Confusing recommendations regarding lower bleph technique that is right for me. Any suggestions?

52-year old with hereditary bags (getting more prominent with age) has consulted four surgeons already. Two of them swear I just need transconjunctival fat removal with no tightening (no canthopexy). The other two say I need skin/muscle tightening. How could this be? Also, I decided to get an upper bleph, after much deliberation, since I'm on the edge of needing this improvement. Thoughts? FYI: My skin is olive, thick, no stretchmarks, no wrinkles, good tone.

Doctor Answers 9

Because of the quality of your lower eyelid skin, I would recommend under eye filler.

There is more than one way to perform lower blepharoplasty.  General plastic surgeons (the ones who refer to themselves as board certified general plastic surgeon ) prefer to make an incision on the skin just below the lower eyelid lashes.  These surgeons have no training in ophthalmology and they are distinctly uncomfortable working close to the eye surface.  For that reason, they tend to avoid the behind the lower eyelid, transconjunctival lower eyelid surgery.  Unfortunately approaching lower eyelid fat through this incision has a number of unintended consequences.  The most significant is that the incision severs the motor nerves that supply the muscle along the eyelid margin primarily responsible for holding the eyelid against the eye and that is bad.  To compensate for this unintended injury, a canthoplasty or lower eyelid tightening procedure is routinely performed now with this procedure to reduce the likelihood of lower eyelid malposition.  Unfortunately, the effects of this little adjunct procedure is seldom aesthetically satisfactory.  It gives the eye a harsh, done effect (Rene Zellweger).   Generally the best way to get out of trouble is to stay out of trouble by avoiding surgeons who cling to the transcutaneous lower blepharoplasty.  More Facial plastic surgeons (board certified otolayrngologists who are fellowship trained in facial plastic surgery, and almost all oculoplastic surgeons (board certified ophthalmologist who are fellowship trained in eyelid plastic surgery) favor lower eyelid surgery performed behind the eyelid with no skin incision.  These avoids the issues associated with transcutaneous surgery.  Generally, it is best to take the fat in the lower eyelid and transpose it as a living pedicle graft to the top of the cheek to provide fullness in the tear thought hollow.  My free ebook on eyelid surgery cited below has examples of this type work.  Again to reiterate, I would encourage you to choose carefully and avoid more surgery that is absolutely necessary.  If your heart does not sing with the surgeons you have seen, keep looking.  This is a very important decision. 


Los Angeles Oculoplastic Surgeon
4.9 out of 5 stars 23 reviews

Lower lid blepharoplasty

There are many different ways to do a lower lid blepharoplasty, and the surgeons are going to recommend what they like to do.  I am a firm believer in repositioning fat, and not removing it.  As you can see in many postings and pictures on Real Self, you can get hollowing and dark circles after fat removal.  By moving the fat through a transconjunctival appraoch down into the tear trough you will have a smoother, fuller, younger looking lid.  Doesn't make much sense to me to remove the fat and then add fillers later on.If you have excess skin, this can be removed as a pinch of skin from under the lashes, leaving the underlying muscles and nerves intact.  If you also have marked laxity of the lid, it may need to be tightened.      

John J. Martin, Jr., MD
Coral Gables Oculoplastic Surgeon
5.0 out of 5 stars 25 reviews

I don't see laxity in your pictures to indicate treatment beyond transconjunctival blepharoplasty and skin quality improvement

Thank you for your question. You’re 52-years-old with olive skin, and you have submitted several photos while asking about clarification about eye bag surgery. You got four opinions from doctors, with two recommending transconjunctival blepharoplasty alone, and two others recommend transconjunctival blepharoplasty with skin/muscle tightening, so naturally, you are confused about what to do. You also state you want to get upper eyelid blepharoplasty.

I can certainly give you some guidance on how I make decisions in my practice for patients like yourself. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been practicing in Manhattan and Long Island for over 20 years. Transconjunctival blepharoplasty and eyelid rejuvenation in general are a core part of my practice, along with complex revision surgeries for people who have complications due to eyelid surgery.  

It is understandable you are a little confused, but it is important to understand  why the doctors recommended skin muscle tightening. When someone like yourself comes to my practice, and this is in the absence of a physical examination, if you have decent skin with no redundant skin in the lower eyelid, which is the case most of the time, then transconjunctival blepharoplasty alone is typically recommended. I do often combine that with skin quality improvement with platelet-rich plasma (PRP) which is derived from your own blood to stimulate collagen and improve skin quality for very thin eyelid skin. For someone with more olive complexion, I will use a thermal energy device like Pelleve to improve the skin quality and tighten the skin to help improve the fine lines and wrinkles. With olive skin, generally good skin, and being only 52, you are not in a terrible situation.

A doctor may recommend skin/muscle tightening because they are concerned about the risk of eyelid retraction with the eyelid being pulled down, or they feel the tendon that supports your lower eyelid is a little loose. This is a judgment call, and I think that one of the things you have to factor in is just understanding how experienced and comfortable the doctors are with doing the procedure as they recommended.

When I consider a procedure to reinforce the corner of the eyelid or the lateral canthal tendon, or do something to change the shape, or deal with some laxity, I always show the patient what would happen if there is a little tightening. From what I can see in your photos, I would be concerned about a little narrowing of the overall shape of the eye with a skin/muscle tightening, or a procedure to support the lower eyelid. I think if you like the shape of your eyes, and you want just to deal with the puffiness, again in the absence of a physical examination, it is likely I would address your situation with transconjunctival blepharoplasty alone.

I always explain to my patients that cosmetic surgery is an art, and we are dealing with the human body in a way that it has to deal with elasticity. From that perspective, if for any reason there is a need for any type of enhancement, then the enhancement can be done later.

In our practice, we have our own facilities approved by the Joint Commission, the same people that inspect hospitals,  so for us there is no disincentive to bring a patient back for enhancement. My general tendency is to be conservative first. I would have to agree that the upper eyelid blepharoplasty can certainly help define the shape of your eyes, and a transconjunctival blepharoplasty alone without some kind of skin muscle flap will probably be adequate. I think it is possible that the colleagues who want to do the skin muscle tightening want to do a more external approach, or a blended approach, but I would also caution that in lighter skin people with type 1 or type 2 skin that is very fair, with light eyes, the incisional line just outside the corner can easily blend; however, with people with olive skin, it sometimes can get a little dark. Even though it’s not terrible and a small area, you have to balance if it is worth it, and does it justify that type of procedure. Again, in the absence of a physical exam, I say that often a skin muscle flap may not be needed to support the lower eyelid or improve the shape, but a procedure like a lateral tarsal strip. This is part of the art of cosmetic surgery, so every doctor you meet will bring to the table their experience and artistic perspective.

I think you need to meditate on this and see who you are comfortable with, and trust in their judgment and move forward. If this is a question of whether or not to do the additional procedure, I don’t see any harm doing the transconjunctival blepharoplasty alone, and if necessary doing some kind of support procedure later. I can tell you that 99.9% of the time in my practice, I don’t have to do any additional procedures to enhance a procedure based on my initial evaluation. If someone has a loose tendon or laxity, then I recommend it from the word go.  I think you had enough consultations, and you might benefit from having one more to get some perspective on this information I provided. I hope that was helpful, I wish you the best of luck and thank you for your question.

This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

Amiya Prasad, MD
New York Oculoplastic Surgeon
4.3 out of 5 stars 61 reviews

Several ways to address the lower eyelid

From the appearance of your eyes in your photos, you have very attractive eyes that would benefit from some surgical intervention to address the bags and hollows of the lower eyelid and the excess skin of the upper eyelids. A physical examination of the lower eyelid would enable me to assess the laxity of the lower eyelid skin, muscle, and tendons to determine if tightening needed to be performed.  From your photos, it does not appear to be the case.  I would suggest a transconjuctival lower lid blepharoplasty with removal AND repositioning of fat.  Good luck!

Philip S. Schoenfeld, MD, FACS
Chevy Chase Facial Plastic Surgeon
4.7 out of 5 stars 25 reviews

Lower lid surgery

As you have discovered, there are a number of ways to treat any problem.If it is just the fatty bulges that are bothering you, then fat removal alone or removal with some excess skin can be carried out.If, in addition, it is the drawn look that you have in the central part of your face then I would find a surgeon that lifts the mid-face, as part of his lower eyelid procedure.If your upper eyelids are concerning you, the best time to treat them is when you have surgery for the lowers.  It will be only one recovery period.

Douglas McGeorge, MBChB
Liverpool Plastic Surgeon
4.0 out of 5 stars 4 reviews

Lower Blepharoplasty Technique

Thank you for sharing your case and photos.  The different recommendations you have received probably have more to do with the surgeon's training and comfort level than any other factor.  I typically perform canthopexy on every lower eyelid blephaoplasty patient because I know that the lids will loosen with age, but this is just my personal approach and I could be convinced to do otherwise on a young patient like you.  
I think you should choose your surgeon based on your comfort level with them.  Even with the most experienced surgeons, complications may occur and you have trust them to ultimately deliver the results that you'd like.  Don't obsess about the technique - leave that up to your surgeon.  Good luck!

Samuel Baharestani, MD
Long Island Oculoplastic Surgeon
4.8 out of 5 stars 24 reviews

Approach to lower eyelids

The proposals you have received are both valid. The choice of approach usually is based on the training and experience of the surgeon or the determination that that more than fat removal needs to be done. Based on your pictures, I would likely propose the transconjunctival approach to trimming the fat, and if there was any skin redundancy (which seems unlikely) a pinch skin resection coukd be done. This approach can be less traumatic than the external approach as the muscle layer of the lower eyelids is not incised which can  lead to greater bruising and swelling. No canthopexy should be needed whose role is often to  prevent  eyelid retraction from scarring of the  incised  muscle incision healing. The upper lids could be done in the same session. 

Sheldon S. Kabaker, MD FACS
San Francisco Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Lower eyelid recommendations

Deciding on the best option for you can be a confusing process, especially for eyelid surgery. A couple points:1) Two equally good surgeons may make different recommendations simply based on their training and surgical experiences, or comfort level with various techniques2) Utilizing either an internal (transconjunctival) or external (transcutaneous) approach may lead to nearly identical results in the long run
While an in-person exam is needed to fully assess your eyelids, including testing the strength of your lower lids, based on your skin tone and complexion I think a transconjunctival approach would suit you well. This way you can avoid an incision line below your lashes that could potentially hyperpigment, given your skin color. Also, if your lids are not lax, no canthopexy should be necessary.
Hope this helps!

Mark Been, MD
Barrington Facial Plastic Surgeon
5.0 out of 5 stars 11 reviews

Surgical approach to the lower lids

The approach that your surgeon chooses to address your lower eyelid bags will be largely dependent on their training and preference. Some of this is related to the era in which your surgeon trained. 
With your age, skin complexion, and skin quality I would likely choose a transconjunctival approach with fat shaping and repositioning as opposed to just fat removal alone. I often do perform canthopexy simultaneously when there is some potential lid laxity, but this is not often the case with younger patients.
To ensure you are receiving the highest level of care, seek out a modernly trained, new-school dermatologic surgeon, oculoplastic surgeon, facial plastic surgeon or plastic surgeon who is board certified and fellowship trained in one of these "core four" cosmetic specialties.
Cameron Chesnut
#realself500 Physician

Cameron Chesnut, MD, FAAD, FACMS
Spokane Dermatologic Surgeon
4.9 out of 5 stars 76 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.