While both upper and lower eyelids experience adverse aging effects, they display different anatomic changes in doing so. While the upper eyelid develops skin redundancies, the lower eyelid is more prone to exhibit the formation of bags. (fat herniation) This is particularly true in the younger patient where any excessive skin on the lower eyelid has not yet developed.
It is best to think of lower eyelid bags developing as similar to that of a hernia. As the tissue layer that holds back the fat from under the eye weakens (a layer that runs between the lower eyelid and the bone), the fat starts to protrude outward. The three well known fat pads of the lower eyelid (medial, central and lateral) all start to protrude by differing amounts. While most people develop lower eye bags from aging, a few have them congenitally. I have treated a few teenagers who had prominent lower eyelid bags naturally due to a congenital weakness in these retaining ligaments.
In treating the aging lower eyelid with bags the pertinent question is whether there is a need for any skin removal. If so, and it is significant, then a traditional lower blepharoplasty is performed. But if not a transconjunctival lower blepharoplasty technique can be done. By going through the inside of the lower eyelid all three fat compartments can be accessed and removed.
The recovery for this type of lower blepharoplasty is fairly quick as no external skin healing is needed. There will be some drainage (bloody tears) the first night of the surgery and some swelling in the first few days after the procedure but thereafter recovery is quick and painless.
The transconjunctival lower blepharoplasty precede is unique because it preserves the blood supply to the outer eyelid skin. As a result, while it is often done by itself it can also be combined with numerous external skin resurfacing methods. A pinch skin removal, TCA chemical peels of various strengths and laser treatments of various depths can be safely combined with fat removal from the inside of the lower eyelid.
The only limitation in my experience with the transconjunctival approach to the lower eyelid is in patients with small eyes or a short distance between the two corners. This can make access difficult in the younger patient who has no lower lid laxity. In these cases a limited external subciliary incision is more effective with an invisible scar line.
Dr. Barry Eppley