Subcillary Incision vs. Lower Lid Bleph - Pros and Cons?

Dear all, I went to see 2 opthalmic surgeons regarding my lower eyelids which are hollowed and have dark shadows. One advised that I have a marked sulcus with a mild degree of cheek ptosis. He recommended lower lid bleph to free arcus marg and mobilise lower lid fat over orbital rim with fat transposition. He added that I could have fat at a later stage if not happy with the results. The other recommended subcillary incision, what are pros and cons of each? many thanks.

Doctor Answers 12

Subciliary incision vs. lower eyelid blepharoplasty vs cheeklift - you get one shot at the lower eyelids

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In my opinion, patients with a downgoing lateral canthus, problems with hollowness and lower eyelid irregularities will benefit most from a cheeklift.  In our practice, an ultrashort incision cheeklift, probably coupled with an autologous graft would be the most beneficial.

Subciliary incision just means an incision below the lashes.  Both of your options, the arcus marginalis technique and the lower eyelid blepharoplasty you described would probably be performed through a subciliary incision. 

It is possible, however, to perform an arcus release and fat repositioning through a transconjunctival incision (no lower eyelid incision), but that would not help your downgoing canthus the way a cheeklift would.  It would also not address your cheek drooping.  Arcus procedures can appear to fail as the fat retracts over time.  It is very difficult to hold the fat in position once the arcus is released.  What do you sew it to?  There is simply no strong tissue there to hold the released fat to so it often retracts over time.

As always, don't focus on the technique as much as the surgeon; as you can see by the discussion above it is a tricky area. 

In my opinion, you get one shot at the lower eyelids,  If they are aggressively done and pull down, even corrective procedures by the best surgeons will not restore fully their shape and function.

Referenced below are several articles and chapters we have written on the subject.

Beverly Hills Plastic Surgeon
4.9 out of 5 stars 195 reviews

You appear to be a good candidate for an Injectable Filler procedure to minimize the appearance of your lower eyelid bags.

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I read your concern and reviewed the photo you posted. You appear to have lower eyelid grooves (tear-troughs) that are excentuating the appearance of bags in your lower lids. This can be improved with an Injectable Filler procedure. My expertise is with Silikon-1000 for permanent results.

I typically advise against lower eyelid blepharoplasty with fat removal, as this is often unnecessary, and may lead to a hollow, operated appearance.

I've attached a photo from my RealSelf gallery for your perusal demonstrating non-surgical lower eyelid rejuvenation with Silikon-1000.

I hope this is helpful for you.

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 435 reviews

Surgical Options to Improve the Lower Eyelid Bags

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Hi London2458 in London,

Eyelid plastic surgery is not merely one procedure, but rather many potential operations. Your plastic surgeon will tailor eyelid surgery to each specific patient's anatomy and personal goals, among many factors. A specific recommendation cannot be made on the out-of-focus & distorted photograph submitted. As other eyelid plastics surgeons have already stated, both eyelid techniques that you have mentioned are appropriate methods of eyelid improvement. Only after a comprehensive evaluation can a plastic surgeon help determine appropriate options for you. Best of luck.

Dr. Chaboki

Houtan Chaboki, MD
Washington DC Facial Plastic Surgeon
4.9 out of 5 stars 89 reviews

Lower eyelid blepharoplasty

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You have several options when considering rejuvenation of your lower eyelids.  Consider that there is some hollowing out of your lateral orbital wall along with loose skin and bulging of orbital fat.  Things that should be addressed are a resuspension of your orbicularis muscle, possible repositionling of your orbital fat and an elevation of your malar fat pad to fill the loss of fullness.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 20 reviews

Lower lids eye surgery

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I always state that everyone makes chicken soup differently, and so to a plastic surgeon. Everyone will do things a bit differently. Look at each surgeons results and see if you like them, and then choose a surgeon.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Lower lid circles result from cheek fat falling

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All of the previous comments present important concepts to consider.  The aging of the lower lid is due to many factors that cannot be corrected by a subciliary resection of skin alone.  The anatomic layers of skin, muscle, and fat need to be addressed as well as the falling midfacial fat pads (or SOOF).  Weight loss can be an aggravating factor.  Restoration of volume by restructuring these components surgically is recommended and can be very satisfactory.  Minimal access procedures such as injectable fillers may provide a less expensive though temporary and subtle correction. 

Lower eyelid blepharoplasty, which approach is best for you.

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Having a side view might be helpful, but it seems as though you have prominent eyes with a much less prominent midface (hypoplastic).  You do not appear to have much in the way of a lot of excess lower eyelid redundant skin, but rather contour irregularities.  I would agree with the arcus marginalis release/fat transposition method, but would only approach this through a transconjunctival incision to keep risks of retraction and scaring less.  You might not have enough in the way of fat to pull down, but this can always be augmented at a later date by filling with fat or a filler.

All the best

Dr. Schwarcz

Robert Schwarcz, MD
New York Oculoplastic Surgeon
4.5 out of 5 stars 23 reviews

Lower Blepharoplasty Methods

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From the picture, you need the procedure recommended and outlined by you with elevation of the cheek and anchoring of it to the tissue over the lateral bone as well as stabilization of the lateral support of the eyelid. This is usually done using a subciliary incision. Therefore, both surgeons may be telling you the same thing. This incision generally heals almost invisibly.

Robert T. Buchanan, MD
Highlands Plastic Surgeon

Its all in the details

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Both techniques are fine when done by individuals who perform them regularly. I agree that there is a slightly higher risk of lower lid malposition with the sub-cilliary approach but this i reduced when the surgeon also makes sure to tighten the lid at the same time. What the real issue here is about recognizing volume loss. I think that this is key to rejuvenate the lower lid and think that you would do best with the fat repositioning procedure that will help fill out the hollows

Benjamin C. Marcus, MD
Madison Facial Plastic Surgeon
4.7 out of 5 stars 46 reviews

Blepharoplasty Incisions

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The major issue concerning the lower lid is prevention of ectropion (eversion of the lower eyelid). The difference between the two incisions is the position of the incision and that there is a slightly decreased chance of ectropion with a lower lid incision.  I am of the opinion that a surgeon should be fairly aggressive in managing the chance of ectropion by managing the lateral canthus.  Of the two incisions I like the subcillary incision.  The transconjunctival approach is superior to either two.

Dr. ES

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