Bulging lower lids are not very attractive, but then hollowed eyelids can look even worse. One way to avoid the risk of trading one deformity for another is to go easy on removal of orbital fat during eyelid surgery. Here's why:
• Orbital Fat Does Not Increase With Advancing Age
Standard blepharoplasty is an operation based around the subtraction of bulging orbital fat and sagging eyelid skin. However, orbital fat does not increase with advancing age. By definition, then, any fat removed during blepharoplasty creates a shortage compared to a more youthful state.
• Something Bulging? It's Not That Easy to Correct
Both transconjunctival and transcutaneous lower blepharoplasty entail removal of orbital fat that is bulging against the lower eyelid and making it appear to be too full.
Determining the exact amount of fat that can be removed without causing hollowness is difficult. If removal is too vigorous, eyelid hollowness may appear just as soon as major swelling from the operation subsides. If removal is only a little bit too aggressive, hollowness may take a year or more to become noticeable.
• Removing Orbital Fat May Have Secondary Consequences
Excessively excising fat during lower blepharoplasty can set off a cascade of unintended regional anatomic changes. For instance, the eyeball may drop lower in its socket. As it does, the upper eyelid crease may elevate and deepen even without surgery. Missing proper support from below, the lower eyelid may collapse downward or turn inward against the eye.
Even with conservative fat removal, such changes may take place in subtle form.
While orbital fat does not increase with advancing age, it can certainly do the reverse (that is, decrease) as age-related metabolic changes cause a redistribution of fat out of our faces and onto our waistlines. That's why it's not rare for some eyelid hollowness to appear in later life in those who have undergone aggressive cosmetic eyelid surgery years earlier.
So, should fat never be removed from the lower eyelid? "Never" is clearly too extreme.
However, fat removal during blepharoplasty should always be conservative. Why? Because it's far easier to prevent eyelid hollowness than it is to treat it.
Newer tissue-sparing techniques still under development allow bulging fat to be returned to normal orbital position with little or sometimes no removal. Over time, such operations may become more widely-available and eliminate many of the concerns discussed above.