Lower blepharoplasty:

Lower lid is one of the first places that change as part of our aging process. It is probably the most common surgery that is performed in males. Usually the complaints are as follows:

• Protruding fatty bags
• Wrinkles
• Deep dark circles
• Depression of the lower lid border (tear trough)
• Rounded contour of the lower lid margin
• Lack of muscular protrusion of the lower lid orbicularis

Protruding fat:

In the lower lid, there are three separate compartments where the orbital fat resides. As we age, the tissues holding the orbital fat becomes attenuated and as a result, the fat becomes more evident. Depending on the severity and whether there is a depression in the lower portion of the lower lid rim, the treatment is different. If there is significant fat, the solution is to remove the fat. I prefer to approach the fat from inside the eyes. This prevents unnecessary scar, and less chance of disrupting the tissues that can cause evertion of eyelid. The removal of the fat must be conservative to prevent unwanted hollowing. If the fat is not too significant, but does exist, the tissues holding the orbital fat can be simply tightened. This is called septal reset. If there is hollowness in the lower lid rim, called tear trough, the fat can be mobilized and transferred to the bony rim margin. This helps with both removal of the protruding fat and filling in the defect of the tear trough.

Wrinkles:

The excess skin of the lower lid can be treated with conservative excision. It is important to remove the skin very conservatively to prevent inadvertent ectropion. The incision is made just below eyelashes and excess skin only removed.

Depression of the lower lid margin (tear trough):

Through multifactorial causes, the area just beneath the margin of the lower orbital rim becomes depressed as we age:

• The skin in the lower lid becomes thinner with age
• The attachment of the undersurface of the skin with the bone becomes tighter
• The fat in the cheek descends, leaving hollow area
• The orbital fat above becomes more pronounced

To just remove the orbital fat in this case may cause even more pronouncement of this depression. Instead, usually it is best to transfer the orbital fat to the lower lid rim and fill in this area. I found at times, fat is not enough and therefore other material such as alloderm is a good alternative. Some people advocate a silastic implant in this area; however, I found that to be too visible at times.

Lower lid margin shape:

Aesthetically pleasing shape of the lower lid margin should have relatively a straight horizontal direction with a slightly upward tilt towards the end. However, as we age, the lower lid margin tension becomes weak and stretched. This results in very loose margin with sometimes a rounded contour. A method of making the margin tighter and more straighter can have a dramatic appearance in the more youthful appearance of the eyes.

I prefer a technique called lateral canthopexy, where the lateral tendon of the eyes is fixed to the orbital bone. Depending on the method, this provides better shape to the eyes and protection against post surgical ectropion( margin of the eyelid being pulled down), which can occur after removing excess skin.

Sculpting the orbital muscle in the lower lid:

One of the prominent features of beautiful lower lid is the prominence of the orbital muscle just under the lower eyelashes. As we age, this can appear less pronounced.

My preference is to insert a thin strip of alloderm through stab incisions on the lower lid margin. Approximately 2mm in thickness.