The eyes may be the window to the soul but they are also a measure of aging. Because of the expressive movement of tissues around the eye and the thinness of the skin, this area shows the first sign of aging changes on the face. The sphincteric action of the orbicularis oculi muscle generates an array of radiating wrinkles to the side and below the eye and exerts a downward pull on the eyebrow. Because we look at this area with great frequency, often the first thing we look at in a mirror, the development of wrinkling is quickly discovered.

Surgical removal of eyelid skin (blepharoplasty) and elevation of the eyebrows (browlift) are well known and effective strategies for periorbital aging. But they are best used in moderate to advanced stages of aging. In addition, some people simply don’t want surgery whether it is because of the recovery or the cost.

The use of lasers for facial wrinkle reduction is well known and has been around now for over two decades. But their use around the eyes and on the eyelids where the skin is thinner is the use of lesser depth laser treatments known as micropeels but with more restricted depths of penetration come less results as well.

The newer fractional laser treatments offer a paradigm shift is how laser energy is delivered. Rather than being ablative to 100% of the treated skin, the fractional laser treats but a portion of the surface. Rather than producing a complete layer of burn tissue, columns are created instead. This leaves a lot of uninjured skin between the vertical columns which allows for faster healing and less risk of scarring. But each column does deeper down into the dermis, creating a collagenous remodeling effect.

When fractional laser treatments are applied in the periorbital area, significant improvements have been reported in numerous clinical studies. Measurable improvements have been seen in reduction of wrinkles, skin tightening and eyebrow elevation. This was found to be true in all skin types, including those with darker pigmentations. The results come exclusively from the changes in the skin and such problems as fat herniation, significant malar and brow sagging and orbicularis muscle hypertrophy will not be improved by this or any form of laser resurfacing.

The caveat to success with fractional laser periorbital rejuvenation, and being able to treat the eyelids directly, is the use of low energies and multiple treatments. This allows for both safety with minimal risk of any adverse scarring and very quick recoveries in the order of a few days. Spaced about six weeks to eight weeks apart, a series of three or four treatments is needed to get the best results. One should anticipate a single maintenance treatment per year. It is also important to use a good topical regimen daily with both exfoliative and regenerative agents such as retinoic acid and ascorbic acids.

The use of the fractional laser offers a new treatment option for the aging eyelids and brows. Some have termed this the fractional eyelid lift or the ‘Madonna Lift’. But names aside, this laser treatment provides an intermediary step before surgery that can serve as an effective treatment for those with early sign of aging or as a delay manuever before blepharoplasty surgery is done later.

Dr. Barry Eppley

Indianapolis, Indiana

Background: The earliest and most recognizeable area of facial aging is around the eyes. Due to the near constant motion of the eyelids and surrounding sphinteric-like orbicuralis muscle action, redundant skin and wrinkles develops on both eyelids. With enough time and aging, the extra skin becomes significant enough to hang down onto the lashes of the upper eyelids and rolls of extra skin hang below the lower eyelids often with protruding fat.

The traditional approach to eyelid aging is blepharoplasty surgery. This highly effective procedure uses wide excision of skin with the final closure/scar lying in a natural eyelid crease in the upper eyelid and just below the lashes on the lower eyelid. This skin removal creates exposure for elimination of herniated fat pads and tightening of redundant or sagging muscle if needed. Complete recovery usually takes about two or three full weeks until all vestiges of swelling and bruising are gone.

While aging of the eye area begins as early as the mid- to late 30s, a traditional blepharoplasty is too invasive and extensive procedure for the amount of aging present. Thus, while many people are bothered by these early eye aging eye issues they delay surgical improvement until they are suitable for a more complete blepharoplasty. But like the limited or mini- versions of facelifts that have become popular in the past decade, similar scaled-down mini-blepharoplasty operations also exist. In the spirit of matching the solution to the problem, these smaller eyelid tucks remove less skin and rely on skin resurfacing to eliminate some of the wrinkles. As a result, they have a fairly quick recovery which is usually half that of a traditional blepharoplasty.

Case Study: This 38 year-old female from Indianapolis Indiana was bothered by her tired eye appearance. Even though she was relatively young, she had a lot of skin rolls on her eyelids and wrinkles on the lower eyelid. These had developed in just the past five years and she felt it was due to a lot of stress in her life. Her eyes certainly did not match her age or the rest of her physical appearance. Creepy loose skin was evident but there was no herniated eye fat or bags present.

Under general anesthesia, her eyelids were treated by a minimal skin excision technique known as a pinch blepharoplasty. A special instrument was used to pinch up the extra skin along the defined upper eyelid skin crease and just below the lashline of the lower eyelid. This pinch amounted to 6 to 7mms of skin in the upper eyelid and 3 to 4mms of skin on the lower eyelid.. The pinched skin was then removed with scissors and closed with a small running dissolveable suture. The lower eyelid was then treated by a chemical peel of 35% TCA until a good frost was obtained.

She had no dressings afterward and only applied a thin layer of antibiotic ointment to the incision lines and peeled skin for one week. She had minimal bruising and swelling that was largely gone by the 10^th day after surgery. Her tired eye appearance was eliminated and she easily appeared five to seven years younger.

The technique of the pinch or mini blepharoplasty is based on the principles of limited tissue removal and no skin undermining. This is why bruising does not occur, or at least very little, as the blood supply to the skin is compressed by the instrument prior to scissor removal. This is also why it is safe to treat the lower eyelid skin by chemical or laser resurfacing as it has an uncompromised blood supply.

Case Highlights:

1) Facial aging first appears on the eyelids with the development of loose skin and wrinkles, creating a tired appearance.

2) Blepharoplasty removes loose skin and in older aging eyes that may be a considerable amount of skin rolls and herniated.

3) In younger patients with early onset aging, more limited pinch blepharoplasties can be performed with lower eyelid chemical peels for a less invasive procedure that better matches the amount of aging present and offers a rapid recovery.

Dr. Barry Eppley

Indianapolis, Indiana

One of the common concerns amongst many patients considering facial rejuvenation procedures is that they don’t want to look ‘done’, ’surgical’ or otherwise unnatural. They would prefer that people do not see them as having had plastic surgery. On the flip side of that concern is that they also want to have some visible improvement and get good value for their investment.

For fear of being overdone, some patients will stay with less invasive procedures like Botox, injectable fillers and light and laser skin treatments. While they don’t produce surgical results, there is no fear of having too significant a facial change.

A recent study published in the February issue of the Achives of Facial Plastic Surgery reports an interesting and perhaps not unexpected finding…the more procedures patients have done, the younger they look. This study looked at sixty patients between the ages of 45 and 72 years old, 90% of whom were females. They were divided into three types of facial rejuvenation procedures. The first group had lower facial rejuvenation of facelifts/necklifts. The second group also had facelifts but also had eyelid work or blepharoplasties done. The third group had more total facial rejuvenation which also included browlifts with blepharoplasty and facelifts. The ages of the patients were then estimated by non-surgeons. (medical students)

The students rated patients in the first group as appearing 5.7 years younger but the second and third groups were rated 7.5 and 8.4 years younger respectively. In essence, the more procedures a patient had done the younger they look. Or, more relevantly, the more parts of the aging face you treat the better or more rejuvenated the entire face becomes.

But the real importance of this study, and something I tell my patients all the time, is that work done around the eyes always produces the most rejuvenated appearance. Periorbital rejuvenation, blepharoplasties and browlifts, creates the most visible evidence of improvement to both the patient and particularly to others. This has to do with a basic element of human interaction and communication…we spend most of our time looking at each other’s eyes. That is actually how most people recognize another’s face. It is also how people perceive, right or wrong, our physical state and emotions. For example, everyone’s been told (numerous times no doubt) that we look tired. It is our eyes that carry that impression.

Cleaning up loose and redundant eyelid skin, getting rid of eyelid bags by fat removal and even lifting sagging brows can make the whole eye area look less tired and aged. The eyes are the first area that begins to show age and often shows it the worst even as the rest of the face ages. For this reason, blepharoplasty in particular is almost always the best value of any facial rejuvenation procedure. It has the greatest anti-aging effect for the money as its benefits will be guaranteed to be seen by all.

Dr. Barry Eppley

Indianapolis, Indiana

Background:  As one ages there are classic changes that occur around the eyes. Skin hangs down from the upper eyelids, wrinkles develop on the lower eyelid and radiate outward and lower eyelid bags develop, worse in some people than others. In addition, as we age our skin becomes thinner and more loose. As the cheeks underneath the eyes becomes hollow with fat atrophy, it causes the lower eyelid to sag or droop downward as well.

One element of this aging eye scenario is the puffiness that develops in the tissues, particularly on the lower eyelids. This is largely the result of herniated fat which extrudes beyond the vertical plane of the lower eye socket.This lower eyelid puffiness is also a cause of dark circles. Dark circles under the eyes are either created by the puffiness or aggravated by it. They result because of a shadow cast by the overhanging eye bag or puffy eyelid.

Many people have tried a myriad of hyped creams and even injections to get rid of their eye bags and dark circles, only to be ultimately disappointed. Frequently accused of inadequate sleep, people so affected get tired of being asked if they are tired. Ultimately, only blepharoplasty surgery can correct puffy eye problems.

Case Study: This 52 year-old female from Columbus Indiana finally came to realize that it was time to improve her aging eyelids. Her eyes had gotten increasingly puffy with darker and darker circles developing. She had tried many over the counter and even doctor-prescribed eye creams but none had worked. She was finally ready to commit to surgery for improvement.

Under general anesthesia, both upper and lower eyelids were treated. The upper eyelids underwent removal of all overhanging skin that had extended down onto the lashlines. The lower eyelids were treated by eyelid fat removed from inside the eyelid (transconjunctival lower blepharoplasty), a pinch excision of 3 to 4mms of skin directly underneath the lashline and 35% TCA chemical peel of the lower eyelid skin.  

It took ten days for most of the swelling and bruising to resolve and three weeks to really look completely non-surgical and recovered. But the change in the appearance of her eyes was nothing less than dramatic. While this surgery is not designed nor will it remove every bit of loose skin or wrinkles, it makes her look years younger and certainly less tired.

The most challenging part of aging eye surgery is the lower eyelid. Because it is a suspended structure, too much skin removal and scarring from surgery can weaken its support structures causing sagging. Known as ectropion, this is more than just a cosmetic problem and can cause significant symptoms of dryness and irritation of the eyes.

To prevent this potential problem, a more conservative approach to lower eyelid surgery has become popular with the herniated fat causing the puffiness being removed from the inside lining (conjunctiva) of the lower eyelid. Limited skin removal is done by not raising a full lower eyelid skin flap but by pinching or rolling up some of the excess skin with a special instrument. This preserves the orbicularis muscle sling of the lower eyelid and causes little scar which can have a downward pulling effect. Because the blood supply to the lower eyelid skin is not disturbed, a simultaneous chemical peel can be safely done for a mild tightening effect and some reduction in the dark circles. This triple combination approach addresses all issues of puffy eyes with less risk of complications.

Case Highlights:

1)      Aging around the eye area affects everyone in different degrees with the most severe manifestation being that of extreme puffiness of the lower eyelids

2)      Puffiness around the eyes is associated with large amounts of redundant upper and lower eyelid skin and herniated fat with persistent tissue swelling.

3)      Puffy eyes can be corrected with standard blepharoplasty techniques that emphasize aggressive upper eyelid skin removal, lower eyelid herniated fat removal and conservative lower eyelid skin resection.

Dr. Barry Eppley

Indianapolis, Indiana

Background: Aging of the eyes is both an unavoidable eventuality for everyone and the first and most noticeable place on the face that it occurs. The classic findings are heavy or extra skin on the upper eyelids and bags on the lower eyelids. This combination makes for a tired or older appearance that is recognized by everyone since most of how people see and remember our face is in the eye area.

While these findings are typical periorbital signs of aging, why do they occur? Since most of eyelid closure comes from movement of the upper eyelid, its thin skin is prone to become lax and wrinkled. It eventually falls down into the eyelashes obliterating the supratarsal fold and making the upper eyelid heavy. The bags on the lower eyelids come from herniated fat. As the lower support structures between the tarsus and the lower eye socket edge weaken, fat that is normally under the eye as a supportive cushion protrudes forward. As it bulges past the vertical plane of the infraorbital rim, it appears a bag-like protrusion. This combined with the development of wrinkled and sagging skin give the lower eyelid its baggy and sagging appearance.

Case Study: This 55 year-old female from Indianapolis Indiana wanted to make her facial appearance fresher and less tired. She felt her eyes were her biggest problem and wanted to get rid of her loose skin and bags. She had an eye history of having had Lasik surgery two years previously and had some mild dry eyes since. On examination her lower eyelid was lax with a delayed snapback test.

Under general anesthesia, she underwent upper and lower blepharoplasty. On her upper eyelids, excess skin and a small strip of orbicularis muscle was removed along her existing supratarsal crease line. No fat was removed. On the lower eyelids the three fat pockets were removed and a small strip of skin excised. (3mms) A canthopexy procedure was performed because of her lax canthal tendon. The skin was closed using an orbicularis muscle suspension technique prior to a superolateral sweep for the skin closure.

Her skin sutures in the lateral canthal area were removed one week later. It took her a full three weeks for all swelling and bruising to completely resolve. She did return to work ten days later and felt comfortable enough to do so with a little make-up. She had no problems with tearing or dryness of her eyes in her recovery.

While blepharoplasty surgery can make a big difference in the appearance of one’s eyes, it is important to recognize that eyelid function must not be disrupted. Management of the lower eyelid is usually the key to preventing postoperative problems. Not removing too much skin and providing tendinous and muscular support on the lower eyelid will minimize the risk of ectropion or lower eyelid retraction.

Case Highlights:

1) Aging eyes have extra upper eyelid skin and lower eyelids bags which bother the owner the most.

2) The emphasis of blepharoplasty surgery is removal of skin in the upper eyelid and fat removal in the lower eyelid.

3) Successful and uncomplicated blepharoplasty surgery is based on judicious skin and fat removal with management of a lax lower eyelid if necessary.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background:  When a man presents for facial rejuvenation it frequently is driven by someone (or many) telling them they look tired. With enough repeated comments and in looking in the mirror, it eventually becomes evident that they in fact are looking tired. This most commonly is due to changes in the eye area.

A man’s eyelids begin to sag and excess skin and fat develop in both of them. The upper eyelid skin hangs down onto the lashes making them feel heavy and obliterating any evidence of a supratarsal fold. The lower eyelid becomes very puffy  and develops a sagging appearance. Dark circles often develop under the eyes which draws extra attention to their changed and aging appearance. Also, the eyebrows may begin to sag and hang below the browbone, creating a ‘hangdog’ or an angry expression. Crow’s feet and other wrinkles develop outside of the actual eyelids.

Blepharoplasty or eyelid surgery is the well known antidote to a man’s aging eyes.While eyelid surgery may seem similar between men and women, there are some subtle and important differences. Men often seek a less obvious and an absolutely natural look compared to women. Eyelid scars are also a major concern, particularly in the lower eyelid as men do not have the option of scar camouflage with cosmetics. (they can use them but usually don’t want to) Men also desire to avoid any periorbital change that would make them look in any way feminine. These include such concerns about too high of an upper eyelid crease/scar, an upward flare to the eyebrow or too tight of a sweep to the tail of the lower eyelid or alteration of the corner of the eye. It is also important to realize that men are not usually interested in getting rid of every single wrinkle around \their eyes, they just want to less less tired and more refreshed.

Case Study: This 52 year-old man from Indianapolis Indiana was tired of being told he looked tired. He was bothered by skin that hung down onto his upper eyelids and eyelashes and the bags under his eyes. His lower eyelid bags were usually fairly swollen in the morning and it took all day until some of the puffiness went down. It took him several years to come to the realization that surgery was the answer.  

Under general anesthesia, he had both upper and lower eyelids treated. The excess skin of the upper eyelid was removed creating a visible supratarsal fold and upper eyelid crease. A skin-muscle flap lower blepahroplasty technique was used removing a significant amount of herniated fat. Minimal lower eyelid skin was removed and the corner of the eye was tightened with the skin closure.

He had the usual amount of swelling and bruising after surgery that took about ten days to look ‘passable’. By three weeks after surgery, he looked non-surgical and was clearly in the benefits phase of the procedure. He did have some mild tearing issues of the left eye which took six weeks to completely resolve due to a slight amount of temporary lower eyelid retraction in the corner. He ended up with a less tired look around his eyes but with an unchanged appearance.  

Case Highlights:

1)      Facial aging in men disproportionately affects the eye area with extra skin, protruding fat, wrinkles and brow sagging.

2)      Blepharoplasty surgery in men must avoid overresection and tightening of eyelid tissues that can look unnatural and more feminine.

3)      Eyelid surgery in men creates a refreshed look but an overall unchanged facial appearance.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Background:  Aging is a lifelong process that is both relentless and progressive. In the face, the earliest signs of aging occur around the eyes. Beginning with wrinkles and eventually ending up with sagging eyelid skin and brows, the eyes and its surrounding structures (periorbital region)  show the range of manifestations that occur with the aging process. Because the eyes are the most visible area seen in every human interaction, their appearance has an influence on the perception of how one is perceived by others. But aging can also affect the main function of the eyes which is to see clearly.

In the latter stages of periorbital aging, usually ages 60 and beyond, the issue of aging goes beyond merely that of wrinkles. Upper eyelid skin becomes so excessive that skin hangs down on the eyelashes, creating not only a heaviness but impinging on one’s upper visual field. Without even knowing it, one loses how much light enters the eyes and the world becomes ‘darker’  and smaller in scope. and  The amount of upper eyelid skin rolling over onto the lashes is made even greater if the eyebrows have also dropped. Sagging eyebrows push the upper eyelid skin lower, dragging the level of the upper eyelid down creating a pseudoptosis appearance.

Case Study: This 69 year-old female presented with heavy eyes and an almost squinting appearance. She felt she looked tired and had a constant feeling of skin on her eyelashes. She regularly pulled up on her brows and eyelids to lift up the overhanging skin. Her eyelashes were completely covered by upper eyelid skin and were not visible. Her eyebrows were slightly below the brow bones. Visual field testing showed that almost all of her upper fields were obscured.

Under general anesthesia, an upper periorbital rejuvenation surgery was done. The first step in her procedure was to do a browlift. Because of her already long forehead, an open browlift was done using a hairline or pretrichial approach. Approximately one centimeter of skin was removed in the midline tapering out into the temporal areas. After the browlift, an upper blepharoplasty was done removing a large amount of skin and a small amount of orbicularis muscle. Her total procedure time was 90 minutes and she was discharged to home a few hours later.

Her frontal hairline and upper eyelid sutures were removed one week after surgery. Her swelling at that point was still discernible with some small amount of bruising. When seen just three weeks after surgery, she looked completely ‘non-surgical’. Her biggest comments were in how everyone told her how much more refreshed she looked and that she could see so much better. She noted how much brighter everything looked with some much more light being seen. She has to start wearing sunglasses again when outside because of the brightness.

Case Highlights:

1)      Opening up the aging periorbital region through upper eyelid tucks and a browlift can make a dramatic difference in one’s appearance and how it is perceived.

2)      When considering an upper blepharoplasty (eyelid tuck), consideration must be given to the position of the eyebrow and the possible need of a browlift.

3)      A good periorbital rejuvenation result makes one look refreshed and less tired but does not make one look like a different person.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Blepharoplasty, or eyelid tucks or lifts, are one of the most common anti-aging facial plastic surgery procedures. Everyone will eventually develop the classic signs of aging around the eyes including excess skin, fat protrusions and wrinkles. Because one’s eyes are focused on in everyday conversation and in photographs, the desire and frequency of different blepharoplasty operations is highly requested.

Despite the often great results that result from blepharoplasty surgery, it is not an operation that is immune from potential complications. What is unique about blepharoplasty complications is that they involve eyelids which have the functional purposes of eye protection and lubrication. This often translates to a range of dysfunctional eye symptoms that can occur in addition to eyelid appearance deformities.

The upper and lower eyelids, however, have significant differences in the risks and types of complications that can occur. As a general rule, the incidence of lower eyelid problems greatly exceeds that of the upper eyelid after blepharoplasty manipulations. This is due to their anatomic differences with the lower eyelid being a tightly suspended structure across the lower eyelid whose support can be easily disrupted by incisions, skin removal and scarring from fat removal and orbital septum disruption.

The most common upper blepharoplasty problems are the removal of too much skin or fat. It is actually rare to ever remove too much upper eyelid skin. Removal of too much skin is reflected in an inability to have complete upper eyelid closure with the lower eyelid. Upper eyelid skin is fairly easy to stretch out and is aided by the flexibility of the eyebrow to move down slightly. Too much upper eyelid skin removal is really only a potential concern with it is being combined with a browlift, which ‘removes’ skin by pulling the upper eyelid upward. Only a skin graft can restore the upper eyelid when too much skin is removed. Fortunately this is uncommon.

The more common upper eyelid problem is either a visible incision line or when too much fat is removed. Hollowing of the upper eye can occur when too much fat, usually from the central fat pad, has been removed. It is the medial pad that fat should be taken from in the upper eyelid but it is easy to mistake the central pad for the medial one. This can lead to central hollowing. Fat grafting can reduce the hollowing and can be done with either a composite graft from the buccal fat pad or injections from liposuction harvest.

While the lower eyelid can have similar complications as that of the upper, they often are more visible and symptomatic. Lower eyelid retraction is the most severe problem and is usually the result of a subciliary lower blepharoplasty with skin, muscle and fat removal. Either too much tissue has been removed or its lateral resuspension has been improperly done. This results in a pulling down of the lower eyelid away from the eyeball. (ectropion) It is always greater in the outer part of the eye near its corner where support from the lateral canthus is the most needed. Many older patients are particularly prone to this potential problem because of a weakened and lax lateral canthal support.

Most of the time, lower blepharoplasty-induced ectropion can be corrected by lower eyelid release and tightening or reattaching the lateral canthal region. I find that this works most of the time for the common ectropions that are seen. In more severe cases, midface lifts or even skin grafts as a last resort can be done. Because gravity is a constant nagging factor, severe ectropions will only get long-term relief from tissue replacement. While concept of a lower eyelid skin graft can be disconcerting, its appearance can be improved by secondary skin resurfacing methods.

The problems that lower eyelid ectropion poses speaks as to why the emphasis of lower blepharoplasties in the past few years has been more towards transconjunctival techniques with limited eyelid skin removal. As always prevention is better than the cure and, despite an understandable patient desire for the smoothest lower eyelid possible, the ‘suffering’ from a few extra lower eyelid wrinkles is at least not physical.

Too much fat removal or lower eyelid hollowing is a complication, unlike ectropion, that is a delayed one and may not be seen for months to years. Again, fat replacement is the treatment but larger amounts are usually needed for the lower eyelid versus the upper. The size of the lower eyelid hollowing may therefore lend itself better to fat injection techniques.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Aging of the eyes is the most recognized and often the first area of facial aging. It happens to everyone and is seen as excessive skin and hooding of the upper eyelids and bags and wrinkles of the lower eyelids creating a tired and aging look. This makes the desire for eyelift lifts and tucks, known as blepharoplasties, one of the most requested facial plastic surgery procedures. It is also one that I can call a ‘great value’ because its effects are seen with a more rested look to the highly visible and viewed eye area.

While improving the appearance of the upper and lower eyelids seems on the surface to be similar, they are significant differences that must be appreciated. The upper eyelid is the more dynamic of the two and is responsible for much of eyelid closure. It is a downward moving structure that has little risk of adverse lid position with skin and fat removal. (possible with disruption of the submuscular levator but this is out of the traditional surgical plane of dissection)

The lower eyelid, however, is a suspended structure that has relatively little closing motion and is held tightly against the eyeball through its tendinous attachments from the inner and outer corners to the orbital bone. Removing skin and fat of the lower eyelid can easily affect its horizontal position, creating a postoperative risk of lower eyelid retraction and undesireable eye symptoms such as tearing and irritation.

This has led to many modifications of the traditional lower blepharoplasty procedure to limit the risk of lid retraction and expedite recovery. The emphasis on skin removal and tightening (which is still needed for some patients) has been replaced by greater emphasis on limiting disruption of support structures and less skin removal. The focus has also changed to improving the shape and contour around the lower eyelid and cheek, not just how tight or wrinkle-free one can make the lower eyelid. This not only leads to less postoperative complications but a more natural and less risk of an ‘operated look’.

Some basics of the modified lower blepharoplasty include fat removal though the inside of the lower eyelid (transconjunctival approach), pinch skin excision (2 to 4mms removed), and a lower eyelid chemical peel. This works well in most younger patients who are generally under the age of 50. Older patients will likely need some additional components to the procedure including fat injections to the malar fat pad (for upward support and contouring), release of the orbicularis retaining ligament and lateral canthal support. (both for prevention of lower lid retraction from skin removal)

For those patients who have ever suffered a lower lid retraction after blepharoplasty, they can testify how uncomfortable and problematic it can be. It would have been far better to have a little extra skin and wrinkles on the lower eyelid than these problems. A more conservative approach that disrupts less of the support structures of the lid is a sound anatomic approach to lower blepharoplasty. Patients should be aware and counseled that the result will not be a perfectly smooth lower eyelid but a more naturally refreshed one.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Aging of the lower eyelid is typified by excessive skin and wrinkles and herniated infraorbital fat. It is this fat that often gives the appearance of lower eyelid bags and puffiness which is always greatest in the morning. This fat is typically removed, in varying amounts, in the commonly performed lower blepharoplasty. While making a dramatic improvement in the short-term, aging and further fat atrophy can create a diametric aesthetic result long-term with a sunken or skeletonized appearance if aggressive fat removal is done.

Today’s lower blepharoplasty surgery places an emphasis on three considerations; more fat retention with redistribution, less skin and muscle removal, and attention to lateral canthal tendon support. It is the idea of redistributing the infraorbital fat rather than simply removing it that has multiple aesthetic benefits. By removing the bulging areas of fat and moving it into the tear trough indentation below, a smoother lid-cheek junction results.

The newer lower blepharoplasty technique uses a transconjunctival approach. By making an incision on the inside of the lower eyelid, the orbital fat is exposed. All three compartments of fat, medial, central and lateral, can be either removed (if no tear trough exists) or transposed into an existing tear trough below. Fat is sutured to the rim of the lower eye socket by suturing through the lower eyelid skin with tie-over bolsters. These visible bolsters stay on for only 5 to 6 days after surgery. This moves the herniated fat over the edge of the bone, thus effacing the tear trough deformity

If one is young and herniated fat is the only issue, then fat removal and transposition is all that is done. If not, then some skin excision is done below the lash line for a few millimeters but no muscle is removed. This allows a good blood suply to be maintained to the lower eyelid skin. Once this incision is closed, then a 30% Trichloroacetic acid (TCA) peel is done. The peel is applied from just beyond the lid-cheek junction up to lose to the suture line under the eyelashes.

Only in those patients with some laxity to the lower eyelid, or some scleral show, get treated as the last step with a lateral canthopexy or tendon tightening procedure. This is usually older patients greater than 60 years of age.

Treatment of the tear trough with the creation of a smoother lid-cheek junction is an important goal in lower blepharoplasty today. This newer transconjunctival approach to the lower eyelid has much less risks for complication such as ectropion. (lower eyelid pulling away or down from the eyeball) It also produces a more natural result as the goal is not to see how much skin and fat can be removed or to make the lower eyelid as tight as possible.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana