Eyelid Surgery
Blepharoplasty is surgical rejuvenation of the upper or lower eyelids. It is often the first procedure that patients will undergo, usually around age 40, earlier or later depending on the individual.
Upper Blepharoplasty
The upper blepharoplasty is a fairly straight forward surgical procedure. The most important issue is diagnosing whether a patient needs a blepharoplasty or a browlift, or both. Both drooping of the brow (forehead) AND excess upper eyelid skin contribute to fullness of the upper lids (See Browlift).
The surgeon first determines how much upper eyelid skin is to be removed. The skin is then excised (removed). Excess fat is sometimes removed from the inner (medial) corner of the eyelid. Fat in the central compartment is sometimes reduced when fat bulging is significant. The upper eyelid scar is generally excellent. (See Commentary on Blepharoplasty).
Lower Blepharoplasty
Surgery of the lower eyelids is much more complex than upper lids. The components of aging include the skin, muscle layer and fat. Bulges of the lower eyelids represent protruding fat. The dark circle of the lower lid worsens over the years due to thinning of the tissues overlying the bony rim of the orbit, especially the inner part of the lower lid (tear trough). Bulging fat also casts a shadow which further worsens the appearance of the dark circles. There are several types of surgery that can be performed for the lower eyelids. (See Commentary on Blepharoplasty).
Standard Lower Blepharoplasty
This is still the most common type of lower blepharoplasty performed. It is a good choice for the patient who has excess skin (not just wrinkles) and excessive, bulging fat. An incision is made just below the lash line (subciliary incision). The skin / muscle layer is lifted exposing the orbital septum. Underneath the septum lie the medial (inner), middle and lateral (outer) fat pads. A small incision is made over each fat pad and a portion of the protruding fat is removed. The skin / muscle layer is re-draped and excess skin removed. The subciliary incision tends to heal beautifully.
Fat Transposition
Fat transposition lower blepharoplasty is a newer technique. It is reserved for the patient who has symmetrical excess fat and a significant tear trough deformity (dark circle due to inadequate coverage over the rim of bone). In this case, rather than removing fat, the fat is “transposed” over the bone to cover the outer surface. The fat is re-positioned to fill in the thin skinned valley responsible for dark circles on a permanent basis. This re-positioned fat is live fat, still attached to its blood supply, and so does not need to “take” as in fat injection (See Fat Injection).
The first portion of this procedure is identical to the standard lower blepharoplasty. However, fat is not removed. Rather, dissection proceeds and the upper portion of the cheek attached to the orbital rim is lifted from the bone. The fat in each pocket is teased from its’ position and laid over the rim of the bone. The skin / muscle layer is then trimmed and closed as in the standard blepharoplasty.
Transconjunctival Blepharoplasty
The patient who has bulging fat and no skin excess may be a candidate for this procedure. Typically this patient is younger and has a genetic predisposition to prominent fat pockets.
Small incisions are made on the inside of the lower eyelid and the fat is removed from the appropriate pockets. There is no external scar, consequently, no skin is removed.
COMMENTARY ON BLEPHAROPLASTY (Dr. Anson)
There is much confusion regarding fat removal in blepharoplasty. In the past, excess fat has sometimes been removed giving the patient a hollow appearance. Whenever possible, I prefer fat transposition blepharoplasty because it yields a permanent improvement in the visibility of the orbital rim (tear trough deformity, dark circle). The draw back is more and longer swelling and that not all patients are candidates depending on individual anatomy. When fat transposition is not possible, fat is sometimes removed. Removing fat is not always a bad thing!! The goal is to remove the appropriate amount of fat to give a flat, non-bulging appearance. Prominence of the dark circle will occur over time regardless of whether fat is removed because the tissues overlying the orbital bony rim will invariably thin over time. The treatment for that will be filler. Fillers work very well to improve the dark circle if there is not bulging fat above it. (See Fillers).
Remember also that aging of the eyelids is not just about skin and fat; it has many factors, each of which will eventually need to be addressed. The skin also thins and we loose fat where we don’t want to loose it. Botox will help with wrinkling at the crowsfeet and Botox will still be beneficial with or without blepharoplasty. Fillers may be required to replace volume loss of tissues along the bony rim of the eye, especially the inner eyebrow area where loss of fat can give the illusion of sagging brow. In this case, deflation is the cause, not actual excess tissue! In the lower lid, filler in the tear trough may be useful with or without surgery. The texture of the skin changes with time and chemical peels or laser resurfacing may be warranted. The bottom line is that because there are so many factors involved in aging eyelid tissues, a blepharoplasty alone will not solve each problem. Maintenance treatments will still be necessary if maximum improvement is desired.