Lower Bleph Without Fat Removal? (photo)

Question

Hi, I am looking at getting a lower bleph, as excess skin forms under my eyes when I smile. When I am not smiling, I have slight troughs under my eyes. I am worried that with a lower bleph this will excentuate the troughs, but get rid of the excess skin. The skin has just lost its elasticity. Is it possible to get a lower bleph without fat removal. What would be best for my eyes? Thank you

Michael Law, MD · Answer

For blepharoplasty patients with true lower lid skin excess or redundancy, some skin must be removed to restore a youthful appearance. This is performed through a subciliary incision, which is an incision placed immediately below the lower lid lashes. This incision is hidden by the lower lid eyelashes and is almost always imperceptible once it has healed.

	As with upper lid, skin excision of the lower lid should be very conservative, amounting to only that amount of skin that is necessary to improve the lower lid skin contour. The muscle layer below must remain completely undisturbed, as it provides horizontal support for the lower lid and helps to maintain the lid position flush against the surface of the eye. Excessive removal of lower lid skin may lead to a complication called ectropion, where the lower lid is pulled down and away from the surface of the eye. This complication often requires additional surgery to correct it, and must therefore great care must be taken to avoid it.

	In eyelid surgery patients that do not have adequate lower lid tone or support, and in any patient felt to be at some risk of ectropion, a lateral canthopexy is performed to protect against that potential problem. The lateral canthus (the lateral corner of the eye) contains a tendon that attaches the lower lid tissues to the orbital rim laterally, and this tendon serves as a 'clothesline' that maintains lower lid position. A lateral canthopexy consists of an anchoring or supporting suture that tightens that tendon and thus the lower lid as well. When desired, a lateral canthopexy can also elevate the position of the lower lid. In patients who desire it, this procedure can produce a more 'almond' shape to the eyes.

	Lower Eyelid Fat Pads or "Bags"

	A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.

	As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.

	In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.

	Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

Michael I. Echavez, MD · Answer

The answer to your immediate question is that a lower blepharoplasty can be done without fat removal. Skin removal alone is frequently done on the appropriate patient. In regards to you in particular, it's difficult to give you accurate advice without seeing you in person. It appears that you do have tear trough depressions below your eyes. This could be improved with filling the area with hyaluronic acid fillers or fat. It is also possible that you could benefit from removal of a small amount of skin on the lower eyelids.

William Portuese, MD · Answer

It is possible to only remove lower lid skin, and not the fat bags. The decision to remove any excess skin must be made at rest, not upon smiling. The excess skin is removed by a pinch technique and closed with Histocryl tissue glue. No stitches needed

James Motlagh, MD · Answer

Yes lower blepharoplasty can be done without fat removal as long as there is no significant fat. You should discuss this with your plastic surgeon in advance so you both are on the same page.

Cameron Rokhsar, MD, FAAD · Answer

It looks (from the pictures) like you may benefit from the fat removal portion of the blepharoplasty because you may have some herniating fat pockets beneath the eyes. If you still have problematic troughs, you can use fillers to fill the hollowness. Best of luck, hope this helps!

John Q. Cook, MD · Answer

There are many surgical options for lower blepharoplasty and skin removal is one. In your case I would probably recommend starting with a filler to the tear trough area, since the hollow in this region appears to be your main problem. Make sure this is done by a highly experienced doctor, since technique matters!

Jessica Kulak, MD · Answer

Looking at your pictures, you appear to have volume loss in your lower eyelids that is exposing your orbital rim. You don't appear to have any bulging fat, which would require a lower lid blepharoplasty to improve. A lower lid blepharoplasty can be performed without removing fat, but I don't think that would be the best treatment for you at this time based on the pictures you have provided. Hyaluronic fillers such as Restylane or Juvederm can be helpful in restoring volume to this area and softening the depression that you see. Its hard to tell from the picture, but if you have significant wrinkling and excess skin, then laser resurfacing can be used to tighten the skin around the eyes and improve the skin texture to reduce wrinkles in this area.

Scott L. Replogle, MD (retired) · Answer

The way to understand blepharoplasty to is view it as a "facelift" for the thin skin of the eyelids that is properly done to restore what used to be there rather than to change your looks. For the upper lids this is mostly to remove excess upper lid skin and minimally to keep the two upper lid fat pad compartments from bulging. In the lower lids the procedure is almost entirely to solve the problem of bulging fat in the three lower lid compartments and much less to remove excess skin. The skin is re-draped over the less bulgy lid area. If the margin of the thin lower eyelid with the thick cheek has stretched or descended then the cheek needs to be lifted back up and probably some stretched skin removed. This is not your situation.

	If your lower lids are bulging more than when you were younger than you might consider removing the bulging fat pads which can even be done without an external incision let alone removal of skin, and will not give you a sunken eyed look as your cheek junction has not descended. 

	I would agree with some of the answers that a filler along the eyelid/cheek junction would be the best approach and is not permanent if it doesn't accomplish your goals. Unlike injections into lips, it can look quite natural.

Lower Bleph Without Fat Removal? (photo)

Answers (8)

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