Skin Wrinkling After Lower Blepharoplasty

Postoperative swelling is of course the rule after blepharoplasty. There is a phase when the eyes can appear "crepey". Waiting until swelling subsides, typically six months, is the standard answer.

The nature of the problem may depend on what was there before the surgery. If there was loose skin present below the eye and nothing was done about it, the loose skin will still be there. If a transconjunctival blepharoplasty was done, with strict fat removal, this can cause the appearance of crepiness to increase.

How to remove the extra skin below the eyes is a very difficult problem. I would respectfully disagree that removal of a pinch of skin is even an option. Removal of lower eyelid skin in my opinion, even if it is "just a pinch" performed with a transconjunctival blepharoplasty, has a high chance of changing eye shape. This change in eye shape typically takes two forms: pulling down of the corner of the eyes, and rounding of the eyes as the lower eyelid skin retracts postoperatively. The retraction is typically not apparent for several months postoperatively.

When a simple canthopexy in combination with a pinch of lower eyelid skin removal is performed to prevent this, another typical deformity can result: rounding of the eyes with a severe upturn at the corners where the canthopexy was performed.

In our practice, we perform midface elevation procedure to tackle the problem of loose skin of the lower eyelid. A superficial cheeklift (the latest version of this technique is called the LUSIC, or LiveFill graft ultrashort incision cheeklift. Here, the cheek is elevated slightly through an incision at the corner of the eye. Sutures are used to anchor the cheekpad higher, "giving" tissue to the lower eyes. Then, a small amount of skin can be removed without significant chance of eyelid shape aleteration.

If the lower eyes have already been done and the eye shape exhibits the typical post-blepharoplasty changes described above, a cheeklift is also helpful in reducing those. LiveFill grafts are used judiciously to restore volume at the same time.

These are all quite complex issues, but patients should be very aware of how their eye shape can be permanently altered with many lower eyelid procedures. The lower eyelid skin, the canthus, the lower eyelid itself, eye shape as a whole, the relationship between the upper and the lower eyelids are all important to consider preoperatively.

Part of the pre operative evaluation for lower blepharoplasty surgery is to assess the amount of skin present. Your surgeon has made a determination as to whether you needed skin removed or not. If you did, then there should be stitches under your lower eyelashes. If you did not, then the surgery was probably done through the inside of the lower eyelid (transconjunctival). Sometimes, the assessment by the surgeon may be slightly inaccurate and someone who was thought not to need skin removal turns out to need skin removal after the transconjunctival surgery. As mentioned by others, there are many ways to address this need, either with laser, other skin tightening technology or a minor surgical skin removal. At any rate, it is much, much too early for you or your surgeon, for that matter, to determine this need. Let things heal, skin will retract (shrink) and scar tissue will be forming over the next several months. Relax and enjoy the ride.

Waiting for at least six weeks is appropriate before determining if you need treatment of the wrinkling. As stated on this blog, blepharoplasty alone does not address the crepey lower eyelid skin. A resurfacing treatment performed in conjunction witha minimally invasive blepharoplasty can take care of both crepey skin and puffiness. My choice for resurfacing of crepey skin is the Fraxel re:pair laser, which is a fractionated CO2 laser developed by the originators of fractional laser therapy.

Lower lid blepharoplasty causes swelling and as the other doctors have said-it takes time to resolve. You can better evaluate the wrinkling at 6 weeks.

It is NORMAL for wrinkles of the lower eyelid to look worse as swelling is coming down, because the swelling expanded the skin and the swelling leaves quicker than the skin elasticity can be restored.

After 6-10 weeks you will be better able to evaluate the wrinkling.

Blepharoplasty alone does not remove eyelid wrinkles-in my experience some type of wrinkle treatment of the surface of the lower eyelid skin is required. I use blepharoplasty to remove bags, puffiness and dark cirlces under the eyes.

If there is significant wrinkling of the lower eyelid before blepharoplasty I personally use laser resurfacing-today I use a fractional ablative 2940 Erbium laser-healing is quicker than with the older CO2 laser resurfacing.

For now wait until you have healed and your eyelid has had a chance to recover.

Hello,

Excellent advice given to you by Dr. Freund.

I would also add that since you are only two weeks removed from your surgery you need to allow more time for further healing to occur before making a final assesment of your results (ie. the wrinkling skin on your eyelid).

Once the swelling has gone done, the underlying scar tissue has formed (this is good & normal scar tissue formation), the lymphatic drainage has been normalized and your skin has "settled in", you can discuss any concerns you have with your surgeon and should have many options to get the final result you desire.

If you do indeed end up with extra, wrinkly skin that bothers you, your surgeon may recommend one of the following options:

1. Skin Removal - the extra skin can be "pinched up" and removed

2. Laser Resurfacing - this can provide extra tone and help reduce the wrinkles

3. Chemical Peel - also improves skin tone and improves fine wrinkles

4. Leave things alone - sometimes based on a Patient's anatomy it is actually better to leave some "excess" skin behind so as to avoid complications or altering the shape of the eye too much.

Take Care,

Dr. Jafri

Matreshka,

2.5 weeks is fairly early to start getting worried about your eyelids after blepharoplasty. Often it takes several weeks to months for the tissues to settle and the swelling to resolve. At the same time, the tissue is healing and the collagen is reorganizing. All of this leads to changes after surgery which may not be apparent yet. However, if after several months you do not see a significant change and still see extra skin, you can have a straight-forward revision or secondary surgery which will help tighten up the extra skin. However, do not be tempted to rush into any revision surgery before your first surgery has completely healed.

David Shafer, MD

Correcting the lower eyelids is one of the trickier cosmetic surgery procedures.

In a young face, you cannot tell where the cheek ends and the lower eyelid starts. There is no sharp line between them. So, with surgery, you should try to recreate this smooth, seamless transition. You also have to preserve the shape of the eyes and not make them round.

There are many different ways to correct the lower eyelids and imperfect results are not rare. But at 2 weeks, you should not look at yourself too closely. Assume you will eventually have a great result.

If in several months, there is indeed excess skin or wrinkled skin, there are several things that can be done depending on the exact anatomy. The possibilities include non invasive skin treatments, Botox injections, laser resurfacing, or revisional sugery

Fine wrinkles of the lower eyelids are not uncommon following blepharoplasty surgery.  In the first two weeks after surgery this type of wrinkle should not be the source of anxiety.

Wound healing is a dynamic process that’s characterized by rapid change in the early post-operative period.  At this point in time, the lower eyelids often have bruising, swelling and wrinkling.  These phenomena gradually resolve over the course of several weeks as the process of wound remodeling begins. During this process, wrinkles gradually smooth and flatten as a result of skin elasticity.

                  It’s important to be patient since the body has a tremendous potential for tissue remodeling. In some cases, massage of the lower eyelids can facilitate smoothing of the lower eyelids. Occasionally, wrinkles persist and secondary procedures should be considered. Under these circumstances, laser resurfacing is effective in treating fine wrinkles of the lower eyelids.

Puffiness under the eyes can mask wrinkles which were already present. In my practice I offer options such as the Mixto SX microfractional CO2 laser and Pelleve’ for people with darker skin. Permanence is relative however you can expect results from these treatments to last for years depending on your health and lifestyle.