The cosmetic procedure is performed primarily to address the fat bags that cause lower eyelid puffiness. Occasionally, lower eyelid wrinkling and excess skin can also be addressed. Lower eyelid repositioning can also help change a sad, down-turned outer appearance to a more raised and “happy” look. In many ways, lower eyelid blepharoplasty is more technically challenging and varied than its upper counterpart owing to many different approaches and the possible benefit of ancillary techniques that can rejuvenate the surrounding facial areas beyond just the lower eyelids. Dr. Burroughs not only performs the newest techniques, but he has published on these techniques in surgical book chapters. Some of the latest advances include fat repositioning from the “baggy” areas down into the “hollows” under the eyes. Additional techniques include lower eyelid muscle tightening, chemical peeling, “Botox”, lower eyelid filler injections, and conservative skin removal on a rare basis. Quite frequently, the lower eyelid “bags” can be addressed through an “invisible” incision done on the inside of the eyelid that maintains the current eye shape, but canthal tightening can also be easily performed at the same time. Dr. Burroughs often provide a pleasing reshaping of the outer canthal angles and lifts the outer lower eyelid and mid-face through an upper blepharoplasty incision, which reduces scarring potential and maximizes the cosmetic benefit through as few incisions as possible. Each patient provides an artistic challenge that Dr. Burroughs enjoys co-developing a treatment plan that is customized for their aesthetic goals and needs.
Frequently Asked Questions Regarding Lower Eyelid Blepharoplasty:
1. Is an incision made through the skin of the lower eyelids when performing lower eyelid blepharoplasty surgery?
Sometimes a lower eyelid skin incision is performed, but quite often this is not necessary or ideal. Many patients with baggy lower eyelids have little or no extra skin. These bags are typically caused by too much fat or fat that has moved to abnormal positions. Skin removal of the lower eyelids can lead to pulling the eyelid downward causing the white part of the eye to show below the colored parts of the eye, which is called lower eyelid retraction. Lower eyelid retraction is an aging sign and surgically causing this problem can cause the eyes to become irritated, dry, and older looking. Lower eyelid retraction from removing skin from the lower eyelids during blepharoplasty surgery is a very common complication of facial plastic surgery. Many patients, including celebrities, that have been described as having had a “bad” face lift often have lower eyelid retraction. Careful observation of their eyes demonstrates the white showing below their eyes and what many label as a “bad” face lift or eye lift. Lower eyelid retraction can be avoided in most cases by performing an internal (inside the lower eyelid) approach and if skin is removed very conservatively and supporting the outside lower eyelid.
2. Is a skin incision always required to improve lower eyelid wrinkles and excess skin?
No. These issues can often be greatly improved by chemical peeling and Botox. In fact, texture changes are better improved with a TCA chemical peel. Some perceived extra skin is actually hypertrophy of the lower eyelid orbicularis muscle that closes the eyes, and it can be safely improved cosmetically with small amounts of Botox. Sometimes there is excess skin that, if removed conservatively and eyelid support is improved, can provide an outstanding improvement.
3. When should lower eyelid skin be removed?
It is done when there is so much excess skin in the lower eyelid that it cannot be tightened with a chemical peel or, for male patients, who often don’t wish to tolerate the temporary color changes of the skin that can accompany a chemical peel. Sometimes careful restoration of the support to the lower eyelid structures at the outside corner will smooth and improve the appearance of wrinkling and excess skin.
4. Where is the surgical incision made to fix lower eyelid bags?
Dr. Burroughs usually places the incision through the soft tissue lining the inside of the lower eyelid. This location allows for ready access to the excess and/or malpositioned lower eyelid fat. It also provides access to the attachments to the lower bony rim of the eye socket, so they can be loosened to allow fat to be optimally repositioned. This will often improve the dark circles and rings under the eyes. It also provides access to the mid-face structures so that they may be lifted if needed.
5. Are the lower eyelid fat bags always removed?
No. Optimal cosmetic eyelid surgery needs to correct all of the facial age-related problems to restore a youthful and natural look. Fatty prominence of the lower eyelids is often familial and presents commonly in the teenage years. In these patients, fat removal alone can often correct the entire problem. However, most patients as they age develop more prominent bags in the lower eyelids, and their rejuvenation needs are often more complicated than simple fat removal. Too much fat removal can lead to hollowness in the lower eyelids that is actually a finding common in the extreme elderly as our facial fat tends to atrophy with age. Some fat removal can be done if necessary, but often a better result is achieved by repositioning this fat to help restore the youthful cheek-eyelid convexity seen in younger patients.
6. What is fat repositioning or transposition?
The lower eyelid fat is an optimal filler to restore age-related lower eyelid/cheek deformities. The fat may be repositioned or transposed from areas of excess to areas that need to be filled. This involves moving the lower eyelid fat down into the “tear trough” deformities under the eyes, which helps fill in the dark circles (rings) under the eyes. Sometimes the mid-face fat pads (SOOF) are elevated at the same time to further fill in the areas of a lower eyelid depression.
7. Can dermal fillers delay or be as good as a lower eyelid blepharoplasty?
Sometimes dermal fillers in the right situation can indeed be as good or better than a surgical result, but is only a temporary improvement (6-24 months) and still can involve some healing from potential bruising. Just like moving fat into the dark circles and troughs under the eyes is helpful, a dermal filler can provide a similar result. However, if there is too much fat, then a dermal filler can’t completely camouflage this situation and can’t replace a mid-face lift.
8. Why do the dark circles and bags occur with facial aging of the lower eyelids?
Various changes occur with aging that lead to dark circles and lower eyelid bags. The normal youthful eyelid has a short length, is full in appearance, and has no darkened areas. As the face ages, the fat from the lower eyelid and cheek separate because gravity has pulled the cheek tissues downward, causing lower eyelid elongation and herniation (coming forward) of the lower eyelid fat. An empty space is created at the edge of the eye socket bone between the lower eyelid fat and cheek fat. This is called amongst facial plastic surgeons as a double-convexity deformity and can be thought of as a valley between two mountains. The lower mountain is the cheek fat pad.
9. What can be done to correct the eyelid bags and dark circles?
Each patient is unique and requires an individualized approach. Lower eyelid blepharoplasty for most patients achieves the best result if the lower eyelid fat is moved (transposed) from the area of excess to the area of deficiency. Some patients do require a small amount of removal if they have considerable prominence, and the results are even better if the mid-face and cheek are lifted at the same time.
10. What if my lower eyelids are retracted despite not having had any prior eyelid surgery? Is it safe to still undergo cosmetic lower eyelid blepharoplasty surgery?
This is actually a very common problem. As we get older, our lower eyelids become loose, which actually affords easier surgical access to the lower eyelid fat pads. In fact, sometimes easier access in younger patients requires the lower eyelid tendon be relaxed during the surgery and then retightened before the end. Dr. Burroughs can often address this situation with no additional outside incisions by performing a lower eyelid “tuck” through the upper eyelid incision. It is important to address lower eyelid laxity during cosmetic eyelid surgery as this can improve eye comfort, especially in the dry climate of Colorado. Additionally, the shapes of the eyes can be improved slightly by tightening and correcting lower eyelid retraction during the surgery.
11. Where is the incision made to lift a drooping cheek?
This varies from patient to patient, but it may be made through the upper eyelid, the lower eyelid, or behind the temporal hair line.