, serving to cushion the eyeball within the bony orbit. With age, the membrane which contains the fat within the orbit (called the orbital septum) weakens, allowing the fat to bulge forward. This creates an effect of puffiness or fullness under the eyes. Although fat is often the main component of this fullness, edema (or fluid accumulation) can also contribute. This explains why the eyes can appear more swollen after sleeping, salt intake, alcohol intake, etc. Nonetheless, for decades, fat reduction served at the mainstay surgical treatment to reduce fullness under the eyes.
The fat can be accessed either from the sub-ciliary incision described above,or through an incision on the inner surface of the eyelid, behind and below the eyelashes—the so-called transconjunctival incision. The choice of incision depends on whether or not the skin needs to be removed. In the past, it was customary to remove a large amount of fat in order to create a large reduction of the fullness in the lower lids. While this approach can lead to smoothing of the contour, in many cases it can lead a gaunt, hollow appearance of the under eye appearance. In recent years, the approach has become less popular, with surgeons instead opting for options to create smooth contour while preserving or even adding volume to the area.
THE MODERN APPROACH TO LOWER EYELID CONTOUR
In the past several years, there has been a change in the approach to lower eyelid contour, favoring preservation of volume. Modern surgeons agree that fullness or volume signifies youthfulness and that by reducing volume, one may cause an aged appearance rather than a rejuvenated look. For this reason, techniques have evolved in which the volume of the under eye area is re-oriented, rather than reduced, in order to smooth contour. Fat transposition is one increasingly popular way to achieve this end. With this technique, the fat under the eye is not removed, but rather transposed into a nearby area in which there is a lack of volume. The tear-trough, which is a natural hollow area under the eye within the facial skeleton, is a common target for fat transposition. The tear trough represents an area of depression under the eye which leads to shadow formation, contributing to an appearance or circles or tiredness under the eyes. “Transposition” implies that the fat that is moved is loosened or mobilized, but is still partially connected to its natural foundation. This allows some of the blood vessels which nourish the fat to remain intact, thus increasing the chances that the transposed fat will survive and endure in its new location. This is essentially a procedure in which fat is moved from an area of excess to an area of deficiency so as to improve contour.
Other methods of volumization are available for the lower lids. One option is the injection of transferred fat, in which fat is completely removed from an area in the body and injected into the desired target site, such as the tear troughs. One criticism of fat transfer is that not all of the fat will survive in the recipient site which may lead to temporary results or even uneven outcomes requiring revision touch-up procedures. Injectable fillers (see link) are also options to fill the under eye areas. At this point, the commercially available fillers for use in the US are “off-label” for application in the under-eyes. Nonetheless, the practice is commonly performed with a high satisfaction rate. The down-sides are that these fillers are not permanent and will re-absorb within a year and in the short term can lead to bruising under the eyes.
