Two common complaints among cosmetic patients include the appearance of bags and wrinkles under the eyes. The aging process of the lower eyelids starts early in life. In the beginning stages, the early signs may be concealed by makeup; but eventually, this method proves insufficient. Additionally, for some male individuals, the use of cosmetics is not an option. Typical aspects of moderate eyelid aging include puffiness, sagging of the skin, fine wrinkles, and an apparent diminishing of the smooth eyelid-cheek junction.

These signs can make us look tired, sad, or older than we feel. For some, it may even hurt their self-confidence. The good news is that there is a great way to restore the youthful appearance of your eyes.

What causes bags and wrinkles under the eyes?

Eyelid skin is the thinnest and most delicate skin in our entire body. With the inevitable effects of aging, sun exposure, and factors related to heredity, the collagen and elastin fibers that grant support and suppleness to the lower eyelid begin to fragment and break down, causing folds and wrinkles underneath the eyes. Also, the orbital septum – a delicate tissue membrane separating skin and muscle from fat deposits in the eye socket – loses its strength, allowing the fat to prolapse forward and create under-eye bags and puffiness.

Another cause of puffy and saggy eyelids is the weakening of the tendons located on the outer corner of the eyes (lateral canthal tendons). Under normal conditions, these sturdy anatomical structures provide eyelid support and help preserve the eyelids’ blinking mechanism. Unfortunately, with time, the tendons become weak, allowing the eyelids to sag under the weight of the cheek and fine wrinkles to appear under the eyes.

Lower eyelid blepharoplasty is the only procedure that can safely and significantly reduce the appearance of bags and wrinkles underneath the eyes and offer long-lasting results. This operation involves multiple steps, some or all of which may be required to achieve the best cosmetic result. Direct excision of excess skin is the best option in patients whose primary complaints are wrinkles and saggy skin. On the other hand, removal or repositioning of orbital fat is the go-to procedure in those mainly bothered by the presence of bags and puffiness. It is essential to employ both steps in patients who present bags, wrinkles, and excess skin.

Lower eyelid blepharoplasty: the procedure

Lower eyelid blepharoplasty is not a one-size-fits-all procedure. On the contrary, it is arguably the most complex facial plastic surgery, full of intricacies that arise from the manipulation of delicate and complex eyelid structures. This operation must be tailor-made according to individual anatomy, facial shape, and the physical findings in each patient.

Your surgeon will consider two variations of lower blepharoplasty, the external or transcutaneous approach, and the internal technique. The external method is more appropriate for patients who mainly dislike their wrinkles and skin folds beneath their eyes. In these cases, surgical incisions are placed on the outside of the lower eyelid, just beneath the eyelashes, to produce the most inconspicuous scar. After the incision, a flap of skin is carefully raised. The surgeon will remove an adequate amount of skin, being careful not to remove more than necessary as this could favor complications such as scarring and eyelid retraction. It is prudent to tighten the lateral canthal tendon whenever skin is removed from the lower eyelid. Therefore, a canthopexy or canthoplasty, which restores normal eyelid tone, is always performed with a transcutaneous lower blepharoplasty. A conservative cheek lift (mini midface lift) can also be achieved through this incision by manipulating the position of the cheek muscles and cheek fat. However, the midface lift, and full facelift are more effective at lifting the cheek.

For removing or repositioning bag deposits from beneath the eyes, the internal approach is recommended when the main complaint is bags and puffy eyelids. This technique is known as transconjunctival lower eyelid blepharoplasty. It involves a single incision made in the thin membrane that lines the inside of the eyelids, called the conjunctiva. Next, the eyelid is gently pulled away from the eye to dissect delicate tissues and expose the fat pockets responsible for the bags. At this time, the fat may be removed conservatively or used as a kind of fat graft by repositioning it onto the upper maxilla. Fat repositioning has become very popular because it restores a smooth eyelid-cheek junction and offers the most aesthetically pleasing results. If the fat is removed, it must be done conservatively to prevent a sunken orbit and hollow eyes.

What type of anesthesia is used for lower eyelid blepharoplasty?

Local anesthesia with mild sedation is best for undergoing cosmetic lower eyelid surgery. This means that the eyelid area is numb, and the patient is relaxed during the procedure but not totally asleep.

Lower blepharoplasty may also be performed with only local anesthesia in selected cases. It is appropriate in cooperative patients when only excess skin needs to be removed (called a skin pinch) but not when fat excision is required. General anesthesia is suitable for patients undergoing simultaneous cosmetic procedures such as a lower lid blepharoplasty and facelift or endoscopic browlift.

Who is a good candidate for lower eyelid cosmetic surgery?

The best candidates for lower eyelid blepharoplasty are healthy individuals with signs of lower eyelid aging and looking to improve their appearance. Realistic goals and a positive frame of mind are essential to achieve the best results. These goals should be carefully discussed with the surgeon before the operation. Unrealistic expectations about what blepharoplasty can achieve will result in an unhappy patient.

Your age alone does not make you a good candidate for lower eyelid surgery, but the signs of aging, and the desire to improve them, do. Having said this, the best candidates for lower blepharoplasty are non-smoking male and female patients in their 40’s to 60’s with a healthy ocular surface and no history of medical conditions that may impair healing.

Blepharoplasty is an excellent operation to treat the signs of eyelid aging and improve one’s appearance and self-image. This surgical procedure has a long track record of offering patients excellent results, making them look younger and more rested. The key to obtaining such results lies in the surgeon’s experience and the patient’s expectations. When these are in perfect accord, natural and beautiful outcomes can be expected.

What are the risks involved in cosmetic lower eyelid surgery?

Cosmetic eyelid surgery should be a personal decision based on a person’s desire to improve their appearance. To make that decision, the patient must understand the potential benefits of the surgery and the risks involved. With elective operations, as with any surgery, the patient must know what complications may arise.

The main risks to consider in lower eyelid blepharoplasty are lower eyelid retraction, unsightly scars and “fish mouthing” syndrome.

From a cosmetic standpoint, lower eyelid malposition is possibly the most common and most feared complication of lower eyelid cosmetic surgery. This complication is characterized by the tale-tell sign of the eyelid margin pulling down (retraction) or rolling out (ectropion) from the eye, causing an unnatural and operated appearance.

Lower eyelid retraction and cicatricial ectropion are generally caused by a less than conservative skin resection or by failing to address lower eyelid laxity during the surgery. Fortunately, both complications are treatable by an experienced oculoplastic surgeon without significantly compromising the cosmetic result.

The term “fish mouthing syndrome” refers to a complication caused by a postsurgical dysfunction of the lateral canthus accompanied by symptomatic deficiency of eyelid closure. Common clinical signs of this condition include eyelash deformity, rounding of the lateral angle of the eye, and eyelid closure deficit. On the other hand, canthal webs are unfavorable scars that form on the lateral angle of the eye, where the upper eyelid meets the lower eyelid. These are more common when upper eyelid surgery is performed at the same time as lower blepharoplasty. Find out more on our service: revisional eyelid surgery

Lower eyelid rejuvenation: surgery or non-invasive treatment?

Not everyone is a good candidate for lower eyelid cosmetic surgery. Some patients may qualify for the operation but may not take time off from work for post-operative care. Other individuals may desire a less invasive option to rejuvenate their eyes until they’re ready to proceed with surgery. Ultimately, when deciding on surgical or non-surgical treatment, it is imperative to understand the various limitations of each approach.

Blepharoplasty is a long-lasting solution for the improvement of lower eyelid appearance. It is especially true for older patients with pronounced bags and significant wrinkles. Because it is a surgical intervention, recovery time is longer than for non-invasive options. However, when non-surgical alternatives cannot achieve a patient’s desired result, it may be the best option to address the signs of aging.

Younger individuals who only have mild puffiness and superficial wrinkles due to heredity or older patients who desire a subtle improvement in their appearance will benefit from non-surgical treatments such as Botox, dermal fillers, and chemical peels. These products improve skin texture, decrease expression lines, and provide volume to the lower eyelids. When expertly applied to the right candidate, they can produce excellent cosmetic results, treating mild bags, dark circles, and superficial wrinkles. For the most desirable results, an experienced surgeon with the clinical eye to choose the right patients and products according to their anatomy, skin type, and expectations is a must.

Before and After Procedure

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