Lower Blepharoplasty with Negative Vector Orbit? (photo)

Judging from your photos, I agree that you have a negative vector anatomy which simply means the mid face bones and lower eyelid/cheek volumes are deficient. This results in the front of the eye (cornea) to extend beyond the upper cheek plane (when you look from the side) so if you draw a line from the surface of the eye to the cheek it moves in a negative vector (towards the body).  

The key in these cases, is to change the negative vector to a positive or neutral vector.  This represents the youthful rejuvenated contour. To do this, augmentation of the midface and lower eyelid region is needed. My preferred approach is to do this with fat transfer to the lower orbital rim and into the cheeks. Next, it is combined with either a transconjunctival lower eyelid blepharoplasty or skin pinch to address the eyelid contribution.  In my opinion, the key in this case, is the volume augmentation.  Alternative ways to add volume is through fillers.

I hope this helps.

Dr. Karam 

We have had the best results with transconjunctival remodeling of the fat and a cheeklift performed at a superficial level.

This raises the fatty tissue of the cheekpad.

The cheeklift should be done in s subtle fashion and not attempt to do heavy lifting through the lower eyelid.

We are very cautious with grafting below the lower eyelids because of the potential for visibility of the grafts.  I have seen many, many cases of unhappy fat injection patients where the visibility of the grafts is very difficult or impossible to treat completely.  

Remember the fat pockets that look like they are right underneath the skin are actually below three layers of tissue!

 

The number of different opinions given here shows you that a lower lid blepharoplasty is one of the more challenging situations that cosmetic surgeons deal with, because the complications associated with it [lid retraction, ectropion, hollowing, etc].

There are many ways to approach your anatomy, which is a challenging one:  low cheek volume, prominent eye with already subtle retraction [right greater than left] with prolapsed orbital fat. From the photos, its not possible to see the amount of skin wrinkling or excess.

In my practice, I perform transconjuntival blepharoplasty with and without fat transposition, skin/muscle blepharoplasty, SOOF-lift [cheek-lift], ectropion repair [tarsal strip], and fat grafting. Having all these techniques at my disposal, allows me to address each patient individually with whichever of these techniques that I feel will give the patient the BEST result while MINIMIZING risk.

Looking at your anatomy, I feel your best option with the least amount of risk would be a lower lid transconjuntival blepharoplasty with fat excision/transposition WITH adjunct fat grafting the the malar region. The fat grafting will not only give you improved volume to the lid/cheek junction and prevent hollowing, but it will also support the lower eyelid position. In a recent presentation at a national meeting [publication in print] we have shown that fat grafting to the cheek region can improve the lower eyelid position by 0.5-1 mm.

As I mentioned, its hard to assess your skin quality from the photos, but if on examination,  I felt you could use skin improvement, AND had good lid tone, I would offer a very conservative skin pinch excision.

As you already have mild lower lid retraction, I would NOT perform a skin muscle flap or skin laser resurfacing, UNLESS a lower lid retraction repair with a graft is also done at the same time.

I have provided a link to pre and post op results on a transconj bleph with small skin pinch along with fat grafting. On my photos, you can see many examples of lid retraction repairs, and example of laser skin resurfacing done WITH lid retraction repair.

You clearly have a negative vector eye and this puts you at significantly greater risk for lower eyelid malposition with any type of skin removal.  The correct approach for your eye is to do a transconjunctival removal of the fat with an autologous fat transfer to the midface.  There is no risk of lid malposition with this procedure.  The second best approach is fillers. 

A lower transconjunctival blepharoplasty without the addition of volume will leave you with hollow looking eyes.

A negative vector is when the cheek bone is relatively back to the projection of the eyeball or the front of the cornea. This means that the eye is forward while the cheekbone is back.

Being a specialist in oculofacial plastic surgery who does a lot of revisional surgery, I have learned that it is important to balance everything. This is because the position of the lower eyelid is very dependent on multiple factors like the lateral canthal tendon, the position of the lower lid retractor, the tone of the skin and the orbicularis muscle. So if you want to push through with the surgery, you have to find a surgeon who can provide you the level of care you need.

As a board certified facial cosmetic surgeon, I not only look at the eyes but I think of the face as a whole. I try to balance everything to help with facial aging. A common strategy for negative vectors is not only addressing the eyes but addressing the mid-face and cheek area. I would add volume using a filler or something more long-term such as a cheek or submalar implant.  I hope that was helpful, and thank you for your question.