Lower Lid Blepharoplasty
The lower lid lift, or eyebag removal remains one of the most difficult cosmetic procedures. The reason is that the lower eyelid cannot be considered on its own but must be taken in consideration with the whole midface and indeed face. The lower eyelid rests against the eyeball and needs to be in perfect position to protect the eye and carry the tears with each blink into the tear ducts. Any attempt to remove too much skin from under the eye carries a great risk of the eyelid hanging away from the eye. This is made worse if there is any underlying lid laxity. This leads to a poor cosmetic and functional result, and a very unhappy patient!
In a similar fashion the orbital fat that surrounds the eyeball in its socket can bulge forward as we age, and the temptation is to remove this fat. Removing too much orbital fat however, can lead to a hollow appearing socket, with again a poor cosmetic result and unhappy patient!
The factors that age the lower lid and midface are volume loss as much as any fat prolapse and tissue descent.
The steps required to acheive good results from lower lid blepharoplasty therefore include:
Always replace lost volume with tear trough filler and cheek filler.
Always assess and tighten a lax lower eyelid.
Release the arcus marginalis to reset the tethering that tucks in and accentuates the lower lid bag.
Move rather than remove orbital fat, and be very conservative in removing orbital fat when essential.
Release the deeper tissues over the orbital margin and into the midface, to allow the deeper layers to be lifted by sutures to the orbital rim.
Be conservative in trimming excess skin, measure the excess with the patient opening their mouth wide.
Even with all these factors in place I warn my patients that if we can acheive a 99% result for the upper lid, the best to hope for with a lower lid is 70%.