Transcutaneous Blepharoplasty - how much skin can be removed?

Question

My lower lids are baggy and I'm concerned that if I get a lower transcutaneous blepharoplasty, the loose skin will hang. What is the safest amount of skin that can be removed (in centimeters) without running the risk of scleral show? I want to maintain the contour of my already small eyes. Might a skin pinch in addition to a 3 or so cm excision help to minimize the skin laxity? Thank you!

Mehryar (Ray) Taban, MD, FACS · Answer

The answer depends on each person. Usually, the answer is NOT MUCH. Safest procedure would skin pinch method to remove safe amount of skin.

John J. Martin, Jr., MD · Answer

The amount of skin to be removed is determined at surgery, whether you do a transcutaneous or transconjunctival blepharoplasty.  A pinch of skin is what is done after a transconj approach.  In a transconjunctival surgery the pinch is part of the skin excision.  When doing either surgery a lid tightening should be done if there is any lid laxity.  To determine the amount of skin to remove, we have the patient open their mouth to put the skin on stretch.  Taking out too much skin can result in an ectropion.  See an oculoplastic surgeon for an evaluation.

Bryson G. Richards, MD · Answer

Thank you for your question.The beauty of the "pinch" technique is that the amount of skin removed differs each patient. The pinch determines the safe amount without pulling down the lower lid causing ectropion (a lower lid that is pulled down and looks abnormal).  Typically it is <1cm of skin removal.I hope this helps.- Dr. Bryson Richards

David W. Rodwell III, MD · Answer

The amount of skin that can be removed is entirely dependent on the lower eyelid anatomy of each patient.One of my primary goals in cosmetic lower eyelid surgery is to never distort the contour of the lower eyelid margin just above the eyelashes.  When removing excess skin after treating the baggy areas (excess fat) one must be very cautious.  The limiting factor is any tension that could pull the lower eyelid down. This must be avoided to minimize the chance of scleral show and any distortion of the contour of the lower lid margin.When you mention transcutaneous blepharoplasty that typically refers to a skin/muscle flap technique with an incision placed on the skin a few millimeters below the lashes.  The entire operation is done through this one incision.My preferred technique is to remove the fat from inside the eyelid using a transconjunctival approach.  Skin excision, if needed, is performed externally with an incision on the outer surface of the lower eyelid using a method often referred to as a "skin pinch."Both the transconj plus skin pinch technique and the classic transcutaneous skin/muscle bleph technique are adequate ways to deal with both the fat and any skin excess.  The skin/muscle technique theoretically has a slightly higher risk of pulling the eyelid down, but in the hands of a competent surgeon that concern really should be minimal.  Each surgeon will have his or her preferred technique, but the most important issue related to the skin excision is having good judgement and careful technique to avoid too much skin removal and a pulled tight look.

Kenneth D. Steinsapir, MD · Answer

No one has that much lower eye lid skin.  There is no fixed formula for what needs to be removed.  The key is that it needs to be precisely tailored for your lower eyelid and it is likely to be just a few millimeters of skin.

Toby Mayer, MD · Answer

Trans cutaneous blepharoplasty for removal of bags and excess skin  The amount of skin that is removed is dependent upon how much is excess skin and how much skin is needed to prevent scleral show. An experienced blepharoplasty surgeon will know how much to remove.

Andrew Pichler, MD · Answer

Excellent question and one that every surgeon assesses carefully for each patient. The "bags" are fat. They can be removed through the transconjunctival approach. Then the question is how much skin should be removed, definitely not centimeters, but rather millimeters. The pinch technique is one of the effective methods. Depends on the status of the lower lid a tightening procedure may also be advisable to prevent lid lag, rounding or scleral show.

Curtis Wong, MD · Answer

should only involve removing excess skin or it will create scleral show as you have mentioned.  Some surgeons remove fat and some transpose fat... removing fat produces hollow eyes down the road and its my preference fat be repositioned to give your lid a smoother and fuller look.  Pinch blepharoplasties are often used withe the transconjuctival approach to minimize your risks if laser resurfacing will be inadequate for addressing the laxity of skin.

Dan Landmann, MD · Answer

Hi LifeIsSweet!That is an amazing question - and as surgeons, we asked that of ourselves every single time we do a procedure. The answer should be as little as possible and necessary. Whoever you choose as your surgeon, you want that doctor to be safe. One of the biggest risks for lower eyelid surgery is scleral show. The trick is, you do need some extra skin for your eyelids to close correctly. If you have 'small eyes' - you might have deep set eyes, which is good, because people with that type of anatomy are less likely to get scleral show than patients with prominent eyes. The amount of skin that we remove varies along the length of the eyelid; and oftentimes we take more skin on one side than the other. Think millimeters!Best Wishes!Dan Landmann

Pierre Guibor, MD · Answer

The amount of skin to be removed depends on the laxity of the lower lids and the amount of orbicularis muscle left in place for the upper lids. I try not to remove much skin from the upper lids and use the Flower's anchor lid crease in order to cut down on the lag ophthalmos post operative. Lower lids, in my hands, should be a combined muscle - skin lateral tightening procedure in most cases. Sometimes, a horizontal shortning is required for lower lid laxity or a lateral canthalplasty. It all depends on the pre-op evaluation and the skill of the surgeon. Over corrected blepharoplasty result in poor patient satisfaction and often a legal problem. See your local oculoplastic surgeon for best results. Dr. Guibor, Secaucus, NJ

Transcutaneous Blepharoplasty - how much skin can be removed?

Answers (14)

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