I'm 45 years old and considering upper and lower blepharoplasty. I've had 2 consultations thus far and 2 different opinions. Lowers - 1st - transjunctional with fat repositioning + TDA peel. 2nd - fat repositioning and slight skin pinch (no peel). One eye has prominent herniated fat, deep crease and is very dark underneath. Other eye not as bad. I was considering the uppers as well to open my eye a bit more and show slightly more lid but a little concerned if that as I age I may start to look hollow?
Which Blepharoplasty Technique is Best? (photo)
Doctor Answers 20
Eyellid surgery, avoid Hollow Eye results
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.
It is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.
Upper Blepharoplasty Surgery Excessive or 'redundant' upper eyelid skin is a very typical aging change that leads people to seek eyelid surgery. In many patients, this surgery can be performed under light sedation with local anesthesia as an outpatient office procedure. In a few cases, protruding fat behind the eyelids is also removed. As with most facial aging changes, no two people present with exactly the same eyelid concerns. Surgical treatment is therefore individualized to the needs of each individual patient.
In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.
Photos are just one way to help you select a surgeon, but it is imperative to look at many, many before and after photos of eyelid rejuvenation before selecting your plastic surgeon.
Upper and lower eyelid surgery options
A correction of the lower eyelids may include a re-elevation of the skin flap, a suspension of the orbicularis muscle, repositioning of any residual fat to fill in the hollowed out areas and elevation of the lateral malar fat pad to fill in the lateral hollow. The upper eyelids would require a standard upper eyelid blepharoplasty.
Transconjunctival blepharoplasty is best for you, along with avoiding skin removal
There are a lot of factors to why lower eyelids look sagging, tired and puffy. In my practice, fat transposition or repositioning is just a limited part of the procedure. Addressing the excess fat that herniated forward is a more significant part of what we do. There are even MRI studies that show people who not only have a hernia of fat, but also have excess fat pockets, meaning, there’s an increase of volume. The surgeon’s experience and how they look at your before and after results will help you make your decision on whether or not transposing that fat alone would address the degree of your puffiness.
The next part of the evaluation is to look at the skin quality. For people with light skin, I do something called a fractional CO2 laser. Years ago, I did do a lot of TCA peels, but I have to say that fractional CO2 laser has more benefits. Unfortunately with the peel, you’re just basically placing the chemical on the skin. You eventually get this frosting effect and then the skin peels off and new skin comes in and it certainly works well. On the other hand, I find that I can really feather, get nicer contractions and customize with a fractional CO2 laser.
I also routinely use platelet-rich plasma to help stimulate collagen under the skin and improve the skin quality. Platelet-rich plasma is derived from the blood and is done through a routine blood draw in the office. We spin down and concentrate the platelets which have a healing response. We’ve had a lot of benefits with this in helping our patients improve their skin quality under their eyelids.
Skin pinch in my practice has something to do with if there is true excess of skin. A lot of times it’s because of a combination of volume loss in the face and the elasticity of the skin. I’ll usually roll the skin up and ask the patient if they like it. After that, I’ll see if the skin has redundancy then we’ll decide if I should do a small skin pinch along the margin. However, from the photos you submitted, it doesn’t look like you have excess skin, so I would be mindful about having any skin pinch procedure. I tell my patients that there’s always room to do a touch-up rather than taking away skin and regretting it after. When the fat is removed and the patient has certain degree of elasticity where the skin doesn’t spring back completely, we can always do a short procedure to enhance the appearance. The decision is made based on the integrity of the support system of the lower eyelid, specifically the lower canthal tendon and the structure that supports the upper eyelid or the lateral corner of the lower eyelid.
In our practice, we do everything under local anesthesia with sedation because patients are able to recover very quickly and not have much disruption. At the same time, there’s not much pressure to do more procedures. I hope that was helpful, and thank you for your question.
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There is no one correct lower eyelid operation.
I most commonly performed lower blepharoplasty by making an incision along the lash margin in dealing with the fat and skin in various ways. Occasionally the trans-conjunctival approach is suitable. There is no one correct way to do the operation. Go with the surgeon you trust the most.
Tranconjuctival Blepharoplasty Techniques
Thank you for posting your pre-operative photographs. Obviously, you are asking for the procedure that will rejuvenate your eyelids with the most natural results. Examination of your photos reveals lower eyelid asymmetry with more herniation of the inner fat pad. You have a deeper lower eyelid crease or tear trough deformity on your left. This is caused by loss of bone along your left orbit. This can be corrected by repositioning the lower eyelid fat through a transconjuctival incision or fat grafting this region to build upper the lost volume. You should have a great result with a conservative transconjuctival blepharoplasty and improvement with the dark circles and asymmetry. I do not recommend a skin pinch in your case, because you do not appear to have much loose skin and it may cause your lower eyelids to pull down and develop scleral show which is when the white part shows and is a sign of plastic surgery. A conservative upper blepharoplasty will give you a natural and rested look. Best wishes with your surgery, Dr. Richard Swift
Either option can achieve the result you are looking for. Trans-conjunctival approach to lower eyelids is a safe way to perform lower blepharoplasty. Skin pinch, peel, or laser resurfacing are all well-established modalities that can help with lower lid skin tightening. As evident from other answers, there are additional nuances in deciding whether fat repositioning or grafting would be of benefit. Other views and exam would be beneficial in this regard. Good luck,
Grigoriy Mashkevich, MD
New York Facial Plastic Surgeon
Either option can work well for the right patient. For you, peel may be better because it would also diminish the pigmentation spots you have on your lower eyelids and face. See an oculoplastic surgeon.
I prefer a transconjuctival approach with conservative fat excision and a skin pinch blepharoplasty.
Transconjununctival fat repositioning
For your case, fat repositioning would be most ideal so deal with the bagginess of the lower eyelids. For the skin treatment, its hard to say with a photo alone. Skin texture, lower eyelid tone need to be assessed in person to determine whether skin peel vs laser vs pinch excision would be best.
A trans-conjunctival approach with either fat repositioning or conservative fat removal would give a nice result for the lower eyelids. A small pinch of skin known as a pinch technique would be better than skin peeling. A skin peel on the lower lids may erase freckles which would leave the lower lids looking unnatural. A conservative amount of skin and a small amount of medial fat can be removed from the upper lids to open up the skin crease on the uppers
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