This is part two of a series on Eyelid Surgery or Blepharoplasty. Last week, we reviewed Upper Blepharoplasty. This week, it’s all about the lower eyelids. Lower eyelids have different anatomy, different function and are operated differently than the upper lids.
Lower Blepharoplasty Before and After Pictures
Lower Eyelid Surgery (Lower Blepharoplasty)
Last post we discussed the changes usually desired for the upper eyelids: removal of excess skin, removal of fat from the inner and central aspect of the upper lids if disproportionate, changing the upper eyelid fold and repositioning the lid margin to open the eye. These goals apply to the lower eyelids too, but the methods and priorities change. For Lower Eyelid Lifts the goals are: removing lower eyelid bags, tightening the lower eyelid skin, creating or maintaining normal lower eyelid position and shortening the length of the lower eyelid.
Removing Lower Eyelid Bags
The primary concern with the Lower Eyelids is the baggage. As we age, the facial fat over the lower eyelid thins and descends, revealing the fat pads located under the eyes. For some, these bags enlarge with age. For others, the large bags are present at birth and become more noticeable as the facial fat descends. Either way, Lower Blepharoplasty is designed to reduce excess fullness under the eyes.
Transconjunctival Lower Blepharoplasty
The heading above is a mouthful, but easily understood. Trans means across, or in this case through, and the conjunctiva is the pink lining of the eyelid. Lower blepharoplasty, from last post, means lower eyelid changing surgery. Transconjunctival Lower Blepharoplasty is a method of reducing the lower eyelid’s fat pads through the lining of the eyelid. The advantage is that the scar is completely hidden inside the eyelid. This method works best for younger patients who do not have excess skin and wrinkles on the lower eyelids as shown below, and is common enough to be shown on the Wikipedia blepharoplasty page.
Transconjunctival Lower Blepharoplasty Before and After Pictures
In the Lower Blepharoplasty Before and After Pictures shown above, you can see the bulge in the lower eyelid caused by the excess fat this woman was born with. You can also see her attempt to minimize the appearance with a lighter shade of makeup over the bag. After her Lower Blepharoplasty, the eyelid is smooth and flat. Just enough fat is removed to flatten the bump the excess causes. Removing too much, will cause a hollow. If this patient had wrinkles of loose skin on the lower eyelid, the transconjunctival approach would not be used. Unlike the external approach described below, excess skin cannot be removed with the completely internal transconjunctival method alone.
Tightening the Lower Eyelid Skin
Bigger problems require bigger tools. When the excess lower eyelid fat is combined with loose baggy skin, a Subciliary Lower Blepharoplasty is preformed. Cilium is Latin for eyelash, so the subciliary incision is placed just below the eyelashes on the lower eyelid. This area heals very well, making the incision difficult to see, hidden in the shadow of the eyelashes.
The advantage of the subciliary approach to Lower Eyelid Lifts is the ability to remove excess skin at the same time as reducing the lower eyelid fat. The lower blepharoplasty before and after pictures above show a marked reduction in the lower eyelid bags with tightening of the lower eye skin using the subciliary approach. In this case, only removing the fat is treating only half the problem, and would leave a deflated bag of excess skin under her eyes.
While deep lines caused by skin folds are improved by Lower Eyelid Lifts, the fine lines within the skin need different treatment. The analogy made is between the eyelids and a quilt. Wrinkles in the quilt can be smoothed by gently tugging the quilt flat. This is what lower eyelid surgery does. However, no matter how hard you pull, you cannot smooth the quilting stitched into the fabric. This requires modifying the quilt, not how it lays. For the skin, topical treatments like chemical peels, lasers and dermabrasion are used.
Creating or Maintaining Normal Lower Eyelid Position
The normally positioned lower eyelid covers the lower edge of the colored iris and white sclera under the iris. When the lower eyelid weakens, more of the iris and sclera are revealed. This is termed scleral show, and is associated with a tired, stressed appearance. As the lid descends further, the lower lid may progress to frank ectropion – gapping away from the eye, and interfering with the lower eyelids function of protecting the eye. The pink conjunctival lining may be seen and the tears may not flow properly. This makes the eye feel dry and look red and inflamed. Lower blepharoplasty can be combined with eyelid tightening procedures to prevent or correct this problem.
Lower Blepharoplasty for the above patient was more risky. He already had scleral show, and the normal lower blepharoplasty removes the excess fat and tightens the lower eyelid skin potentially removing support and pulling the eyelid down further. However, when the problem is recognized before surgery, the lower blepharoplasty is modified to include a lid tightening procedure. This improves the eyelid position and prevents the scleral show from progressing to hound-dog appearance of frank ectropion. Nothing against hound-dogs.
Shortening the Length of the Lower Eyelid
All the pictures above show a reduction in the overall height of the eyelid. More accurately, this is caused by a decrease in the how far onto the cheek the eyelid descends. As discussed above, supporting the eyelid during Blepharoplasty is important to preserving the function of the lower eyelid and for maintaining a rested, alert appearance. A shorter eyelid is also associated with youth. An infant’s lower eyelids are so short that often it looks like the cheeks are encroaching on the eye opening. As we age, the cheek drops, and the lower eyelid becomes more apparent. Around puberty, the eyelid appears as its own aesthetic unit, and as we age, it occupies more vertical space above the cheek, While blepharoplasty can help decrease this appearance, the underlying cause is the cheek descending. Cheek decent is more directly treated with a Facelift, or in cases where the cheeks are small or retruded, with Cheek Augmentation.
Blepharoplasty Consultation Appointment Available Now
If you are considering tightening up you eyelids, give me a call at (925) 943-6353. Eyelid surgery and other facial cosmetic plastic surgery procedures are provided by my San Francisco Bay Area private practice in the East Bay city of Walnut Creek, CA. Your personalized consultation will include reviewing the areas you want addressed and creating a plan specific to your goals.