Which Blepharoplasty Technique is Best? (photo)

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.

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.

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