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Lower lid blepharoplasty

Lower eyelid blepharoplasty

Blepharoplasty comes from the Greek words blepheron, meaning eyelid, and plassein, meaning to form. It essentially refers to the reshaping of the eyelids and is used to describe plastic surgery to the eyelids. Lower eyelid blepharoplasty primarily involves removal of excess skin and/or re-contouring the lower eyelid fat, and is often combined with some kind of lower eyelid support or tightening. In addition it can be combined with a limited midface lift where required. A thorough consultation with an experienced oculoplastic surgeon is therefore essential to determine which procedures best suit an individual’s eyes and concerns. This is often termed a “customised blepharoplasty”.

Different types of lower eyelid blepharoplasty exist, some of which can be performed without cutting the skin and which therefore can be “scarless”. If the aim of the surgery is primarily to re-contour the lower eyelid fat then and no skin needs to be removed, then this can be done through a hidden incision on the inside of the lower eyelid. This is termed a “trans-conjunctival” approach to surgery and means that there is no visible external scar. If, however, some skin needs to be removed, then a “trans-cutaneous” approach to surgery is necessary. This involves an incision along the length of the lower eyelid skin but which is hidden just below the eyelashes making it almost invisible to onlookers when healed. The incision usually extends beyond the corner of the lower eyelid into a crows foot line.

Fat recontouring can be performed in different ways and is tailored to suit the requirements of the individual patient. In certain cases some prominent fat needs to be trimmed, although this must be done with caution as a hollow look can develop. Alternatively, the lower eyelid fat can be repositioned within the lower eyelid, particularly into tan existing adjacent tear trough hollow.   

Many patients proceeding to lower eyelid blepharoplasty have some kind of lower eyelid stretching (laxity) and require a form of lower eyelid support as part of their surgery. This can be achieved by tightening the lower eyelid muscles with a muscle “sling” or by tightening the lower eyelid tendon. The latter is usually termed a “canthopexy” and involves the placement of a stitch from the lower eyelid tendon to the bony rim by the outside of the eye. In extreme cases a lateral tarsal strip may be perfomed.

In cases where malar bags are present, additional surgery may be required. Options include a limited cheek lift involving the soft tissues only; a more extensive midface lift; or some kind of cheek volumisation procedure such as a cheek implant or infraorbital implant. A cheek lift will usually require a slight extension of the normal lower eyelid scars beyond the corner of the lower eyelid out into a crows foot.

The incisions in lower eyelid blepharoplasty can either be made with a blade or a cutting laser. There are advantages and disadvantages to both techniques and which is used is largely a question of the surgeon’s preference.

Various methods are used to close the wounds during lower eyelid blepharoplasty. Incisions made from within the lower eyelid need minimal suturing and any sutures placed are usually absorbable and do not need removal. Skin wounds are usually closed with permanent nylon sutures as these are easy to remove and cause very little reaction in the skin. Deeper tissues e.g. muscle is closed with absorabable sutures that dissolve around 3 months after surgery. Sometimes deep permanent sutures are placed e.g. for some canthopexies. Some tissue adhesives can even be used but these can irritate the eye when placed along the lower eyelid margin. The choice of sutures does depend on the type of surgery you are having and your surgeon’s preference.

Lower eyelid blepharoplasty can be performed under local anaesthetic only (with the patient completely awake and an injection into the eyelids); under local anaesthetic with sedation (the patient is awake but is given something to make them feel very relaxed); or under full general anesthetic with the patient asleep. Local anaesthetic does have a quicker surgical recovery time than general anaesthetic but no longer term advantage. There is additional benefit gained from the patient being able to open their eyes during lower eyelid surgery unlike in upper eyelid surgery. Surgery to both lower eyelids usually takes around 90 minutes depending on what is being done. The surgery is usually performed as a daycase operation.

Recovery from the procedure usually takes two weeks. During the first week both eyelids will appear swollen and bruised, and are likely to feel stiff and itchy. By the end of the first week when the sutures have come out, the eyelids feel much more comfortable and the swelling and bruising is greatly reduced. By the end of the second week most patients feel ready to face the world without sunglasses on.  

Most patients are very happy with the results of lower eyelid blepharoplasty surgery and the removal of lower eyelid bags can really improve the aesthetic of a person’s face. However, the factors affecting lower eyelid contours are numerous, and include certain factors such as gravity, the weight of the cheek and midface, the presence of the natural tear trough etc.. which mean that there are certain limits on what lower eyelid surgery can achieve. The effects of lower eyelid surgery, especially fat re-contouring, will last several years and usually do not need repeating. However, the eyelids and face do continue to age throughout a person’s life, and, depending on an individual’s aging process and their preferences, some people will chose to have additional lower eyelid blepharoplasty surgery later on in their life. This does not usually pose any problems if performed appropriately.

Benefits of lower eyelid blepharoplasty

Lower eyelid blepharoplasty is a very successful procedure with a high level of patient satisfaction. To quote William Shakespeare: “The eyes are the windows to your soul” and the facial feature that we pay most attention to. This is confirmed in modern society by the fact that the most popular cosmetic procedure is a blepharoplasty. Tattler Beauty and Cosmetic Surgery Guide recommended “ if you only have one anti-ageing operation, an eyelid lift is the one to choose”.

Lower eyelid blepharoplasty is usually performed to reduce the presence of lower eyelid bags, which many people feel are too prominent and which may disproportionately age a face or make it look tired. Others state that they are fed up with friends asking them whether they have had a bad night’s sleep. For many people, being able to remove such bags is extremely beneficial to their social interactions and confidence, especially with the pressures faced in our modern, highly visual world. 

Risks of lower eyelid blepharoplasty

As well as appreciating the many benefits of lower eyelid surgery, it is essential that patients are fully aware of the risks before undertaking any kind of surgery. Lower eyelid blepharoplasty is a successful procedure with a high level of patient satisfaction. However, as with all surgical procedures it does carry some small risks, which all patients need to be aware of.

Whenever the skin is cut, as necessitated by upper eyelid blepharoplasty surgery, there is a risk of bleeding, scarring and infection. However, the eyelid wounds are small and therefore these are not usually major problems. Many patients are understandably concerned about eyelid scarring.

In general, the scars from upper eyelid blepharoplasty surgery are well hidden in the skin fold or crows foot line and not a problem. However, some people may have an unusual scarring reaction or feel that their scars are more visible than they anticipated, particularly at the outer corners of both eyes where the skin is thicker. It can take a full year for scars to completely mature and therefore it is always best to let things settle fully prior to considering any form of further treatment. Massaging the scars regularly with an unperfumed moisturizing cream can help to speed up scar maturation. see How long does it take the scars to heal?

Other risks of blepharoplasty surgery do include asymmetry of the upper eyelids in terms of height or contour. Most people do have some difference in their upper eyelids and it is likely that there will be some trvial difference between their eyelids after surgery. However, occasionally this can be more noticeable and require further treatment. Whenever skin is removed rom the upper eyelid there is a risk of poor eyelid closure. Most patients do have stiff eyelids straight after surgery and eyelid closure can be weakened immediately after surgery. However, this should completely settle over the next few weeks. Rarely, people can have a prolonged problem with eyelid closure that needs further treatment. Poor eyelid closure can cause dry eye and all patients are given moisturising drops after surgery to keep the eyes moist. However, most people are able to stop these drops around two weeks after surgery as their eyes are confortable by then.

Although it seems obvious, blepharoplasty surgery will alter the way you look and patients need to be prepared for this. Similarly, patients need to have reasonable expectations of surgery otherwise they may be disappointed.

Finally, any surgery around the eye does have the potential risk of causing some visual disturbance. This is extremely unlikely in upper eyelid blepharoplasty as the eye itself is not involved in any way but is something that patients should be aware of.