Overview

Eyes are the focal point of one's face. They are the first thing people notice and are the key to facial expression. This is the main reason why so many people seek cosmetic eyelid surgery. We hear over and over again, My eyes always look tired and old even when I feel wide awake.This is very profound because often if you look old and tired you will feel the same way. How many times have you dressed up and prepared to go out feeling good about yourself only to look in the mirror to see that your eyes look older than you feel. The reason for this is that during the aging process the region around your eyes shows the effects of aging much sooner than other areas.

In the attractive, youthful lower eye lid, the lateral canthus should be higher than the medial canthus. The lower lid should just touch the colored part of the eye.

Aging affects the entire face but usually affects the eye region earliest. The reason for this is because early in life there is a large amount of fat surrounding the eyes. You can verify this yourself by looking at the cheeks of a newborn. They are round and full of fat. As we age, this fat will either descend downward on the face or may go away completely. When this happens, it exposes the underlying facial skeleton resulting in the familiar gaunty appearance that we recognize as aging. Also, the fat and underlying muscles act as a filler creating the volume seen in the cheeks of youth. When this filler descends or goes away we see wrinkling. This process is similar to a grape which turns into a raisin when the water is removed.

Skin With Aging

Youthful Lower Eye. Notice how high and subtle the crease is under the eye.

Aged Lower Eye. Notice how the lower eyelid crease has descended and has become very deep creating bags. Also, notice how the lower lid and lateral canthus has descended producing a tired appearance.

Muscles With Aging

Youthful Eyes. Muscles around the eyes are circular in shape.

Aged Eyes. Notice how the muscles and the lateral canthus sags.

In the past, eyelid rejuvenation was based on tightening the skin via skin excision. This has changed dramatically in the past decade. Today, well trained plastic surgeons realize that skin excision is just a piece of the facial rejuvenation puzzle. In fact, there are four major components that make up the face. 1) Skin. 2) Fat. 3) Muscle. 4) Bone.

The importance of the underlying fat and muscle has been revolutionary in the field of plastic surgery over the last 10 years. It is no longer acceptable to think of eyelid rejuvenation as merely a procedure to tighten the skin. This is why many doctors feel it is so important to correct the problem itself and not just the effects of the problem. Reposition cheek fat is called a Cheek Lift and it can be done at the same time as a lower blepharoplasty. Once again, not everyone needs a cheek lift. This is determined during your consultation.

Fat With Aging

Cheek fat in youth is located high underneath the lower eyelid. This prevents the formation of the lower eyelid crease that is characteristic of an aged face.

Aged Eyes. Notice how the cheek fat has descended creating a deep lower eyelid crease and a deep fold above the lips.

Just text to prevent overlaping

Example of how repositioning the muscles and fat can markedly improve bags under the lower eyelid

Oblique view of same patient.

Another contributing factor to the appearance of old age within the eye region is the fact that the lower eyelid, especially toward the temple region, begins to descend. This gives a depressed, sad appearance. This is much different than the appearance that one had when he/she was younger. The lower eyelid of youth has a bright, elegant appearance with the lateral aspect being higher than the nasal aspect. It is important to address this issue. Often, docrtors will elevate the lateral portion of the lower eyelid to re-create that youthful, almond-shape appearance. This is a powerful and very effective maneuver and is well worth the additional time.

Example of how elevating the lateral canthus in addition to lower blepharoplasty can create an attractive, almond-shape appearance

Lateral view of same patient.

Eyelid surgery alone will not correct crow's feet. It will help but often a concurrent brow-lift and/or face-lift is necessary.

It is often very useful to perform fat transplantation, as well as either chemical peeling or laser skin resurfacing, in addition to eyelid surgery. This allows the plastic surgeon to address all the components associated with aging around the eye. Remember, the aging eyelid is a result of problems within the skin, muscle, and fat.

Example of how fat transplantion can add the necessary volume to fill in crease underneath lower eyelid

Lateral view of same patient.

Benefits

There are many benefits to eyelid rejuvenation surgery. The key is to determine exactly what the problem is.

Lower eyelid surgery benefits.

• Tightens and smoothes out bags underneath the eyes.
• Repositions lower eyelids into a more elegant, almond-shaped appearance.
• Repositions underlying fat to get rid of the sunken, aged appearance.
• Repositions skin and underlying muscles to smooth out wrinkles.
• Markedly fills out the deep crease known as the tear-trough between the eye and nose.
• Eliminates circles underneath the eyes.
• Improves dark discoloration within the lower eyelid.
• Improves fine wrinkles.

Are you a good candidate?

Most people as they age can obtain improvement from eyelid surgery. Specifically, good candidates include people with the following problems around the eyes:

• Bags and loose skin.
• Sad or tired appearance.
• A deep crease circling underneath the eyes.
• Excess skin and wrinkles.
• Dark discoloration underneath the eyes.
• Crow's feet within the lateral eye area.
• Sunken appearance to the eyes.
• Sagging cheek fat.

Possible complications

The most common complication is inadequate correction of the problem. If this is the case, correction can usually be made with a minor additional procedure. Other complications include ectropion, or downward pulling of the lower lid, asymmetry, and dryness of the eyes. Complications that can occur with any surgery include infection, blood or fluid collection, and unfavorable scarring.

Do's and Don'ts prior to surgery

• Medications. Certain medications thin your blood and should not be taken within three weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery.

• Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your plastic surgeon for something to help you sleep.

• Smoking. Do not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, makes anesthesia much more difficult.

• Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with your doctor and the anesthesiologist.

• Washing. It is a good idea to wash your face and eyelids thoroughly the night before and the morning of surgery. Wash your hair and comb it straight back. Do not apply makeup.

• Arrival. It is best to arrive on time so things go smoothly. Please be sure to have someone else drive you.

• State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned.

Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you prior to the procedure. He/she will take into consideration your medical history, the procedure, and your personal wishes.

Eyelid surgery can be performed under general anesthesia or under local anesthesia with or without sedation. If several procedures are being done at once then general anesthesia is the better option. This will be discussed during your consultation with a plastic surgeon and the anesthesia team.

After the procedure

The procedure itself will take about 2 hours. If other procedures are also being done then, obviously, the operative time will be longer.

• Immediately. Right after the operation you will be watched by a nurse for 1 or 2 hours and encouraged to walk around. It is very important that you keep your head elevated to decrease swelling. Still, you can expect that your eyes will swell and there will be bruising. You will be able to eat and drink when you get home.

• That evening. It is recommended that you take it easy. You can walk around, eat, but not much more. Eyelid surgery has surprisingly little pain. You look worse than you feel. Still, you should take as much pain medication as necessary and try to go to sleep early. It is very important to keep your head up the first 3 days. This will markedly decreased the swelling and bruising. The eyes tend to swell and bruise quite easily, so do not be concerned by this. It will go away. If you have general anesthesia you may become nauseated. It is very important not to vomit as this increases bruising and swelling. You will be given anti-nausea medication. You should take it at the first sign of nausea.

• First 48 hours.  You can take a shower the day after. Just be gentle. Use cool water to hit your scalp and then trickle over your eyelids. Do not wash your eyelid with anything, merely, allow water to trickle over it. Afterward, dab dry. Mild oozing will continue for about 2 to 3 days. Dressings are not necessary. Your first post operative appointment with your plastic surgeon will usually be 1 week after surgery.   

• First week. At about day 3, the swelling will be at its maximum. The majority of the bruising and swelling will go away in about 2 to 3 weeks. It is not uncommon for the lower lid to start to pull downward the first few weeks after eyelid surgery. Do not be concerned. This is normal. It will go back up as healing occurs.

• Beyond. Swelling will not completely resolve for about 6 months but, as mentioned above, the majority of it will be gone by 2 weeks. The final result will not be evident until at least 3 to 6 months when all the swelling has resolved and skin contraction is complete. Patients who have fat transplantation or cheek lifting tend to swell more.

Recovery time

Usually, people are off work for about 1 to 2 weeks depending on how self-conscious a patient is about the swelling and bruising. Once again, patients who have had fat transplantation tend to take longer for the swelling to subside.

Consultation For Lower Eyelid Surgery

We have outlined below what you can expect from your lower eyelid consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to your plastic surgeon what it is you want to accomplish.

Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used but also applies to local anesthesia. Prior to meeting with the plastic surgeon you will be given a health history questionnaire. There are five areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.

• General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What will the plastic surgeon do if I have medical problems?

In short, he/she will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem or are over 50 years of age you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.

If you are not able to tolerate general anesthesia it may be possible for your procedure to be done under local anesthesia. This must be discussed with your plastic surgeon.

• Past Surgical History

On your questionnaire you will be asked about previous surgeries. Be sure to identify any problems you may have had with anesthesia. Of particular concern are previous cosmetic surgeries especially if you do not like the result and are interested in revision.

• Medications

Be sure to list all medications including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least 10 days before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.

• Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information!  Nausea is not an allergy but it is important to mention as well.

• Smoking, Drinking and Drug Use

These there will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 2-3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.

Specific Eye Issues

During your consultation you must be very accurate with your eye problems. These include glaucoma, lazy eye, retinal problems, and cataracts. Of particular concern is Dry Eye. Dry eye is characterized by frequent blinking, red eye, itching and burning. It is important because it can made worse by eyelid surgery especially if proper measures such as canthopexy or canthoplasty are not taken.

Patients with thyroid disease must be particularly careful with eyelid surgery as it can cause dry eye and/or persistent swelling if it is not controlled. Therefore, it is important to bring documentation of your last thyroid function test to your consultation as this will be a requirement prior to surgery.

What Do You Want To Change?

It is important that you have a clear idea of what you want changed when you go for consultation. The least favorite thing a plastic surgeon wants to hear is: What do you think I need done?

Look in a mirror and identify what bothers you. Be specific. It may be helpful to look back at younger pictures to see if that problem always existed or if it is part of aging. Bring the picture as it may be helpful.

Physical Exam

The exam can be broken up into 5 anatomic parts that make up the lower eyelid. During your consultation your plastic surgeon will examine each part individually and determine which of them needs to be changed to obtain the desired result.

• Skin

Do you have an excess of skin?  Usually, this will result in wrinkles. If so, then skin removal may be needed.

How is your skin texture. If you have dark circles or age spots then some type of textural rejuvenation will be necessary such as laser or a chemical peel. Often, proper skin care with Retin-A and/or glycolic acid will help tremendously. Other types of treatment such as IPL, and micro-dermabrasion are helpful but often take many treatments. They will not obtain the significant improvements that laser and chemical peeling can but they also do not have as much, if any, down time.

 

Example of lower blepharoplasty that required skin excision to diminish wrinkles from excess skin.

• Muscle

The orbicularis oculi muscle is right under the skin. It is responsible for the wrinkles around the eye that occur with smiling. As we age this muscle sags and give a tired appearance often leaving circles under the eyes. When this is present, resuspension of this muscle is necessary. The woman above had muscle resuspension in addition to skin excision.

 

Youthful Eyes. Muscles around the eyes are circular in shape.

Aged Eyes. Notice how the muscles and the lateral canthus sags.

 

 

 

 

 

The above picture dramatically shows why muscle resuspension is often necessary.

• Fat

There are two types of fat related to the lower eyelid. The first is located just under the eyelid. During aging this fat often bulges out and causes bags. If bags are present there are two ways to get rid of them. The most common way is to map out exactly where they are and cut them out during a lower blepharoplasty. If the bags are not severe then they can be flattened by resuspension of the orbicularis muscle.

 

Example of bags caused by bulging fat. Fat excision combined with muscle resuspension effectively diminished the problem.

 

 

The second fat related to the lower eyelid is the cheek fat. This fat often descends with aging. This leads to loss of cheek height and the characteristic signs of cheek aging. As the fat descends it causes the nasolabial folds to get bigger. Correction of this problem is accomplished either by a face lift or by a cheek lift performed through the same incision as the lower blepharoplasty. A cheek lift is done by elevating the orbicularis muscle and cheek fat as a unit back up to where they once were.

 

Cheek fat in youth is located high underneath the lower eyelid. This prevents the formation of the lower eyelid crease that is characteristic of an aged face.

Aged Eyes. Notice how the cheek fat has descended creating a deep lower eyelid crease and a deep fold above the lips.

 

 

 

 

 

 

 

 

A third modification of lower eyelid fat can be performed by fat transplantation. This is done by harvesting fat, usually from the abdomen, and injecting it directly where it is needed. This is described in more depth in the section fat transplantation.

 

Example of how fat transplantion can add the necessary volume to fill in crease underneath lower eyelid

Lateral view of same patient.

 

 

 

 

 

• Bone

The bone is rarely modified but it always must be taken into consideration during lower eyelid surgery.

Note how far forward the cheek bone is on the patient on the left compared to the patient on the right. The patient on the right is much more difficult to treat because she does not have much cheek support under her lower eyelid. This patient will definitely need lower eyelid support if she has a lower blepharoplasty. This support is obtained by resuspending the orbicularis oculi muscle or by resuspending the lower lid itself by a canthoplasty, or both.

Bone modification can be performed by implants. The most common implants are silicone. Cheek implants are very effective in cheek augmentation.

• Position

The fifth part of the lower eyelid exam is the position and laxity of the lower eyelid. This is extremely important.

 

In the attractive, youthful lower eye lid, the lateral canthus should be higher than the medial canthus. The lower lid should just touch the colored part of the eye.

 

Normally the lower lid position is just touching the colored portion of the eye (the iris). If it is below this then lower lid support is necessary by tightening it via a canthoplasty.

Performing a lower blepharoplasty on a patient with laxity of the lower lid without tightening the lower lid (i.e. canthoplasty) can be disastrous.

Lower lid tightening is necessary to prevent the lower lid from descending so that it no longer touches the iris. Plus, it is a powerful technique to creating an elegant, almond-shape eye. This is especially true in patients with a descended lateral canthus.

 

Example of how elevating the lateral canthus in addition to lower blepharoplasty can create an attractive, almond-shape appearance

Lateral view of same patient.

 

 

 

 

 

 

Laxity can be determined via the snap back test. This is done by pulling the lower eyelid away from the eye ball. Without blinking the lower eyelid should snap back against the eye. If it takes a few seconds or does not occur until you blink then you know that lower eyelid tightening is necessary.

Putting it all together

As you can see, lower blepharoplasty is not simple. This is why it is imperative that you have it done by an experienced Board Certified Plastic Surgeon. All the factors above must be taken into consideration in order to achieve the desired results safely and to prevent complications.

Typical Incisions

 

Lower blepharoplasty incision runs just under the eye lashes until it gets to the lateral canthus. It then cants downward. It becomes hidden in a natural skin crease with time.

The incision remains red for about 6 weeks but then becomes essentially unnoticeable unless there are wound healing problems.