Overview of Lower Eyelid Blepharoplasty
Blepharoplasty is a type of surgery that fixes issues or changes the appearance of the eyelids. It involves removing skin and fatty tissue and strengthening surrounding muscles and tendons. This corrects any problems around the part of the face from the eyebrow to the upper part of the cheek, known as the periorbita. Interestingly, this procedure is more popular amongst women, who made up 85% of blepharoplasty surgeries in the USA in 2014, and 88% in the UK.
The main aim of undergoing a blepharoplasty is to improve the functionality of the eyelid(s) and improve the appearance of the eye area on the face.
Anatomy and Physiology of Lower Eyelid Blepharoplasty
When checking the condition of lower eyelids, several aspects need to be reviewed. Among these, a vital test is known as the snap-back test. This is carried out by gently tugging the lower eyelid away from the eyeball and observing how swiftly and smoothly it retakes its natural position. If an individual has to blink for the eyelid to return to its usual position, then the lower eyelid or a connecting ligament, known as the canthal tendon, may be too loose. Also, if the lower eyelid can be pulled away from the eyeball by more than 5mm, this suggests a loose lower eyelid.
By carefully assessing the lower eyelid’s position, we can identify if the lateral canthal tendon (the ligament at the outer corner of the eye) is also loose. As we grow older, our eyelids’ collagen fibers, responsible for their firmness, may lose their elasticity, causing the eyelid to droop more than it should. In this case, the lower eyelid’s position may be lower than normal, a case known as inferior scleral show, and it can be measured in millimeters. The doctor will measure how far down the lower eyelid has shifted in comparison to the lower edge of the cornea.
The normal anatomical position of the lateral canthal tendon should be slightly higher than the medial canthal tendon (the ligament at the inner corner of the eye). If the two switch positions such that the lateral canthal tendon is lower, this indicates looseness in the lateral canthal tendon. In contrast, if the medial canthal tendon is too loose, the symptoms are either a flipping outward of the tear duct (punctal eversion) or an increased gap between the tear duct and the inner part of the eyelid (lacrimal caruncle).
Laxity in the lateral canthal can be treated during a lower eyelid reshaping surgery, known as blepharoplasty. Looseness in the lower eyelid’s lateral canthal can be fixed via a lateral canthopexy or canthoplasty. If the medial canthal tendon is loose, a medial canthoplasty can be performed to address it.
Lower eyelid skin looseness, known as dermatochalasis, can occur as we age, resulting in excess fold of skin in the upper and lower eyelids. The skin appears very loose with many deep and superficial wrinkles. A condition called blepharochalasis can cause severe eyelid skin looseness at a young age. Individuals with this genetic condition often complain of intermittent swelling of the tissues around their eyes, including the eyelids.
To correct loose skin on the lower eyelid, surgeons use a method known as the pinch technique, which treats moderate to severe skin looseness. Skin laxity can also be treated with laser skin resurfacing using either a CO2 or Erbium Yag laser, usually for milder cases. However, these types of laser treatments are not suitable for everyone, the CO2 laser resurfacing is only appropriate for lighter skin types (Fitzpatrick skin types 1 to 3), whereas the Erbium Yag laser can be used carefully on darker skin types.
The pinch technique is applicable for patients with significant looseness of the lower eyelid skin. In this method, the doctor will ask the patient to look up while opening their mouth wide. The doctor will then mark the lower eyelid skin with a smooth forceps and a marking pen. Injecting local anesthetic, the marked skin area can be cut and then stitched back with a thin thread. This procedure is shown in the video below.
Why do People Need Lower Eyelid Blepharoplasty
If you’re thinking about having an eyelid surgery, known as a blepharoplasty, your doctor will first need to perform a comprehensive review of your medical and surgical histories. Then they will have a detailed look at the area around your eye, from your eyebrow to cheek to nose, to determine if you can safely have this surgery. This procedure can be both functional, meaning it helps the eye work better, and cosmetic, meaning it improves the appearance of the eye area.
If the skin on your lower eyelids is drooping, or if the muscles and ligaments – like the orbital septum that helps hold your eye in place – are sagging, blepharoplasty can help. It can also reduce extra fat around your eye socket, correct a mispositioned lower eyelid, and reduce the prominence of the area where the curve of your nose meets your eye socket, known as the nasojugal groove. In other words, it can help to make your lower eyelid area feel more comfortable and look more youthful.
As for the upper eyelid, blepharoplasty can also resolve problems caused by sagging skin that folds over your eyelashes and interferes with your peripheral vision. This means that sagging skin in your upper eyelid can affect the outer and upper parts of your field of vision, making everyday activities like driving or reading a book more difficult. In this situation, having a blepharoplasty can help to clear up your field of vision as well as make your eye area look fresher and more alert.
When a Person Should Avoid Lower Eyelid Blepharoplasty
People who are hoping that cosmetic surgery will improve their personal relationships may not be the best candidates for this kind of treatment. Likewise, if a patient expects to be fully satisfied with the result rather than focusing on the restoration and reduction of signs of aging, they might not be ideal candidates for cosmetic surgery.
Certain health conditions can make cosmetic surgery absolutely not safe. For example, if there’s any disease affecting the eyelids or the structures around the eye (the orbit), then this type of surgery is not advisable. Additionally, other health conditions that may affect how a person’s body reacts to the anesthesia used in the surgery could also be a reason not to go ahead with the procedure. These are known as relative contraindications – it doesn’t necessarily mean the surgery can’t be done, but the risks may be higher. Further, if a patient’s expectations about the results of the surgery are unrealistic, this may also be a factor to consider before deciding on cosmetic surgery.
How is Lower Eyelid Blepharoplasty performed
Eye surgery typically involves changes to the upper and lower eye lids, including the tissues around the eyebrows, the upper part of the nose, and the upper part of the cheeks. These changes are made by altering the protective layer of the facial bones that form the eye socket.
Interestingly, this protective layer (known as the periosteum) is made up of two layers of connective tissues that cover the bones in the human body. The outer layer is a dense network of connective tissues filled with blood vessels. The inner layer is made up of bundles of collagen (a protein that provides structure to our skin and connective tissues), comprising special spindle-shaped cells (cells that are thin and elongated), and a net of thin, stretchy fibers.
The accurate assessment of the lower eyelid is vital for excellent results in eye surgery. This can be difficult even for expert surgeons, making this a demanding procedure.
Possible Complications of Lower Eyelid Blepharoplasty
Blepharoplasty, or an “eyelid lift,” can sometimes have complications. Here are some problems that may occur:
1. Infection: Like any surgery, there’s a chance of getting an infection in the area where the operation took place.
2. Bleeding: There may be some bleeding after the surgery.
3. Wound separation: The surgical wound may not heal properly and can separate.
4. Suture cysts: Small lumps can form around the sutures or stitches used to close the wound.
5. Asymmetry: The two eyes might not match each other in appearance after surgery.
6. Problems with skin or fat removal: Sometimes the surgeon may remove too much or not enough skin or fat during the surgery.
7. Excessive muscle removal: Too much muscle might be taken out during the surgery.
8. Scarring: There might be a lot of visible scars both inside and outside the eyelid.
9. Concerns with the crease: The crease in the eyelid might not look right after surgery.
10. Rounding at the corner: The outer corner of the eye might start to look rounder after surgery.
11. Drooping upper eyelid: The upper eyelid might droop or sag after surgery.
12. Fat necrosis: The fat in the eyelid might start to die after the surgery, causing lumps and discomfort.
13. Swelling on the eye surface: The front part of the eye might swell up after surgery.
14. Lacrimal duct injury: The tear ducts could get injured during the surgery.
15. Double vision: You might start seeing double after the surgery.
16. Loss of vision: In extreme cases, you might lose some or all of your vision.
17. Anesthetic complications: You might have a negative reaction to the anesthesia used during the surgery.
These complications don’t happen to everyone, and your doctor will discuss them with you before the procedure.
What Else Should I Know About Lower Eyelid Blepharoplasty?
Blepharoplasty is a type of surgery that helps improve the function of your eyelids and enhances the appearance of your eyes and the surrounding facial areas. This is done by removing extra skin from your eyelids, smoothing the muscles under your eyes, making the supporting structures firmer, and removing extra fat from the back area of your eye. This results in smoother transition where your lower eyelid meets your cheek.
