Which Blepharoplasty Technique is Best? (photo)

Question

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?

Michael Law, MD · Answer

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.

Vincent N. Zubowicz, MD · Answer

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.

Grigoriy Mashkevich, MD · Answer

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

Mehryar (Ray) Taban, MD, FACS · Answer

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.

Guy Cappuccino, MD · Answer

I prefer a transconjuctival approach with conservative fat excision and a skin pinch blepharoplasty.

A.J. Amadi, MD · Answer

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.

Scott Trimas, MD · Answer

I would tend to favor a transconjunctival lower blepharoplasty with fat repositioning and conservative removal based upon the photos you submitted. It does not appear that you have much lower lid skin and a peel or laser resurfacing would help tighten the skin and improve pigmentation issues. Good luck.

Evan Ransom, MD, FACS · Answer

Thank you for the question and your photo. It would be useful to see a profile and 3/4 view to determine the relative projection of your cheekbones. In addition, an exam in person is needed to check the laxity of your lower eyelid. I agree with some other assessments that volume would be helpful. In appropriate patients, I use the orbital fat and transpose this over the orbital rim to fill in the hollow area. When there isn't enough fat, I recommend fat grafting to my patients. For the upper eyelids, a skin-only approach is appropriate in many cases.

Anthony Corrado, DO · Answer

I agree with the consultant who suggested lower eyelid transconjunctival approach with fat re-positioning I do not think at your age there is any need to make incisions on the lower lid. I would also suggest some volume augmentation to the cheek in the form of fat grafting. Lastly, I would suggest laser skin resurfacing in the lower lid to achieve a small amount of skin tightening. I would also agree with a "skin only" upper blepharoplasty which would rejuvenate the upper lids.

Toby Mayer, MD · Answer

If there is excess skin that is significant then you need an external incision. Otherwise transconjunctival is ok. Your uppers should be left alone and have a browlift instead to prevent hollowness and give you a "happy" look.

Which Blepharoplasty Technique is Best? (photo)

Answers (20)

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