Which Blepharoplasty Surgery Technique Works Best?

I'm looking into lower lid Blepharoplasty and have received two contraditctory opinions:

(1) that it can be done from the inside

(2) it should be done from the outside.

I don't know which procedure is best? Also, I'm interested in Fractional Laser Resurfacing and wonder if the MiXto is the right laser for me. Any comments would be appreciated.

Doctor Answers 15

Chose Eyelid Surgeon Not Technique

Both information points are correct regarding approaches to a blepharoplasty. What is most important however is for you to chose the best blepharoplasty surgeon and not the technique. That is their job.
Expert Eyelid surgeons include Board Certified Plastic Surgeons, Facial Plastic Surgeons (ENT), and ophthalmology. There is no such thing as a "eyelid fellowship". The most critical decision to be made in achieving the best plastic surgical result is picking the most experienced and talented, that is the best, plastic surgeon possible. Too often, patients choose a physician based on a catchy ad, the brand name of a technique, the basis of one or two before and after photos, or their web site’s search engine ranking. These criteria will not find the most experienced and talented plastic surgeon. See the below link on how I would research the identity of the best plastic surgeon for your eyelid surgery.#BestEyelidSurgeon

There may be no need for Blepharoplasty incisions at all

Based on the photo you provided, it appears that there's no need for an external incision under your lashes. In fact, you might not need any incisions at all. Of course, it's sort of a glamour shot and you're smiling somewhat so it's hard to say for sure.

You appear to have hollowness under your eyes. This can be corrected either with fat transfer surgery or Restylane injections. Whatever you do, do not have any fat removed under your eyes (you don't appear to have any!)

I would need to examine you in person to know for sure if this preliminary evaluation is accurate.

Jonathan Hoenig, MD
Beverly Hills Oculoplastic Surgeon
5.0 out of 5 stars 40 reviews

Which Blepharoplasty procedure to perform

The key element here in your decision making process and why it is hard to determine from these photos is the following.

Is your problem:

  1. Prominent fat deposits?
  2. Loose skin?
  3. Both of the above?

If it is 1, then use the transconjunctival technique.

If is is 2, then use the external approach.

If it is 1 and a mild amount of 2, then use the transconjucntival technique plus fractional resurfacing.

If it is 1 and a large amount of 2, the use the external approach.

Although the fractional laser was thought to be excellent in skin tightening, it has also been shown to provide benefits with skin discoloration.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 72 reviews

Best blepharoplasty procedure depends on your anatomy

This is an impossible question to answer without an examination. The "best" procedure depends on your clinical examination. If you have received different ideas from different surgeons you should either go see another plastic surgeon or even an oculoplastic surgeon (specializes in eyes) to get a third opinion!

You need to be comfortable and understand your decision before you proceed....

Lower Lid Blepharoplasty

Hi Stephie,

I prefer doing most blepharoplasties from the "inside" or through a tranconjunctival approach. I agree with Dr. Berkowitz regarding the benefits of this approach. If the over lying skin requires tightening, then I use Fraxel re:pair fractionated CO2 laser; sometimes I will use the older traditional CO2 laser.

Mixto is a good fractionated CO2 laser. Whether it is right for you is difficult to answer without examining your skin, and knowing what your expectations are. Good luck and be well.

Dr. P

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 34 reviews

Eyelid Surgery and the Mixto Laser A Perfect Cosmetic Pair!

Lower eyelid blepharoplasty can be performed from both the outside (transcutaneous) or inside (trans conjunctival) of the eyelid. 99.9% of the 3000 cases I have performed as an Ocular Plastic Surgeon in Sterling Hieghts, Michigan have been transconjuctival. The advantage of my technique is: NO stitches; NO skin incision, and NO Scalpel blade. I perform the procedure with the MIXTO laser.

This carbon dioxide (CO2) laser allows me to gently remove the fullness ( fat) from the inside of the eyelid. The beauty of this laser is that it stops bleeding as it removes this tissue so the surgery is faster and my patients have less swelling (than traditional methods) and get back to work faster. Instead of removing skin which can leave a tell tale scar line underneath the lashes, I tighten the skin with the Mixto laser! The Mixto is phemomenal to resurface (refresh) the skin. Smoothing of the skin with the laser is a perfect accompaniment to lower eyelid surgery.

Mark Berkowitz, MD
Sterling Heights Oculoplastic Surgeon
4.7 out of 5 stars 48 reviews

Both inside and out

I have found in most patients that removing most of the fat from the inside and then tightening the skin on the outside works the best. In some patients who are young I don't tighten any skin or make an external incision but these are patients under 40 who I think the stretched skin from the fat will shrink back into position. So to answer your question both is a good option. Without looking at you in person it is hard to tell how much fat you would need removed if any and what the best technique is for you in particular. A non smiling photo (mug shot style) is better to evaluate you in rather than the photo you have submitted. 

Chris Thiagarajah, MD
Denver Oculoplastic Surgeon
4.9 out of 5 stars 7 reviews

Each and every surgical procedure should be individualized for the patient

Each and every surgical procedure should be individualized to the specific patient that is being treated. No single surgical technique is suitable for all patients. Having said this, my most common approach in the lower eyelids is through a transconjunctival incision (made on the inside of the eyelid so that there is no visible scarring). The surgical technique I prefer involves repositioning both the fat and muscle of the lower eyelid. Occasionally, the skin must also be removed in the lower eyelids. In the upper eyelids, a combination of removal of skin, muscle, and fat is commonly used. The most effective technique is always individualized for each patient.

Michael R. Macdonald, MD
Bay Area Facial Plastic Surgeon
4.8 out of 5 stars 17 reviews

Approaches to lower eyelid surgeries

The lower eyelids must be evaluated in terms of excess skin, protruding fat pads (bags), and laxity of the eyelid.  Only after properly assessing these issues, can the best approach be determined. 

It appears that your concern may be fullness of the lower eyelids without excess skin.  Fat transposition is a good option because it does not result in a hollowed out look and uses the local fat to fill in the depression beneath the bags.  In essence it decreases fullness in one place and fills another, therefore you get 2 benefits with this technique.  Fat transposition may be performed through either the inner or the outer approach.  Because you don't require removal of excess skin, the inner eyelid approach may be better for you.

Michael Baroody, MD
Danbury Plastic Surgeon
5.0 out of 5 stars 8 reviews

Best blepharoplasty techniques

Your photo is difficult to analyse but I can tell you that there is rarely a need to do a lower blepharoplasty for fat repositioning or fat removal with an external incision. If there is a need to remove skin then you do need an external incision but it does not appear that you would require that. You can have your lower eyelid skin tightened with a chemical peel or fractionated co2 laser if it is slightly crepey or loose.

Jason B. Diamond, MD, FACS
Beverly Hills Facial Plastic Surgeon
3.7 out of 5 stars 11 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.