Current Trends for Lower Eyelid Surgery?

If a surgeon has vast experience in eyelid surgery, can one be assured that because of excellent skills that the usual issues with the transcutaneous approach is considerably lessened? A bit of loose skin aside, I would almost rather get fillers (which also seem fraught with issues) than risk all these problems I've read about here, the biggest of which seems to be "sad eyes" or a change in eye shape years down the line. The skin under my eyes has NO bags but is rather crepe-like; if I pinch it, a few seconds must pass for it to smooth itself out. I have some fine lines and have developed a groove-like half crescent where my cheekbones meets the lower lids. Thank you in advance for your thoughts.

Doctor Answers 22

It is an interesting question.

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Unfortunately, vast experience does not seem to protect the surgeon or the patient from complications associated with transcutaneous lower blepharoplasty.  The biggest problems associated with transcutaneous lower blepharoplasty relate to the damage done to the innervation of the orbicularis oculi muscle along the eyelid margin.  The incision, which is generally carried into the underlying orbicularis oculi muscle, cuts the motor nerves that supply the orbicularis oculi muscle at the lower eyelid margin.  This is a big problem because the lower eyelid is held in position due the action of this muscular sling.  Injury to the motor nerves causes the lid margin to slump.  This fall in the position of the lower eyelid margin can also be worsened by removal of too much "excess lower eyelid skin," and the mid-lamellar scar that develops after surgery.  Other factors also contribute including lack of bone projection at the orbital rim.  The next effect is that the surgery effectively couples the injured eyelid to the weight of the cheek.  Non-expert lower eyelid surgeons have attempted to compensate for this effect by performing a canthoplasty or canthopexy procedure at the time of the lower eyelid surgery.  This is a good example of why being a high volume surgeon does not make one an expert surgeon.  The canthal procedures are for lower eyelid tightening, they are not capable of lifting the lower eyelid margin.  Canthal shortening procedure actually contribute to post-procedure malposition by forcing the shorten eyelids to find the shortest path around the curvature of the globe, which will always be lower than desired.  Unfortunately the plastic surgery literature doubles down on these incorrect concepts by having several well read and often quote papers misstate how the lower eyelid is innervated leading well meaning surgeons to reproduce these complications over and over again.  It is possible to have very nice lower eyelid surgery results.  The key is a clear understanding of the limitations of these published papers that sometimes present hypothesis as proven anatomic reality.  Procedures that do not violate the muscle plane of the lower eyelid are much less likely to pull the lower eyelid down.

Alternatively, lower eyelid fillers for those who do not need lower eyelid surgery is a very good alternative.  Here the premium is on finding an artistic injector who is able to sculpt the lower eyelid with the right product to produce the desired result.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Eyelid surgery evolution

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We certainly have become much more sophisticated and knowledgeable regarding the do's and don'ts of eyelid surgery over the years.

For the upper eyelids:

Remove skin only. The eyelid closure muscle [Orbicularis Oculi] is there for a reason: to close the eyelids. Furthermore it provides volume to the upper eyelid. Removing it can contribute to eyelid hollowing.

Do not remove upper eyelid fat [except possibly a touch from the nasal aspect.]

Again, the more fat your remove, the more hollow the upper eyelid will get.

Recognize eyelid ptosis [droopy eyelid] from excess eyelid skin. These two problems need very different surgeries.

For the lower eyelids:

Again, minimize fat remove if possible. Alternatively, try to reposition fat into more hollow areas. This may not be possible in all patients, but it should be recognized that hollowing an eyelid is not aesthetically pleasing

Minimize manipulation of the lower eyelid muscle as well. Just like the upper eyelid is closed by the Orbicularis oculi muscle, the lower eyelid is supported by the it, and weakening it can alter the lower eyelid position.

Skin excision is sometimes necessary, but scarring can pull the eyelid down, so you have to make sure the structures that anchor the eyelid to the bone have adequate support, and if they don't, to augment them.

These are the main ways eyelid surgery has evolved over the past 5-10 years.

Furthermore you should choose a surgeon that is familiar with all the techniques of eyelid/brow rejuvenation. Not every technique fits every patient, and the "cookie cutter" approach to surgery is taking a step backward in the evolution of eyelid surgery.


A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 42 reviews

Lower eyelid surgery trends

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 Surgeons are removing less fat now  then we did 10 and 20 years ago from the lower lids. For the last 25 years we have performed transconjunctival blepharoplasty for the fat removal. When needed, we perform  conservative pinch technique when excess skin is present on the lower lids. This incision is closed with  Histocryl tissue adhesive. A conservative blepharoplasty  procedure should give natural results without complications

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 158 reviews

What Is Important In Choosing An Eyelid Technique And a Surgeon

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Experience is very important. So are before and after photos that give the results you like, happy patients, good reputation, great training, and a lot of experience with the specific procedure that interests you. All procedures carry risks (including fillers). The most important thing is that when you do decide to do something that you know (emphasis on know) that it is the right thing to do, the right time to do it, and that the right person is doing it. Good luck.

Michael R. Menachof, MD
Greenwood Village Facial Plastic Surgeon
4.4 out of 5 stars 28 reviews

Current trends in lower eyelid surgery

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The currernt trend in lid rejuvenation is much less fat removal, and softer skin elevation to reduce a hollowing of the lower lid and change in the lid line. Fillers are 'safe' if very well done, however fat grafting, also if well done, is at the top of current trending and may preclude surgery for many.

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Lower lid blepharoplasty approaches.

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For 35 years I have used both transconjunctival (excess fat removal only) as well as external incision to rove excess skin and fat without sad or pulled down eyelids. If the surgeon does not "pull" the lower lid you should not have a probl. 

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 38 reviews

Lower lid Blepharoplasty

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When doing a lower lid  tc blepharoplasty I do not remove any skin. If no skin is removed then you should not have any problems with scleral show or change of eye shape. The procedure is done to remove the excess lower lid fatty deposits and not to necessarily remove excess skin. When a patient has excess skin then often times a laser treatment is done in conjunction with the tc blepharoplasty or a different technique is used. I perform lower lid tc blepharoplasty procedures frequently and they have minimal complications and a very high level of patient satisfaction. Best regards, Michael V. Elam, M.D.

Michael Elam, MD
Orange County Facial Plastic Surgeon
5.0 out of 5 stars 218 reviews

Lower eyelid surgery trends

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lower lid surgery is more conservative.
transconjuctival surgery will not improve the skin and is only good for repositioning or removing fat
crepy skin can best be treated on the surface with laser or chemical peels

Jed H. Horowitz, MD, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 116 reviews

Cosmetic Surgery is an Art and a Science

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Thank you for the question. After 25 years of experience, the trends in lower eyelid surgery have evolved. We do more reconstruction with you tissue than fat removal. We tighten 2 of the 3 layers in the eyelid now and the results are much better. Make sure you are happy with your consulatation before you proceed. Thomas Narsete, M.D. Austin, Tx 

Crepe-like skin, demarcation between eyelids and cheek

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Eyelid rejuvenation is complicated as so many different changes take place in the eyelid skin, muscle, and fat, as well as the eyebrows above and the midface below.  It is thus impossible to make a specific recommendation without examining someone.  However, I find that crepe-like wrinkles are best treated with laser skin resurfacing rather than surgery.  The dermarcation line between the eyelids and cheek may be addressed surgically but in many cases can also be improved simply with injection of a filler like Restylane.  You should see a physician who is highly skilled in surgery, injections, and lasers when deciding how to proceed.

Brian Biesman, MD
Nashville Oculoplastic Surgeon
4.8 out of 5 stars 43 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.