Cosmetic Lower Eyelid Surgery

Cosmetic Lower Eyelid Surgery | Definition

Cosmetic lower eyelid surgery is an outpatient surgical procedure which reduces the puffy appearance of the lower eyelids and treats bags and wrinkles under the eyes. It typically involves removal or repositioning of the fat pockets responsible for the bags and, if necessary, excision or ablation of the skin beneath the eyes.

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Indications for surgery

Lower eyelid surgery (lower blepharoplasty) is considered a cosmetic procedure and, as such will not be covered by most insurance providers. The main indication for surgery is rejuvenation of the lower eyelids in patients that are bothered by the puffiness, dark circles, and wrinkles underneath the eyes. There really isn’t a perfect age to do the operation since there are genetic as well as age-related factors that may motivate a person to seek the operation. Having said this, cosmetic lower blepharoplasty is best indicated in patients who have realistic expectations about the outcomes of the surgery and are willing to comply with the surgeon’s instructions during the recovery process.

Risks of the operation

It is imperative to understand the benefits of a lower eyelid blepharoplasty as well as the risks and complications of the surgery before proceeding with the operation. These risks involve, but are not limited to bruising, infection of the wound, visible scarring, and prolonged eyelid swelling. Under or overcorrection are also possibilities and may prompt a need for re-operation. Fortunately, the incidence of these complications is quite low when the procedure is executed by a plastic surgeon with experience in lower eyelid blepharoplasty.

Duration of the procedure

The duration of a lower eyelid blepharoplasty varies significantly because of the diversity of surgical approaches and the different techniques used by surgeons. For example, a traditional blepharoplasty with fat resection may last about 1 hour, while a more sophisticated procedure in which the surgeon transposes the fat may take twice as long. Additionally, lower eyelid surgery is frequently performed alongside other cosmetic procedures such as upper blepharoplasty and facial fat grafting. If this is the case, the surgery will run for much longer.

Type of anesthesia

Lower eyelid blepharoplasty is normally performed under conscious sedation (monitored anesthesia care). It could technically be done with local anesthesia, but the surgical manipulation of the sensitive tissues of the lower eyelid can be quite uncomfortable for the patient. Therefore, most surgeons prefer intravenous sedation, unless he or she is only removing a small amount of skin from underneath the eyes.

Pre-surgery instructions

Pre-operative instructions for a lower eyelid blepharoplasty are similar as for any other cosmetic eyelid procedure. However, there are a few directives that are particularly important for this operation as they have a big impact on the outcome of the surgery. These should be followed carefully if the patient wants to guarantee a smooth recovery and the best possible surgical result.

First, all medications and supplements that may increase bleeding must be stopped at least 2 weeks before the operation. The most feared complication of a lower eyelid blepharoplasty is the onset of bleeding behind the eye during the first 24 hours after surgery (retrobulbar hemorrhage). This event will require an emergency intervention that may lead to an unsightly scar in the best scenario or can permanently jeopardize the patient’s vision in the worst of cases. Therefore, a normal coagulation status must be assured in all patients undergoing this surgery. A list of these medications and supplements is given to every patient in advance. It includes Aspirin, NSAIDS (ibuprofen, naproxen), and supplements that may contain vitamin E and omega 3 fatty acids. Also, a standard laboratory test to determine the quality of coagulation is performed in all patients.

The day of your surgery

You should arrange to have someone with you at the surgical facility while you are being operated. Please do this ahead of time. This person will also take you home as you will not be able to drive for the first 24 hours.

  • Wash your hair and face with an antibacterial soap and baby shampoo the morning of your surgery. This is important to prepare your skin for the surgical procedure. Also, remember that you must keep an 8 hour fast if you are having intravenous anesthesia. The fast includes all drinks and foods. However, if you take a daily medication for blood pressure, you should do so in the day of surgery with a sip of water.
  • We ask that you abstain form wearing makeup, lipstick, moisturizer or any other skin and hair product and that you leave all your jewelry at home.
  • Wear comfortable clothes and avoid pull over tops as these will be difficult to put back on. A bottom up or zip-up shirt is ideal. Also wear comfortable shoes that are easy to put on and take off.
  • Arrange to have someone stay with you for the first 24 hours after surgery. This person could be the same one that takes you to the surgical facility or a caregiver that you desire.

Post-surgery care

Doctor Gómez will give the person accompanying you specific instruction about your postoperative care upon your discharge. These same instructions were sent to you via email beforehand so that you will be able to go back and read them at home if you have any questions.

First, apply cold compresses or ice packs on your eyes every 1 to 2 hours for 10 minutes while awake. Ice helps to reduce swelling and will also feel nice.

A frequent concern for patients is which activities they should and should not perform. Although cosmetic lower eyelid blepharoplasty is an outpatient procedure, it is still a mayor surgery. Therefore, the patient needs to rest and limit all unnecessary activities per the doctor’s instructions and until the tissues have had enough time to heal.

Patients should not drive during the first 24 hours after lower eyelid surgery if sedation was used during the operation. The ability to drive is significantly impaired by the medications and can very easily cause an automobile accident. Patients should also abstain from drinking alcohol and smoking the first day.

Keep in mind that swelling and bruising is completely normal after a blepharoplasty. Bloody drainage for the wounds should also be expected the first 3 days. You may dab your eyes gently with clean gauze to remove the drainage, but do not rub your eyes.

The recovery after lower eyelid cosmetic surgery is not painful but it can be a bit uncomfortable. Take the oral medication that your surgeon prescribed as directed. Tylenol and Advil are usually enough to manage pain.

Try to rest the first week after your surgery. Please avoid exercise, heavy lifting, and bending for prolonged periods of time. You may take short walks a couple of times a day to keep active during this first week. It is also very important to avoid sun exposure until approved by your doctor. UV light will affect the healing of your incision and may cause the scar to pigment or become red.

Finally, Dr. Gómez will want to see you one week after your eyelid surgery. He will remove stitches and evaluate your progression. At this moment, you may ask the doctor about resuming your daily exercise routine and other activities.

Description of the surgical technique

The surgery is performed in an operating room, in a sterile environment and under intravenous sedation. With the patient relaxed, the surgeon injects local anesthesia in the areas if the lower eyelids to be operated and waits for the medication to take effect.

Attention is turned to the right eye where an incision is made through the mucosa lining the inside of the eyelid. Meticulous dissection allows the surgeon to identify the three lower eyelid fat pads. At this moment, the fat can either be removed or transposed to fill the cheek. The decision about the best approach will depend on the patient’s anatomy, their age and the discussion made with the surgeon during the preoperative consultation.

Lower blepharoplasty with removal of orbital fat

After the fat pockets have been identified, a surgical clamp is used isolate each pocket and the fat is cut and cauterized. Extreme care is taken to respect the delicate tissues surrounding the fat to prevent unnecessary damage to these structures. It is essential to be conservative when removing fat to prevent a hollow appearance after the surgery. The amount of fat removed is done as per the preoperative measurements.

Lower blepharoplasty with transposition of orbital fat

Careful tissue dissection is performed to separate each fat pocket as a single pedicle. An incision is made on the thin layer of connective tissue covering the cheek bone (the periosteum) and this layer is elevated off the bone to create a space where the fat will be transposed. A suture is passed through the tissues of the lower cheek and up to the eyelid to engage the fat pedicles. After passing the suture through the fat pockets, the suture is pushed through the cheek tissues again to exit at the same point where it entered. This maneuver pulls the eyelid fat to the upper cheek to create a smooth eyelid-cheek junction and fill the hollows.

Lower blepharoplasty with skin excision

After the eyelid fat has been manipulated, the surgeon will proceed to remove skin form underneath the eyes, if it was deemed necessary before the surgery. An incision is made about 3 mm below the eyelashes and a flap of skin is carefully raised. After measuring the amount of excess skin, the surgeon uses microsurgical scissors to cut the skin. Delicate sutures are then used to close the incisions.

It is important at this point to correct any laxity of the eyelids with a canthal suspension procedure (see link). The surgeon will perform a canthopexy or canthoplasty operation depending on the amount of skin removed, the patient’s bony framework and the laxity of the tissues.

Finally, antibiotic ointment and a surgical dressing is placed on the surgical wounds. The patient is discharged on the same day.