Lower Blepharoplasty with Negative Vector Orbit? (photo)

We have had the best results with transconjunctival remodeling of the fat and a cheeklift performed at a superficial level.

This raises the fatty tissue of the cheekpad.

The cheeklift should be done in s subtle fashion and not attempt to do heavy lifting through the lower eyelid.

We are very cautious with grafting below the lower eyelids because of the potential for visibility of the grafts.  I have seen many, many cases of unhappy fat injection patients where the visibility of the grafts is very difficult or impossible to treat completely.  

Remember the fat pockets that look like they are right underneath the skin are actually below three layers of tissue!

 

The number of different opinions given here shows you that a lower lid blepharoplasty is one of the more challenging situations that cosmetic surgeons deal with, because the complications associated with it [lid retraction, ectropion, hollowing, etc].

There are many ways to approach your anatomy, which is a challenging one:  low cheek volume, prominent eye with already subtle retraction [right greater than left] with prolapsed orbital fat. From the photos, its not possible to see the amount of skin wrinkling or excess.

In my practice, I perform transconjuntival blepharoplasty with and without fat transposition, skin/muscle blepharoplasty, SOOF-lift [cheek-lift], ectropion repair [tarsal strip], and fat grafting. Having all these techniques at my disposal, allows me to address each patient individually with whichever of these techniques that I feel will give the patient the BEST result while MINIMIZING risk.

Looking at your anatomy, I feel your best option with the least amount of risk would be a lower lid transconjuntival blepharoplasty with fat excision/transposition WITH adjunct fat grafting the the malar region. The fat grafting will not only give you improved volume to the lid/cheek junction and prevent hollowing, but it will also support the lower eyelid position. In a recent presentation at a national meeting [publication in print] we have shown that fat grafting to the cheek region can improve the lower eyelid position by 0.5-1 mm.

As I mentioned, its hard to assess your skin quality from the photos, but if on examination,  I felt you could use skin improvement, AND had good lid tone, I would offer a very conservative skin pinch excision.

As you already have mild lower lid retraction, I would NOT perform a skin muscle flap or skin laser resurfacing, UNLESS a lower lid retraction repair with a graft is also done at the same time.

I have provided a link to pre and post op results on a transconj bleph with small skin pinch along with fat grafting. On my photos, you can see many examples of lid retraction repairs, and example of laser skin resurfacing done WITH lid retraction repair.