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 The emphasis on skin removal and tightening (which is still needed for some patients) has been replaced by greater emphasis on limiting disruption of support structures and less skin removal.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
Indianapolis, Indiana