How Many Times Can Lower Blepharoplasty Be Done?

Question

How many times can lower blepharoplasty be done? Is scar tissue build up going to be a problem with it?

Brent Moelleken, MD · Answer

The lower eyelid is the trickiest and most complication prone area in the body to operate on.  Every single operation produces more scar tissue.  The surgeon and patient must decide carefully on expected benefits, as well as the risks and benefits of each procedure.
Every surgery, from the first to the revision cases should have a very specific plan to reduce againg, but also to protect the eyelid from scarring and from changing its shape.  Changing the eye shape inadvertently can give a bizarre, operated appearance, or a staring appearance to the eye, not to mention problems with dry eye or even corneal damage.
In our practice, revision lower eyelid surgery, more likely than not, involves a cheeklift to restore the eye shape to a pleasing almond shape from a rounded appearance that is often seen after conventional subciliary blepharoplasties.  Often revision surgeries will involve placement of grafts into hollow areas (i.e. LiveFill), elevation of the cheeks, restoration of the canthus (corner of the eye), possibly replacement of tissue lost to scar tissue.
We have several articles and book chapters on our website drbrent.com for specific discussions of these issues.
So the question is why should so many repeat surgeries be necessary on the lower eyelid? 
Is the patient chasing any morsel of fat that appears at the base of a prominent globe?  Is there hollowness that is distracting from the appearance of the eye that could be treated in other ways?   The eye protrudes more in some patients than others. This causes a "chain reaction" of effects on the lower eyelid fat, the upper eyelid configuration etc.  Does the patient have a prominent globe?  Are the patient's needs reasonable or are they risky?
These are all issues to address before a trip to the operating room.

Vincent N. Zubowicz, MD · Answer

Generally eyelid surgery, upper and lower, is a once in a lifetime endeavor. Redoing the lids is occasionally indicated but revisional surgery, especially with the lower lids, introduces more risk. With the lower lid that risk is lid position. Great care should be exercised by the plastic surgeon redoing lower eyelid surgery.

Michael A. Persky, MD · Answer

Hi BJ,
There is only so much skin in the lower lid, and only so much fat.  The majority of patients only need one lower blepharoplasty, some may have a second or revision, but it is certainly not an area where multiple procedures are indicated.  Good luck and be well.
Dr. P

Mark Berkowitz, MD · Answer

Surgery can be repeated on the eyelids more than once. Each time the eyelids are operated on scar tissue forms. This scar tissue can pull the lid down ( retraction or ectropion). This is more likely to occur if the surgery is performed through a skin incision ( transcutaneous) versus through the conjunctiva ( transconjunctival). When the incision is made through the skin there is a septum that becomes shortened which can retract the lid. Most patients that have eyelid surgery usually will not need a touch up for at least 10 years. Preventive measures are best. So chose an Ocular Plastic or skilled Cosmetic Surgeon the first time you have eyelid surgerywhich can avoid early reoperations.

William Portuese, MD · Answer

A lower blepharoplasty can be done usually no more than twice in a lifetime of a person because of the fear of changing the shape of the eyelids. The goal of lower blepharoplasty surgery is primarily to remove the fat pads and bags underneath the lower lids, and then if needed, to pinch a small portion of excess skin which is present at repose, not at animation.

Peter E. Johnson, MD · Answer

Aging in the lower lid can be caused by many factors such as thinning of the septum which holds back the fat to create bags, thinning of the skin with laxity, relaxation of the muscle causing festoons on the cheek, laxity in the supporting structure in the lid with a floppy lid prone to pull down called ectropion. Any or all of these issues can be addressed with the initial lid procedure and it is usual for results to last ten years.Still some lid procedures can miss the mark and revision is possible if the cause of concern or dissatisfaction can be properly identified, and the means of correction are at hand. You should be able to discuss revision with your surgeon who can best guide you. Remember, all surgery carries risk as well as rewards and minor improvements may not be worth the effort.

Hisham Seify, MD, PhD, FACS · Answer

Lower blepharoplasty is one of the most technical procedures in facial rejuvenation. Revision lower lid surgery carries more potential risks due to repeat scarring, possibility for development of ectropion (exposure of the eye ball leading to dryness).A good knowledge of anatomy and good command of several techniques to avoid these side effects is a must in repeat surgery.There is no specific number of times after which lower lid surgery becomes obsolete .Your Board certified plastic  surgeon will be able during his lower lid exam to access the laxity of the lower lid, the support structures available as well as the amount of excess fat or skin. He will be able to advice on the safest course of action. The more surgery, the more risk for sure.I hope that will help

Robert M. Freund, MD · Answer

Lower blepharoplasty is a term which describes cosmetic treatment of the lower eyelid. This treatment can include: excess skin removal, tightening of the eyelid muscle, tightening of the ligament at the corner of the eye, injection of fat in the tear trough and/or removal of excess fat from around the eye. Any procedure may include some or all of these procedures. You may need different aspects of a blepharoplasty at different times. Thus, you may have several procedures over time which are not duplicate procedures. A simple warning is that scarring and scar tissue can disturb the shape of the eyelid. If you are having trouble from previous surgeries- repeat corrections will become harder and harder.

George J. Beraka, MD (retired) · Answer

To babyjoe,
Hi!    A revision of the lower eyelids is not that unusual, and very rarely someone might need a third operation.
But the key thing to understand is that a "lower blepharoplasty" is not just one operation that you keep doing over and over again.  There are about 10 different ways to operate on the lower eyelids.  Usually, in a revision, you try to UNDO what was done before.
For example, if too much fat was removed, you can replace it or reposition it.  If the lower lids were pulled down, you bring them back up with a canthopexy or by making the lower lids shorter.  If a lot of fine skin wrinkling was left, you can make the lower lids smoother with laser resurfacing (and sometimes a little Botox).

Brooke R. Seckel, MD, FACS (retired) · Answer

Babyjoe,
There is no correct number. Any secondary or revisional blepharoplasty risks further scarring and the 2nd blepharoplasty is harder than the first.
The most common blepharoplasty revisional surgery is correction of the sagging lower eyelid, also called the hound dog eye or sad eyed look. This procedure involves tightening the canthal ligament near the corner of the eye, does not require opening the entire incision, and is fairly easy to do.
The correction of hollow eye following too much fat removal done during blepharoplasty can be done through a small incision on the inside of the lower eyelid. This is called a transconjunctival blepharoplasty approach-the incision is made through the conjunctiva-the pink part inside the lower eyelid.
The transconjunctival approach gives the surgeon an excellent view of where to place a fat graft.
More importantly, the transconjunctival approach means that the surgeon does not have to make an external incision and open up the scarred area from the previous surgery. This avoids many problems associuated with operating in scar tissue.
The transconjunctival approach also does not ruin the support of the lower eyelid and is thius less likely to change the eyelid shape or cause the sad eyed look.
If you are contemplating revisional blepharoplasty I strongly urge you to consult a board certified plastic surgeon who is very experienced and specializes in eyelid surgery. There are very few plastic surgeons who are comfortable with and do a lot of revisions. Your result will be entirely dependant upon the skill, experience, and expertise in revisional eyelid surgery. It is not for the novice or faint of heart.

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