Surgery of the lower eyelids is, in most cases, more anatomically and surgically complex than surgery of the upper lids. While skin excess or redundancy may be an issue, as it is with the upper lids, there are the added issues of lower lid position and support, protruding lower lid fat pads or 'bags', soft tissue atrophy in the 'tear trough' area, and the relationship of the lower lid to the midface (cheek area). Each component of lower lid surgery is discussed below; beginning with what is a concern for almost all patients, the lower lid skin.
Some people develop creases or 'crepey' lower eyelid skin as early as their late twenties or early thirties. The treatment of this issue depends primarily on the severity of the wrinkles. If the problem is skin wrinkling, but not truly skin excess, then surgical skin excision is generally not indicated.
Traditional treatment of lower lid wrinkles and creases, without true skin excess or redundancy, has been a 'chemical peel' or 'laser peel' of the lower eyelid skin. The problem with these aggressive 'peels' is that they smooth out wrinkles by burning through the epidermis (and stimulating the dermis below to produce collagen), and this burn injury produces a 'down time' of, at minimum, several weeks. This is a reasonable approach for patients with significant sun damage or 'weathering' of the lower lid skin.
For eyelid surgery patients with a lesser degree of lower lid wrinkles, new technology is now available to stimulate dermal collagen production and improve wrinkles, without injuring the epidermis and thereby avoiding weeks to months of 'downtime' while erythema (redness) resolves. We now offer Candela GentleYAG Laser Skin Tightening, which is an FDA-approved treatment for the improvement of facial wrinkles. A series of six treatments at intervals of three to four weeks can improve and even eliminate some wrinkles, without the downtime associated with a burn injury of the skin.
Lower Lid Skin Excision +/- Lateral Canthopexy
For blepharoplasty patients with true lower lid skin excess or redundancy, some skin must be removed to restore a youthful appearance. This is performed through a subciliary incision, which is an incision placed immediately below the lower lid lashes. This incision is hidden by the lower lid eyelashes and is almost always imperceptible once it has healed.
As with upper lid, skin excision of the lower lid should be very conservative, amounting to only that amount of skin that is necessary to improve the lower lid skin contour. The muscle layer below must remain completely undisturbed, as it provides horizontal support for the lower lid and helps to maintain the lid position flush against the surface of the eye. Excessive removal of lower lid skin may lead to a complication called ectropion, where the lower lid is pulled down and away from the surface of the eye. This complication often requires additional surgery to correct it, and must therefore great care must be taken to avoid it.
In eyelid surgery patients that do not have adequate lower lid tone or support, and in any patient felt to be at some risk of ectropion, a lateral canthopexy is performed to protect against that potential problem. The lateral canthus (the lateral corner of the eye) contains a tendon that attaches the lower lid tissues to the orbital rim laterally, and this tendon serves as a 'clothesline' that maintains lower lid position. A lateral canthopexy consists of an anchoring or supporting suture that tightens that tendon and thus the lower lid as well. When desired, a lateral canthopexy can also elevate the position of the lower lid. In patients who desire it, this procedure can produce a more 'almond' shape to the eyes.
Lower Eyelid Fat Pads or "Bags"
A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.
As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.
In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.
Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.
Structural Fat Grafting of the Lower Lid
As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.
In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.