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Cosmetic eyelid surgery, or blepharoplasty, is an operation undertaken to enhance the appearance of the tissues around the eyes and has been performed in rather crude form for several centuries.
More than fifty years ago, the basic techniques behind a more controlled approach were described and then applied widely without much change in the years that followed. About twenty years ago, a fundamentally new approach to lower eyelid surgery was introduced.
Transconjunctival blepharoplasty, as the operation is called, represents a significant advance over the more customary lower eyelid procedure and has gradually grown in popularity both because of its increased safety and superior cosmetic outcome.
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Initially intended for younger patients with only minimal skin excess, the procedure has become the preferred approach for most patients of all ages.
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Much of the fullness that develops in the lower lids is determined by an inherited family tendency that is expressed with age. Due to the loss of muscular tone and a relaxation of supporting structures, the socket's fat pockets bulge forward like a hernia.
Wrinkles, on the other hand, are the result of damage to the skin from sun exposure, muscular pull (smiling, squinting), and smoking. Since wrinkles are not caused by extra tissue, removal of eyelid skin cannot erase them.
While some true stretching of lower eyelid skin may develop, such change is much less than that typically found in the upper eyelid. What may appear to be extra skin is, in many cases, a near normal amount of tissue either pushed outward by bulging fat or pulled downward by a droopy cheek.
Because of this, the traditional method of lower eyelid surgery (transcutaneous method, as described below) in which the eyelid skin is cut and redraped can be risky. Its most common complication is rounding at the outer corner of the lids and lower eyelid retraction, or a pulling down of the lower eyelid with increased exposure of the eye surface, a change that smacks of overdone surgery and can worsen with age.
Not only can the skin-approach procedure end up trading one deformity (a bulge) for another (retraction), but it may well accelerate the very changes for which rejuvenation surgery was first sought.
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In the traditional transcutaneous operation, an incision is made through the skin just beneath the eyelashes. A long flap of skin and muscle must be dissected downward and then elevated. The orbital septum, a structural layer in the middle of the eyelid, must be opened to expose the fat pockets. Once the pockets are thinned, skin is usually removed from the top edge of the flap. Scarring inside of the lid from the extensive dissection as well as tightness from excess skin removal may combine to create a shortened and relatively immobile eyelid that appears more rounded (that is, less almond in shape).
In people with average-set eyes, the risk of developing at least some degree of eyelid retraction is about 15%; in people with prominent eyes or poor lower eyelid support, the risk is much higher.
While the specific steps of transconjunctival blepharoplasty surgical technique are presented elsewhere on this site, the most crucial difference between the two procedures is that the interior of the eyelid is entered less invasively without disrupting the overlying supporting structures.
Not only does the transconjunctival incision leave no external scar, but there is almost no risk of eyelid retraction from internal scarring.
Because the skin and muscle are not disrupted, the normal position and natural shape of the eyelids are preserved.
Other advantages of transconjunctival blepharoplasty include less bruising and swelling, less post-operative restriction on activity, no sutures to remove, and a faster recovery.
More recently, tissue-sparing techniques have allowed for restoration of bulging lower eyelids without removing fat. While relatively new, such operations may eventually replace transconjunctival fat removal in all but the mildest cases or in those patients who simply will not accept a lower eyelid scar.
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In patients with substantial skin excess (for instance, smokers with extensive sun damage), a tiny strip of skin may be excised without disturbing the middle layer of the eyelid. Fat, however, is still removed or reposited back into the orbit using the transconjunctival approach.
Chemical peeling may improve skin quality, tighten the skin slightly, lighten its color, and blunt the appearance of wrinkles.
If the muscles and tendons supporting the lower eyelid have weakened and stretched due to wear-and-tear and the influence of gravity, reinforcement by canthopexy may be indicated.
Following healing, any objectionable depressions and dark circles in the areas between the nose and eyelid (tear trough) or along the upper cheek may be treated with commercial fillers injected by a dermatologist.
More advanced descent of the cheek may require surgical procedures outside the scope of blepharoplasty (face lift).
Canthopexy: Pros and Cons
Avoiding Eyelid Hollowness After Blepharoplasty
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