Lower Blepharoplasty

Lower blepharoplasty involves surgical rejuvenation of the lower eyelids. It differs from upper eyelid surgery because the focus is often on lower eyelid hollowing, dark circles, or puffiness. The treatment can vary and is customized based on the consultation visit. For many patients, the surgical correction involves approaching the fat pads in the lower eyelid that have shifted forward using an incision on the inside of the lower eyelid. The fat can then be removed and potentially repositioned to fill the hollows under the eyes. In some patients who have significant hollowing, it may involve fat transfer from a different area of the body. Finally, for those patients who have loose skin in the lower eyelids, it may involve tightening of the skin through removal and anchoring of the lower eyelid. The approach and combination of procedures is determined based on the surgical consultation visit.

During the consultation, the upper and lower eyelids are assessed to determine whether you can benefit just from surgery on the upper eyelids, lower eyelids, or all the eyelids at once. You can tell if you need upper eyelid surgery if you notice an increase in the amount of skin covering the upper eyelid and puffiness of the upper eyelid. In the lower eyelid, it can be more challenging to determine because the treatment varies if you have hollowing versus puffiness, and sometimes surgery is not the best approach.

However, if you notice a lot of puffiness in the lower eyelids, surgery is the most effective way to deal with the shifted fat pads. You do not have to do the surgery for the upper eyelids and the lower eyelids at the same time, even if you notice changes in both. Recovery from the lower eyelids can take longer than from the upper eyelid surgery, so sometimes it is easier to separate the two procedures. But for most patients, it is best to allow a continuous period of recovery from both at once so they can experience full rejuvenation of the eyelids.

If the lower eyelid changes leading to dark circles have more to do with hollowing of the lower eyelids or darkening of the skin, then non-surgical options such as fillers or lasers can be considered to replace the volume and improve the skin tone and texture. However, it is important to go to an oculofacial specialist to determine whether those treatments would be effective in your particular case. With fillers, there can be long-term complications including risk of permanent vision loss as well as recurrent swelling and migration, so they must be used carefully and sparingly. There are also alternatives to standard hyaluronic acid fillers such as fat transfer that can last longer and may be a better option depending on your individual concerns.

Lower blepharoplasty can address multiple concerns about the lower eyelid and upper cheek.

• Loose skin can be addressed by a skin pinch and tightening of the outer part of the lower eyelid with surgery, especially when combined with laser for the right candidate.
• Under-eye bags can be addressed by removal and repositioning of the fat pads that have shifted forward and are causing puffiness.
• Dark shadows under the eye can be filled in with fat transposition or fat transfer. Sometimes, the darkening can be related to pigment in the skin, which can be addressed with lasers or peels.

In many patients, there are numerous factors including bags, loose skin, and shadowing that can all be addressed at the same time with lower eyelid blepharoplasty.

For the right candidate, lower blepharoplasty can shorten the distance between the eyelid and the cheek to create a more youthful transition and reduce the appearance of dark circles and puffiness in the lower eyelid. It can also help to smooth the lower eyelid, particularly when significant skin changes are leading to wrinkling and bunching of the skin.

In my practice, lower eyelid blepharoplasty is approached via a transconjunctival incision, meaning that the cut is made on the inside of the lid, where it can easily be concealed. This approach is also safer because it protects the septum, which, when violated through the skin, can increase the likelihood of the lower eyelid being pulled down or retracted.

For skin removal in cases where there is skin laxity, the skin is tightened from the outside at the outer corner of the lower eyelid, but the incision hides nicely in the natural skin line. Also, because only skin is removed through that cut, the likelihood of the eyelid being pulled down is significantly reduced because the septum is not violated. The lower eyelid blepharoplasty procedure is typically performed with a combination of local anesthesia through injections of nerve block in the area as well as either IV sedation or full general anesthesia, though these days, most patients opt for IV sedation to reduce the amount of sedation they receive.

The specific approach varies depending on whether the primary problem is puffiness from the fat pads, looseness of the skin, or a combination of the two. If the only issue is puffiness and the skin quality is good, the approach may purely involve a transconjunctival approach. If there are some skin changes but not significant laxity, that approach can be paired with skin resurfacing.

On the other hand, if there is significant skin laxity in addition to the fat pads shifting, the best approach is a combination of transconjunctival and skin incisions to address both concerns at once. Skin resurfacing by laser or peel can then also be performed to enhance the results by polishing the skin that remains.

After lower blepharoplasty, patients often feel very comfortable with minimal pain. The biggest issue is cosmetic downtime relating to swelling and bruising. For the majority of patients, the peak swelling and bruising occurs in the first 48 hours and can last 10-14 days. The final results can take 3-6 months, because there is a small amount of bruising that can take months to dissipate.

However, for the purposes of being presentable for day-to-day work or casual events, most patients are comfortable returning to social engagements within 2-3 weeks. If you are considering lower blepharoplasty for a significant life event such as a wedding, it is advisable to allow several months to account for the small amount of residual swelling that gradually resolves over the months after the surgery.

Because of the concern of bleeding in the eye socket and compartment syndrome specific to lower blepharoplasty, it is advisable to avoid strenuous exercise, bending, and heavy lifting for at least 1 week post-surgery, ideally 2 weeks. It is advised to avoid contact lenses and eye makeup for 2 weeks after surgery. It is also advised to avoid swimming for 2 weeks after surgery. This ensures adequate time for the incisions to heal, minimizing risks of bleeding, infection, and wound dehiscence. Work can be resumed within a few days depending on the nature of the job. For example, if you have the option to work from home, you may be able to conduct meetings off-camera or do offline reading and computer work within a few days of the surgery. However, work that involves heavy lifting or significant face-to-face interaction cannot be resumed for at least 10-14 days after surgery.

The biggest risk with lower blepharoplasty is vision loss due to bleeding in the eye socket, which can lead to compartment syndrome. Sudden bleeding in that fixed compartment can put too much pressure on the optic nerve, which is why it is very important to avoid blood thinners around the time of surgery, as advised by your primary care doctor and/or cardiologist.

Also, avoid situations that can lead to increased blood pressure and heart rate, such as vigorous workouts or lifting heavy things right after surgery, as those can predispose to bleeding in the recovery period. Other risks can include dry eye, transient vision changes, eyelid malposition, double vision, bleeding, and bruising. There may also be the need for other procedures or surgeries in the future.

Dry eye is a frequent symptom during the recovery period, most likely due to swelling and bruising in the muscle involved in blinking and eyelid closure. For most patients, this gradually improves as the body recovers from surgery. Those with a pre-existing dry eye history are at higher risk, and it is advised that these patients carefully manage their dry eye symptoms in conjunction with their eye care providers to make sure they are optimized for surgery.

The best approach to minimize the eyelid pulling down is to remove a conservative amount of skin, if any, depending on the patient’s needs, and also to avoid violating the septum, which is an important structure in maintaining the position of the lower eyelid. The latter can be achieved by using a transconjunctival approach to address the undereye bags rather than doing the whole surgery through the skin.

Lower eyelid blepharoplasty should not change your eye shape or expression unless that is an intended cosmetic outcome, such as in some cases of canthoplasty surgery, which can be done with lower blepharoplasty. For patients who wish to keep their eye shapes and expressions the same, lower blepharoplasty can do so while still addressing the fat pads and the extra skin. It is important to discuss your aesthetic goals with your surgeon at the time of your consultation to make sure you are aligned on the surgical plan.

Lower blepharoplasty results can last 10 years on average, but there are patients for whom it can last much longer. Fat pads do not “grow” back, but deeper fat pads can sometimes shift forward with age, in which case the surgery can be redone. Sometimes, the problem changes to one of skin changes or hollowing, in which case other approaches such as fat transfer or laser resurfacing can be considered rather than lower blepharoplasty surgery.

If the undereye bags come back in the form of deeper fat pads shifting forward, the surgery can be redone to remove and reposition those fat pads. However, if the changes later become secondary to loose skin, hollowing, or darkening of skin, you can consider filling the hollows with hyaluronic acid fillers or fat transfer, tightening the skin with lasers or chemical peels, and potentially even more surgery if the skin has stretched past a certain point.

Whether combining lower eyelid surgery with upper blepharoplasty, brow lift, or skin resurfacing would be appropriate depends on whether you have extra upper eyelid skin, drooping eyebrows, or skin changes such as discoloration and crepiness or wrinkling of the skin on the face or around the eyes. These determinations are made during the consultation visit when a full assessment of the face is done.

Lower blepharoplasty does not specifically address eye shape unless there is a request to change the eye shape, which can be done with canthoplasty. Otherwise, the approach is the same across different eye shapes and ethnicities. The difference depends more on whether there are skin changes, fat pad shifts, or both. In darker skin types, the use of laser resurfacing may be modified, as too much heat can potentially trigger skin discoloration. Sometimes, in those cases, skin pinch is favored over laser resurfacing to minimize the risk of lightening or darkening of the skin in response to heat from laser treatments.

At your consultation, the location of the fat pads is observed both at rest and with gentle pressure on the eye to determine the gravitational impact of the fat pads. The relationship between the lower eyelid, the fat pads in the eye socket, and the cheek is also observed three dimensionally to determine whether there is shadowing from the fat protruding over the cheek and/or whether loss of cheek projection is causing the lid to droop down or puts you at risk for that issue, in which case the lid must be supported either through tightening of the lid or fat transfer/transposition or both.

Dr. Mahsa Sohrab is a board-certified, fellowship-trained ophthalmic plastic and reconstructive surgeon. After completing her undergraduate studies at Barnard College of Columbia University, she went on to obtain a medical degree from the Columbia University College of Physicians and Surgeons. She then completed residency training in ophthalmology at Northwestern University, followed by a highly selective two-year, dedicated American Society of Ophthalmic Plastic and Reconstructive Surgery fellowship at the Wilmer Eye Institute at Johns Hopkins University, widely recognized as one of the top programs for eye and eyelid surgery training in the world.

Dr. Sohrab served as the director of ophthalmic plastic and reconstructive surgery at Yale University prior to starting her own private practice in Greenwich, Connecticut. Her extensive training and experience have made her an expert in cosmetic surgical rejuvenation of the upper and lower eyelids and eyebrows.

Transconjunctival lower blepharoplasty involves approaching the fat pads through the inside of the eyelid. The technique has several advantages, including that the incision is hidden on the inside of the lid and not visible from the outside and that it does not involve violating the septum.

Scarring in the septum can potentially lead to issues with the position of the eyelid and a condition known as lower eyelid retraction, where the eyelid is pulled down due to scarring, so avoiding the septum through the transconjunctival approach can provide added protection against this kind of complication.

The subciliary approach is an older technique for lower blepharoplasty in which the entire correction of the lower eyelid, including skin and fat removal, is performed from the outside of the eyelid. The disadvantages can include a more visible scar as well as violation of the septum, since you must pass through the septum to access the fat pads, thereby increasing the risk for retraction of the lower eyelid both in the short- and the long-term.

Before-and-after photos of lower blepharoplasty can be found on our website.

Lower blepharoplasty costs with Dr. Sohrab start at $8,000, not including sales tax, anesthesia and facility fees. The final pricing depends on the surgical plan recommended during your consultation visit.