Lower Blepharoplasty

Overview

Are your lower eyelids baggy or puffy? Do you appear tired or swollen all the time? Or do you have sagging, wrinkled skin behind your eyes? Lower eyelid bagginess can produce a lot of tension, which can have a big influence on your life. Lower eyelid sagging can affect how you feel, both physically and psychologically, as well as how others see you.

Lower Blepharoplasty, on the other hand, can remove lower eyelid bags and enhance the texture of your eyelid skin, resulting in a smoother, more youthful appearance that improves your comfort and quality of life.

Lower blepharoplasty refers to a group of surgical procedures aimed at improving the look of the lower eyelids. Lower blepharoplasty was formerly a reduction treatment in which skin and/or fat were removed to decrease lower eyelid creases, skin redundancy, and fat bulges.

While fat and skin excision is still used in modern lower blepharoplasty, current developments adhere to a tissue-preserving philosophy, which may involve orbital and sub-orbicularis fat relocation and fat transfer methods to repair apparent volume loss associated with face aging. Hyaluronic acid-based dermal fillers first appeared as an off-label method of lower eyelid and infra-orbital volumization in the early 2000s.

Non-surgical lower blepharoplasty options or non-surgical adjuncts to incisional blepharoplasty have also been developed using laser energy and light-based therapies.

Eyelid Structures

Eyelid, movable tissue made primarily of skin and muscle that covers and protects the eyeball from mechanical injury while also contributing to the moist chamber essential for proper conjunctiva and cornea function. The conjunctiva, like the cornea, is a mucous membrane that borders the eyelid and covers the visible area of the eyeball (the transparent part of the eyeball that covers the iris and the pupil). Each eyelid is supported by a fibrous plate known as a tarsus, as well as muscles that move the eyelids and meibomian (or tarsal) glands that secrete lubricating secretions.

The lids are skin-covered, coated with mucous membrane, and bordered by a fringe of hairs, the eyelashes. The lids move due to the activity of the orbicularis oculi, a circular lid-closing muscle, and the levator of the upper lid, a lid-raising muscle. The face (seventh cranial) nerve sends closure impulses, while the oculomotor (third cranial) nerve sends opening impulses. An oily fluid (called sebum) of the meibomian glands keeps the lid borders moist. This secretion is incorporated into the tear film and helps to minimize evaporative tear loss.

Why Lower Blepharoplasty?

Pre-operative medical and surgical histories, as well as a physical assessment of the patient’s periorbital area (eyebrow-to-cheek-to-nose), decide if the patient may safely undertake a blepharoplasty treatment to resolve the functional and cosmetic indications offered by the patient.

Lower eyelid blepharoplasty can successfully address the anatomic issues of excess eyelid skin, slackness of the eye muscles and the orbital septum (palpebral ligament), excess orbital fat, lower eyelid malposition, and prominence of the nasojugal groove, where the orbit (eye socket) meets the slope of the nose.

A blepharoplasty procedure on the upper eyelid can correct the loss of peripheral vision caused by the upper-eyelid skin draping over the eyelashes. The patient’s peripheral and higher vision are damaged, making it difficult for him or her to do everyday tasks such as driving a car and reading a book. Here are some common indications:

Rhytidosis and lower eyelid dermatochalasis.
Relative steatoblepharon.
Pronounced nasojugal groove.
Infraorbital/malar deflation.
Malar mounds or festoons.
Lower eyelid asymmetry.
Lower lid retraction.

When Lower Blepharoplasty is Contraindicated?

Patients who are looking for secondary benefits, such as bettering their personal relationships, are not good candidates for cosmetic surgery. Patients who measure the effectiveness of the operation based on their happiness rather than restoration and reduction of age changes.

Any pathologic state of the eyelids or orbital structures is an absolute contraindication. Any medical condition that may alter the patient’s response to anesthesia, as well as unrealistic patient expectations, are considered relative contraindications.

Unachievable patient goals / unrealistic expectations.
Coexisting severe or unstable medical conditions (e.g. Uncontrolled DM, heart diseases).
Active thyroid ophthalmopathy (relative contraindication).
Uncontrolled dry eye syndrome.

How you prepare?

You will meet with a plastic surgeon and an eye expert (ophthalmologist) or a plastic surgeon who specializes in eye procedures (oculoplastic surgeon) before scheduling blepharoplasty to discuss:

Your medical background. Your surgeon will inquire about previous operations as well as past or present illnesses such as dry eyes, glaucoma, allergies, circulatory issues, thyroid issues, and diabetes. Your doctor will also inquire about the prescriptions, vitamins, herbal supplements, alcohol, cigarettes, and narcotics you take.
Your expectations. An open discussion about your expectations and reason for surgery can help set the foundation for a successful outcome. Your surgeon will explain whether the operation is likely to be successful for you.

Before your eyelid surgery, you’ll undergo:

A physical examination. Your surgeon will perform a physical examination, which may involve evaluating your tear production and measuring sections of your eyelids.
A vision test. Your eye doctor will check your eyes and assess your vision, particularly your peripheral vision. This is required to support an insurance claim.
Eyelid photography. Your eyes will be captured from various angles. These photographs aid in the planning of the operation, analyzing its immediate and long-term consequences, and establishing an insurance claim.

And you’ll be asked to:

Stop using warfarin (Coumadin, Jantoven), aspirin, ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve, others), naproxen (Naprosyn), and any other drug or herbal supplement that has been linked to increased bleeding.
Ask your doctor how long you should wait before discontinuing these medications. Take only drugs prescribed by your surgeon.
Stop smoking several weeks before your procedure. Smoking might impair your capacity to recuperate following surgery.
If you’re having outpatient surgery, make arrangements for someone to drive you there and back. Plan to have someone remain with you for the first night after surgery.

Surgical Options for Lower Blepharoplasty

A successful surgical rejuvenation of the lower eyelids resolves the patient’s complaints that match to anatomic abnormalities discovered during the evaluation. Appropriate procedures and details might differ amongst surgeons. A single technique or a mix of procedures may accomplish the desired outcome (e.g. transconjunctival fat manipulation with anterior skin pinch).

Markings are frequently performed with the patient sitting. A surgical pen is used to draw the steatoblepharon and hollowing borders.

A local anesthetic liquid containing lidocaine and/or bupivacaine with epinephrine is injected at the surgical site. A corneal shield might be used. It is necessary to employ a sterile preparation.

Trans-conjunctival approach:

The transconjunctival method is one of the most often utilized procedures for lower eyelid blepharoplasty. This is an excellent alternative for people who have an abundance of lower eyelid fat prolapse rather than extra lower eyelid skin. There are several approaches available, but one of the most common is discussed here.

A desmarres retractor is used to provide access, and an infratarsal incision is made using conjunctiva and lower eyelid retractors. Ballotement of the globe aids in viewing the fat pads and finding the best spot for the incision. Exposure is aided by traction sutures put at the proximal conjunctival margin. If the exposure is insufficient, lateral canthotomy and inferior cantholysis may be necessary. The orbital septum is not disrupted, allowing direct access to the three lower eyelid fat pads.

The orbital fat pads are debulked or mobilized as pedicles to be repositioned to locations of inferior concavity to the orbital rim. Monopolar or bipolar cautery is used to maintain strict hemostasis. The inferior oblique muscle is visible and unaffected. After generating a pocket and loosening attachments, fat redraping might occur in the suborbicularis or subperiosteal plane. Percutaneous sutures or internal absorbable sutures are used to secure the fat pedicles. Through a transconjunctival incision, the suborbicularis oculi fat (SOOF) can be lifted and secured to the orbital rim periosteum using absorbable sutures. A SOOF lift, like orbital fat repositioning, assists in the effacing of the tear trough and infraorbital hollows.

Skin approach (infraciliary):

An incision is made 1-2 mm below the eyelash line or within an existing infraciliary crease, continuing to the lateral eyelid crease. By compressing the skin with a hemostat without producing traction on the eyelid edge, a skin “pinch” can be used to evaluate the degree of redundancy. Alternatively, a skin flap may be formed, extending as far as necessary to allow proper mobility while preserving the contour of the eyelid aperture.

To avoid anterior lamellar deficiency, only a little quantity of skin is removed. To determine the allowable amount of skin trim, the patient is requested to look up and open their mouth. The skin-muscle method begins with a flap deep to the orbicularis and allows for improved advancement and trimming of skin and muscle as a single unit or independently. The infraciliary incision allows access to the orbital fat pads and SOOF and is treated in the same way as the transconjunctival approach.

Additional procedures:

Canthopexy or lateral canthoplasty is used to treat significant lower lid laxity prior to blepharoplasty.

To enhance volume to the infraorbital hollows and the lid-cheek junction, fat grafting procedures may be performed. Volume and projection defects can also be improved using alloplastic orbital rim and malar implants.

In eligible individuals, laser skin resurfacing (ablative or non-ablative) or chemical peels enhance lower eyelid skin quality and minimize rhytidosis and dyschromia.

Ligation, sclerotherapy, or laser treatment can all help to decrease or eradicate the appearance of unsightly lower eyelid veins.

Botox reduce the dynamic wrinkles that occur in the periorbital area and lower lids.

What happens after?

After surgery, you will be monitored for issues in a recovery room. You may depart later that day to rest at home.

Following surgery, you may experience:

Blurred vision from the lubricating ointment applied to your eyes
Watering eyes
Light sensitivity
Double vision
Puffy, numb eyelids
Swelling and bruising similar to having black eyes
Pain or discomfort

Your doctor will likely suggest you take the following steps after surgery:

The night following surgery, apply cold packs to your eyes for 10 minutes per hour. The next day, apply cold packs to your eyes four to five times during the day.
Gently wipe your eyelids and apply prescription eyedrops or ointments.
For a week, avoid straining, hard lifting, and swimming.
For a week, avoid intense activities like aerobics and jogging.
Smoking should be avoided.
Try not to rub your eyes.
If you wear contact lenses, wait about two weeks following surgery before putting them in.
Wear darkly coloured sunglasses to shield your eyelid skin from the sun and wind.
For a few days, sleep with your head higher than your chest.
To minimize edema, apply cold compresses.
Return to the doctor’s office a few days later to have any sutures removed.
Avoid aspirin, ibuprofen (Advil, Motrin IB, and others), naproxen sodium (Aleve, and others), naproxen (Naprosyn), and other drugs or herbal supplements that may cause bleeding for roughly a week. To relieve discomfort, take acetaminophen (Tylenol, etc.).

When to call your Doctor?

Seek medical attention right away if you suffer any of the following symptoms:

Breathing difficulty.
Chest ache.
High heart rate.
New severe eye ache.
Bleeding
Vision issues.

Results of the Procedure

Many people are pleased with the outcomes of blepharoplasty, which include a more relaxed and young appearance as well as increased self-confidence. The effects of surgery may endure a lifetime for some people. Others may have recurring droopy eyelids.

Bruising and swelling should go away in 10 to 14 days, which is when you should feel safe going out in public again. Scars from surgical cuts may take several months to fade. Take care not to overexpose your delicate eyelid skin to the sun.

Alternatives to Lower Blepharoplasty Surgery

Patients may prefer a nonsurgical eye lift over a surgical operation for a variety of reasons. Anesthesia may not be an option for some, while others are concerned about the cost or downtime involved with surgery. Furthermore, younger patients who exhibit just mild to moderate indications of aging may not believe that their problems warrant invasive surgery at this time. Nonsurgical blepharoplasty alternatives can be effective in any of these situations.

Cosmetic injectables:

Injectable dermal fillers like JUVÉDERM® and wrinkle relaxers like BOTOX® can offer dramatic results with little to no downtime. A combination of fillers and neurotoxins may often assist generate the most dramatic results by treating a variety of issues, such as hollow undereyes, dark circles under the eyes, and wrinkles or Crow’s feet around the eyes.

Radiofrequency(RF) microneedling:

Another wonderful nonsurgical alternative for renewing the skin and generating a more lifted, tighter, younger-looking eye region is radiofrequency microneedling. A specialized equipment will cause microscopic micro-injuries on the skin’s surface during RF microneedling, which uses a topical numbing medication to make the therapy more pleasant. This procedure destroys skin cells while stimulating the creation of new, healthy skin cells, resulting in a firmer, more youthful, and radiant complexion. Furthermore, radiofrequency energy stimulates cells deep beneath the skin to increase collagen and elastin formation, boosting the benefits over the following several weeks and months.

Because the strength of RF microneedling can be regulated, it is light enough to be utilized on the delicate skin of the upper and lower eyelids, making it an excellent nonsurgical alternative to blepharoplasty.

Platelet-rich plasma(PRP)therapy:

Platelet-rich plasma treatment is another novel option for rejuvenating the eyes without surgery. PRP is commonly used with microneedling to improve its effects and generate even more stunning, longer-lasting results. During microneedling with PRP, a little quantity of blood is extracted from the patient’s arm. A specialized centrifuge equipment is used to separate the platelet-rich plasma from the other components of the blood. Furthermore, the microneedling device is passed over the skin, creating small punctures that promote the growth of new, healthy skin cells on the surface. Finally, the PRP serum is massaged into the skin, boosting the body’s healing process as well as collagen and elastin production for firmer, more youthful skin texture.

Laser skin resurfacing:

With a variety of highly modern ablative and non-ablative laser therapy systems available, patients of virtually every skin type, tone, and color may address minor to severe issues and obtain their desired results. Non-ablative treatments address more moderate issues and assist regenerate the skin and stimulate collagen synthesis, whereas ablative treatments address more severe symptoms such as severe sun damage and deep wrinkles.

Complications

Retrobulbar hemorrhage is a rare but serious complication that should be emergently addressed.
Chemosis.
Pyogenic granuloma.
Undercorrection or overcorrection of steatoblepharon.
Lagophthalmos.
Inferior oblique muscle injury / diplopia.
Hypertrophic scar.
Suture cysts.

Lower eyelid retraction is a risk of lower blepharoplasty and may be more prevalent when the septum is broken from the anterior approach rather than the transconjunctival approach. Scarring of the middle and/or posterior eyelid lamellae causes retraction, which is seen as a low-positioned eyelid that is tied to the orbital rim.

Overzealous skin removal, adverse contraction following surgery, or poor healing after eyelid skin resurfacing can all induce anterior lamellar deficit.

Ectropion can occur after lower blepharoplasty regardless of retraction or skin deficit if a lax lower eyelid is left untreated or if postoperative tractional forces are unopposed in the setting of weak canthal support.

Lower Blepharoplasty Cost

Lower blepharoplasty operations are more expensive than upper blepharoplasty procedures because they are more difficult and frequently require a general anaesthetic, which adds to the expense. In general, this technique is used to enhance the look of a patient’s under-eye bags by decreasing puffiness or tightening the skin right under the eye.

According to experts, the typical cost ranges from $75 and $9,200.

Conclusion

There’s no doubt that a person’s eyes influence their whole appearance. In reality, sagging eyelids and wrinkles around the eyes can make a person look fatigued, irritated, or older than they are. Because many of the first indications of face aging appear on the eyelids and around the eyes, an increasing number of people are choosing for cosmetic eyelid surgery to restore a more youthful appearance.

Lower Blepharoplasty is a surgical method for treating abnormalities, deformities, and disfigurations of the eyelids, as well as cosmetically changing the eye region of the face. Blepharoplasty treats functional and aesthetic concerns of the periorbital area, which is the region between the brow and the top section of the cheek, through excision and removal of skin and adipocyte fat and strengthening of the appropriate muscle and tendon tissues. The surgery is most popular among women, who accounted for around 85 percent of blepharoplasty surgeries in the United States in 2014 and 88 percent in the United Kingdom.

The operational objective of a blepharoplasty is to restore the proper functioning of the damaged eyelid(s) as well as the aesthetics of the eye-region of the face.

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