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.

I understand your confusion - there are many ways to address your concerns.  Based solely on your pictures, I wouldn't say that you should avoid a lower lid blepharoplasty completely.  You do have either a neutral or very slightly negative vector (would prefer to examine you to determine this for sure).  This would put you at a slightly higher risk for an ectropion.  

That simply means that the surgeon should be more conservative in the surgery than they would normally be.  In your case, I would combine a transconjunctival approach to remove/move the fat around in your lower lid with a pinch blepharoplasty (remove just a small amount of skin).  This all depends of course on findings during a consultation with an actual examination of your eyelids.  Another reasonable approach would be to just do a standard blepharoplasty but be very conservative in the amount of tissue removed.  There are other maneuvers and post-op techniques that can also be performed to reduce the chance of an ectropion. 

I hope this helps.  I know it's confusing, but the best thing you can do is find a surgeon that is experienced in this area that you trust.

Best,

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.

Thanks for sharing your concerns.

A negative vector orbit refers to the part of the bony eye socket under the eyes that is smaller than normal due to loss of bone volume. This can be fixed by either a cheek and orbital rim implant, fat transfer or fillers. In doing so, you do not affect the lower lid structurally but visually it looks better. A lower lid blepharoplasty in your case would deal with the excess skin , bulging fat and tightening the eyelid margin by a canthopexy. Combining lower blepharoplasty with volumizing the orbital rim and the under eye area will be the best option.

 The primary goal for a lower blepharoplasty is to remove the excess fat bags which are creating the puffiness look This is performed through trans-conjunctival approach. If there is excess skin present on the lower lids than a pinch technique or fractionated laser resurfacing can be performed. A flat maxilla is best treated with small cheek implants placed through intra-oral approach to give more volume in the mid face area. Both procedures can be performed together or separately.

As you see from the responses to your question, there is no single answer. I offer my patient skin incision, fat removal and tear trough implants place subperiosteal to augment the check and change the vector. The concern with the transconjunctival fat removal is long term recurrence.

The first surgeon is correct in that doing your lids via an open approach even with canthal tightening will lead to an increased risk of scleral show and even frank ectropion. However, doing a transconjunctival approach with a SOOF lift is quite safe for patients with a negative (neutral and positive) vector mainly because the midface SOOF lift actually helps support the lower lid rather than the converse. As the originator of the SOOF lift blepharoplasty (which is performed with a transconjunctival incision) I can tell you that in my opinion this is the best procedure for improving the hollow look under the eyes that accompanies the aging process as well as the associated fat herniation. I use this approach in over 90% of my patients.  Seek a facial specialist and get two to three opinions, look at the doctor’s photos and you'll do alright in most cases.