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Let’s discuss the evolution of lower eyelid blepharoplasty and how we deal with the lower eyelid "bag."
Many patients are interested in this procedure because the lower eyelid "bag," compounded by volume loss of the cheek, makes us look and feel tired.
The decline in purely subtractive surgical techniques in blepharoplasty surgery and the advent of fat repositioning and other volume enhancement techniques has improved surgical outcomes when it comes to the lower eyelid blepharoplasty.
Initially known as a “subtractive” surgery where fat was removed in the lower eyelid to deal with the lower eyelid "bag," now more than ever we know the importance of re-volumization of the “tear trough” area and cheek to achieve optimal outcome. We can address this with fat preservation and repositioning with adjunctive procedures, such as cheek and periorbital fat grafting or cheek lifting at the same time. We know that occasionally this can also be done with HA fillers in younger patients with tight skin and mild signs of aging. However, many patients are not true candidates for filler and require surgery to achieve that smooth transition from the lower eyelid to the cheek in a natural way.
The transconjunctival route for lower blepharoplasty was first described by the French surgeon, Bourget in 1928, so it has been around for almost a CENTURY. He described going through the conjunctiva in order to reach the fat pads. At the time, the technique described removing the fat pads.
In this figure, you see at the top left the approach to go through the conjunctiva which is the "scarless" technique. On the bottom right, you see the transcutaneous route where an incision is made beneath the lashes and the route is taken through the lid externally to reach the fat pads.
You will see some surgeons referring to this as their “scarless” technique. What they mean is we are approaching the lower eyelid fat from the transconjunctival route. The older route would involve making a subciliary incision below the lashes and going through the orbicularis muscle in order to reach the fat pads. The issue we see with this is it does have a higher incidence of retraction of the eyelid because of mid-lamellar scarring and so that route has largely fallen out of favor. There are some surgeons who do advocate for that route and they do it well. However, overall the "scarless" transconjunctival route offers less risk of retraction and eyelid malposition.
While previous surgeons did describe a transcutaneous (external) route to reposition the fat of the lower eyelids to fill in the "tear trough" deformity instead of taking the fat out,
Bob Goldberg (1998), an oculoplastic surgeon, was the first to describe a transconjunctival route to perform a lower blepharoplasty with preservation of the orbital fat, where the fat is draped over the orbital rim to efface the tear trough, add volume to the tear trough and ensure a smooth transition from the lower eyelid to the cheek.
So, how do I personally deal with the fat, the periorbital volume loss, and the eyelid "bag."
I utilize a combination of techniques for patients depending on their anatomy and what is needed. I utilize a "scarless" technique in all of my patients to access the fat. In the overwhelming majority of patients, I also reposition the fat instead of simply removing the fat (unless absolutely needed to get the best result). I then either add fat with micro fat grafting taken from the abdomen or inner thigh and processed specifically to be injected with cannula into the face like filler. This allows for revolumization of both the tear trough and the cheek to attain a nice transition from the lower eyelid and the cheek. Alternatively, I revolumize the cheek with an endoscopic cheek lift at the same time as the transposition lower blepharoplasty (fat reposition blepharoplasty) which has added benefits in patients that have more descent of the mid-face and redistribution of fat to the lower face.
How do I treat the skin? I will describe this in more detail later, but for now either with CO2 laser resurfacing, skin pinch, or skin removal.
In this figure, I am demonstrating the combined techniques of transposition lower blepharoplasty with mid-face lifting or revolumization of the cheek with fat grafting. On the right side you see the pedicle fat from the lower eyelid that will be draped over the orbital rim into the tear trough to revolumize the tear trough, while decreasing the bulge above that created the eyelid "bag." The fat is preserved and repositioned. On the bottom right, you can see the advantage of building up the midface with autologous fat to aid in providing a smooth contour from the lower eyelid to the cheek (with volumization on the left versus the right).
Here is one of my patients that had a lower eyelid fat preservation and repositioning blepharoplasty only. You can see from the oblique profile the difference before with a "double convexity" and restoration of the more aesthetically pleasing S-curve, known as the Ogee curve. Due to her anatomy, I was able to achieve a smooth transition from the lower eyelid to the cheek without having to perform fat grafting or midface lifting.
Another example of a "scarless" technique with preservation and repositioning of fat into the tear trough. In this case, I combined it with endoscopic cheek lifting to provide that smooth contour from the lower eyelid to the cheek.
#blepharoplasty #eyebags #eyelid #eyelidlift #oculoplasticsurgeon #eyelidspecialist #cheeklift #endoscopicfacelift #CO2laserresurfacing #beforeandafter #lowereyelidblepharoplasty
References:
1) Holds, JB. Lower Eyelid Blepharoplasty: A Procedure in Evolution. Mo Med. 2010 Nov- Dec; 107(6): 391-395
2) Bourguet J. Fat Herniation of the orbit: our surgical treatment. Bull Acad Med. 1924; 92: 1270.
3) Goldberg, RA, Edelstein C, Balch K, Shorr N. Fat repositioning in lower eyelid blepharoplasty. Semin Ophthalmol. 1998; 13: 103-106.
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