Lower Eyelid Blepharoplasty

Lower eyelid blepharoplasty encompasses a range of surgical techniques aimed at enhancing the aesthetic appearance of the lower eyelids. Historically, it involved the removal of skin and/or fat to address wrinkles, skin redundancy, and fat bulges. Modern trends, however, focus on tissue preservation, incorporating techniques like orbital and sub-orbicularis fat repositioning and fat transfer to restore volume lost during facial aging. Non-surgical options, such as hyaluronic acid-based dermal fillers and light-based treatments, have also gained popularity as alternatives or adjuncts to surgical blepharoplasty.

Patient Selection

History:

Thorough medical and ophthalmic history is obtained, covering current illnesses, medications, allergies, dry eye symptoms, and relevant lifestyle factors. Patient goals and expectations are discussed.

Physical Examination:

A comprehensive examination includes visual acuity, tear film evaluation, lower eyelid laxity, skin assessment, evaluation of fat distribution, and assessment of globe position and asymmetries. Standard external photographs are taken before surgery.

Indications:

• Rhytidosis and lower eyelid dermatochalasis
• Steatoblepharon
• Nasojugal groove
• Infraorbital/malar deflation
• Malar mounds or festoons
• Lower eyelid asymmetry

Contraindications:

• Unrealistic patient goals
• Severe or unstable medical conditions
• Active thyroid ophthalmopathy
• Uncontrolled dry eye syndrome

Surgical Techniques:

Transconjunctival Approach:

• Effective for patients with lower eyelid fat prolapse and no excess skin.
• Debulking or mobilization of orbital fat pads.
• Fat redraping in suborbicularis or subperiosteal plane.
• Conjunctival incision closure.

Skin Approach (Infraciliary):

• Incision made 1-2 mm below eyelash line or within infraciliary crease.
• Skin pinch test to assess redundancy.
• Conservative skin removal to avoid anterior lamellar shortage.
• Closure with fine sutures.

Additional Procedures:

• Canthopexy or lateral canthoplasty for significant lower lid laxity.
• Fat grafting for volume restoration.
• Laser skin resurfacing or chemical peels for skin quality improvement.
• Ligation, sclerotherapy, or laser treatment for unwanted veins.
• Botulinum toxin injections for dynamic creases.

Postoperative Care:

• Cold compresses for initial swelling, followed by warm compresses.
• Application of ointment or antibiotic drops.
• Avoidance of strenuous activity.
• Follow-up visit within a week for suture removal.

Complications:

• Retrobulbar hemorrhage (rare but serious).
• Chemosis, pyogenic granuloma.
• Under or overcorrection of steatoblepharon.
• Lagophthalmos, muscle injury, diplopia.
• Hypertrophic scar, suture cysts.
• Lower eyelid retraction, anterior lamellar shortage, ectropion.

Lower eyelid blepharoplasty is a cosmetic procedure addressing aging-related changes in the lower eyelids. It involves careful patient selection, various surgical techniques, and potential adjunct procedures. Postoperative care is crucial, and complications, although rare, should be managed promptly. As with any surgical decision, thorough evaluation by a plastic surgeon is essential.