As people age, the eyelid skin stretches, muscles weaken, and fat accumulates around the eyes, causing "bags" above and below.

The surgeon closes the incisions with fine sutures, which will leave nearly invisible scars.

Before surgery, the surgeon marks the incision sites, following the natural lines and creases of the upper and lower eyelids.

Underlying fat, along with excess skin and muscle, can be removed during the operation.

In a transconjunctival blepharoplasty, a tiny incision is made inside the lower eyelid and fat is removed with fine forceps. No skin is removed, and the incision is closed with dissolving sutures.

After surgery, the upper eyelids no longer droop and the skin under the eyes is smooth and firm.

Overview

Eyes are the focal point of one's face. They are the first thing people notice and are the key to facial expression. This is the main reason why so many people seek cosmetic eyelid surgery. We hear over and over again, My eyes always look tired and old even when I feel wide awake.This is very profound because often if you look old and tired you will feel the same way. How many times have you dressed up and prepared to go out feeling good about yourself only to look in the mirror to see that your eyes look older than you feel. The reason for this is that during the aging process the region around your eyes shows the effects of aging much sooner than other areas.

In the attractive, youthful lower eye lid, the lateral canthus should be higher than the medial canthus. The lower lid should just touch the colored part of the eye.

Aging affects the entire face but usually affects the eye region earliest. The reason for this is because early in life there is a large amount of fat surrounding the eyes. You can verify this yourself by looking at the cheeks of a newborn. They are round and full of fat. As we age, this fat will either descend downward on the face or may go away completely. When this happens, it exposes the underlying facial skeleton resulting in the familiar gaunty appearance that we recognize as aging. Also, the fat and underlying muscles act as a filler creating the volume seen in the cheeks of youth. When this filler descends or goes away we see wrinkling. This process is similar to a grape which turns into a raisin when the water is removed.

Muscles With Aging

In the past, eyelid rejuvenation was based on tightening the skin via skin excision. This has changed dramatically in the past decade. Today, well trained plastic surgeons realize that skin excision is just a piece of the facial rejuvenation puzzle. In fact, there are four major components that make up the face. 1) Skin. 2) Fat. 3) Muscle. 4) Bone.

The importance of the underlying fat and muscle has been revolutionary in the field of plastic surgery over the last 10 years. It is no longer acceptable to think of eyelid rejuvenation as merely a procedure to tighten the skin. This is why many doctors feel it is so important to correct the problem itself and not just the effects of the problem. Reposition cheek fat is called a Cheek Lift and it can be done at the same time as a lower blepharoplasty. Once again, not everyone needs a cheek lift. This is determined during your consultation.

Fat With Aging

Example of how repositioning the muscles and fat can markedly improve bags under the lower eyelid

Oblique view of same patient.

Another contributing factor to the appearance of old age within the eye region is the fact that the lower eyelid, especially toward the temple region, begins to descend. This gives a depressed, sad appearance. This is much different than the appearance that one had when he/she was younger. The lower eyelid of youth has a bright, elegant appearance with the lateral aspect being higher than the nasal aspect. It is important to address this issue. Often, docrtors will elevate the lateral portion of the lower eyelid to re-create that youthful, almond-shape appearance. This is a powerful and very effective maneuver and is well worth the additional time.

Example of how elevating the lateral canthus in addition to lower blepharoplasty can create an attractive, almond-shape appearance

Lateral view of same patient.

Eyelid surgery alone will not correct crow's feet. It will help but often a concurrent brow-lift and/or face-lift is necessary.

It is often very useful to perform fat transplantation, as well as either chemical peeling or laser skin resurfacing, in addition to eyelid surgery. This allows the plastic surgeon to address all the components associated with aging around the eye. Remember, the aging eyelid is a result of problems within the skin, muscle, and fat.

Example of how fat transplantion can add the necessary volume to fill in crease underneath lower eyelid

Lateral view of same patient.

Benefits

There are many benefits to eyelid rejuvenation surgery. The key is to determine exactly what the problem is.

Lower eyelid surgery benefits.

• Tightens and smoothes out bags underneath the eyes.
• Repositions lower eyelids into a more elegant, almond-shaped appearance.
• Repositions underlying fat to get rid of the sunken, aged appearance.
• Repositions skin and underlying muscles to smooth out wrinkles.
• Markedly fills out the deep crease known as the tear-trough between the eye and nose.
• Eliminates circles underneath the eyes.
• Improves dark discoloration within the lower eyelid.
• Improves fine wrinkles.

Are you a good candidate?

Most people as they age can obtain improvement from eyelid surgery. Specifically, good candidates include people with the following problems around the eyes:

• Bags and loose skin.
• Sad or tired appearance.
• A deep crease circling underneath the eyes.
• Excess skin and wrinkles.
• Dark discoloration underneath the eyes.
• Crow's feet within the lateral eye area.
• Sunken appearance to the eyes.
• Sagging cheek fat.

Possible complications

The most common complication is inadequate correction of the problem. If this is the case, correction can usually be made with a minor additional procedure. Other complications include ectropion, or downward pulling of the lower lid, asymmetry, and dryness of the eyes. Complications that can occur with any surgery include infection, blood or fluid collection, and unfavorable scarring.

Do's and Don'ts prior to surgery

• Medications. Certain medications thin your blood and should not be taken within three weeks of surgery. The most notable is aspirin and aspirin containing products. Vitamin E and many herbal products also thin the blood and should not be used within 3 weeks of surgery.

• Sleep. It is important to get a good night's rest prior to the procedure. If you think this may be a problem, please, do not hesitate to ask your plastic surgeon for something to help you sleep.

• Smoking. Do not smoke within 3 weeks before and after surgery. Smoking has a profound effect on reducing wound healing capabilities. It significantly increases the likelihood for infection, wound healing problems, and scar formation. It also affects your airway, therefore, makes anesthesia much more difficult.

• Eating. Do not eat within 8 hours of surgery and do not drink within 6 hours of surgery. It is OK to take medications with a sip of water. Please discuss all medications with your doctor and the anesthesiologist.

• Washing. It is a good idea to wash your face and eyelids thoroughly the night before and the morning of surgery. Wash your hair and comb it straight back. Do not apply makeup.

• Arrival. It is best to arrive on time so things go smoothly. Please be sure to have someone else drive you.

• State of mind. Remember, this should be a happy and exciting time. A certain amount of nervousness is normal but you should not be overly concerned.

Anesthesia

The anesthesiologist will discuss with you what type of anesthesia is best for you prior to the procedure. He/she will take into consideration your medical history, the procedure, and your personal wishes.

Eyelid surgery can be performed under general anesthesia or under local anesthesia with or without sedation. If several procedures are being done at once then general anesthesia is the better option. This will be discussed during your consultation with a plastic surgeon and the anesthesia team.

After the procedure

The procedure itself will take about 2 hours. If other procedures are also being done then, obviously, the operative time will be longer.

• Immediately. Right after the operation you will be watched by a nurse for 1 or 2 hours and encouraged to walk around. It is very important that you keep your head elevated to decrease swelling. Still, you can expect that your eyes will swell and there will be bruising. You will be able to eat and drink when you get home.

• That evening. It is recommended that you take it easy. You can walk around, eat, but not much more. Eyelid surgery has surprisingly little pain. You look worse than you feel. Still, you should take as much pain medication as necessary and try to go to sleep early. It is very important to keep your head up the first 3 days. This will markedly decreased the swelling and bruising. The eyes tend to swell and bruise quite easily, so do not be concerned by this. It will go away. If you have general anesthesia you may become nauseated. It is very important not to vomit as this increases bruising and swelling. You will be given anti-nausea medication. You should take it at the first sign of nausea.

• First 48 hours.  You can take a shower the day after. Just be gentle. Use cool water to hit your scalp and then trickle over your eyelids. Do not wash your eyelid with anything, merely, allow water to trickle over it. Afterward, dab dry. Mild oozing will continue for about 2 to 3 days. Dressings are not necessary. Your first post operative appointment with your plastic surgeon will usually be 1 week after surgery.   

• First week. At about day 3, the swelling will be at its maximum. The majority of the bruising and swelling will go away in about 2 to 3 weeks. It is not uncommon for the lower lid to start to pull downward the first few weeks after eyelid surgery. Do not be concerned. This is normal. It will go back up as healing occurs.

• Beyond. Swelling will not completely resolve for about 6 months but, as mentioned above, the majority of it will be gone by 2 weeks. The final result will not be evident until at least 3 to 6 months when all the swelling has resolved and skin contraction is complete. Patients who have fat transplantation or cheek lifting tend to swell more.

Recovery time

Usually, people are off work for about 1 to 2 weeks depending on how self-conscious a patient is about the swelling and bruising. Once again, patients who have had fat transplantation tend to take longer for the swelling to subside.

Consultation For Lower Eyelid Surgery