Lower Eyelid surgery is most commonly performed due to patient dissatisfaction with lower eyelid “bags”. Lower lid surgery is done by a wide variety of surgeons across a range of specialties. At Aesthetic Surgery Associates, we emphasize that the lower eyelids should never be evaluated for problems by themselves. The appearance of the lower eyelid is heavily dependant on the position of the midface, or cheekbone area. If you learn nothing else about the lower eyelids, please “take home” the fact that the lower eyelids and the midface are an integral unit. One should never be evaluated without simultaneously evaluating the other. Problems with lower lid position after cosmetic surgery are common, and difficult to correct when serious.
Q & A
Why do my lower eyelids have bags that keep getting worse? Lower eyelid “bags” can result from a variety of causes. Most people intuitively realize that swelling from allergies or sinus infections can make them worse, just as they are worse in the morning after a good night’s sleep. Lower lid bags that appear with aging are a bit more complicated to explain. These are caused by weakening of the soft tissue barriers that hold fat in the eye socket, in combination with descent of the tissues that make up the midface. The midface is the fat pad over the cheekbones in the upper part of the face. With aging, the soft-tissues of the midface lose volume and descend to a lower position on the face. The result is that a crease appears below the eyelid (in some patients it is also a darker color), and the eyelid bulges more significantly due to loss of support. You can easily demonstrate this on yourself by looking in the mirror and pushing your cheeks up against the lower eyelid. The eyelid immediately assumes a more natural and youthful appearance, and the bags become less conspicuous. The point here is that the lower lid and cheek are and integral unit with the appearance of one being dependant on the other. Bulging of the lower lid is caused by the combination of changes in the midface and lower lid structures that function as a barrier to retain fat in the eye socket. Over time, the bulging can stretch the thin skin of the lower lid creating significant wrinkles in addition to the bulging. Some of the wrinkles can appear to be very deep due to thickened bands of muscle on either side of the wrinkle.
What other problems can the lower lid have? In addition to “bags” under the lower lid, the lid can become loose, or “lax” with time. This is especially true in older patients where the lower lid can actually hang away from the eye, a condition termed “ectropion”. Patients with laxity of the lower eyelid also typically have descent of the lower lid. Descent is evident when looking at the eye by noticing that too much of the white of the eye shows lateral to the iris. This is termed “scleral show”, and is an all-too frequent problem after lower eyelid cosmetic surgery. Ecropion too can be caused by overly-aggressive surgery designed to improve the appearance of the lower eyelid. Lid descent can cause symptoms of “dry eyes” due to increase tear film evaporation resulting from greater exposure of the surface of the eye.
Can the excess lower lid skin simply be cut out? This is a commonly performed operation which is referred to as a lower lid blepharoplasty. The scar is just below the eyelashes of the lid, and is very cosmetic. The problem with this approach is that it tends to pull the lid down, resulting in excessive scleral show,, or an abnormally round appearance to the shape of the eye. This is especially true in patients who have laxity of the lower lid, or who have protruding eyes (eyes that “bug out). It is vital that the surgeon evaluate each patient for factors predisposing to lower lid descent, and counsel them appropriately before surgery. Frequently, the “simplest” operation can lead to long-term problems.
What else is done in addition to removing the excess skin? Most surgeons recommend removal of excess fat from the lower lid to help decrease the bulging. The fat can be removed through the lower lid blepharoplasty incision, or through an incision on the inner surface of the lower lid – a procedure known as “trans-conjunctival blepharoplasty”. Trans-conjunctival approaches are most appropriate for younger patients who have few wrinkles on the lower lid. The scar is invisible, and combining the operation with peeling of the lower lid skin can yield a very satisfactory result in these patients. Whatever the technique, overly aggressive fat removal should be avoided to help prevent “hollowing” of the eyes later in life with aging.
What if the midface has dropped down? In this situation the midface needs to be elevated. Lifting the midface position adds support to the lower lid and improves the cosmetic result. This is accomplished by a mid-face lift, or “cheek lift”. There are a variety of techniques used to elevate the midface. Most separate the cheek tissue from its attachments to the bone and re-attach it at a higher position. Some also “tighten” the structures that retain fat in the lower lid. Although midface lift is not essential in all patients, it illustrates the need to address the lower lid and midface as a unit when discussing the most appropriate surgical option
What are the risks of surgery? Although serious complications are very rare, the most feared complication is blindness. It is caused by bleeding within the eye socket post-operatively, and is a complication that few surgeons have seen. Another serious problem is ectropion due to overly aggressive skin removal. Occasionally, scarring inside the lower lid can result in ectropion that evolves over time rather that immediately following the operation. If tightening of the lower lid is performed, patients can have an “asian” appearance to the eye for two weeks post-operatively. This appearance resolves to leave a pleasing, and more youthful shape to the lower lid. “Mis-matched” eyelids usually result from underlying facial asymmetries that are unmasked by the surgery. Careful study of you pre-operative photographs will enable you surgeon to point this out to you before surgery. After healing is complete, these asymmetries are usually subtle and seldom require correction.
How long does it take to recover from surgery? If only blepharoplasty is done, the majority of the recovery is complete at 7 to 10 days. Some patients have more extensive bruising which can take two weeks to completely clear, similar to a black eye. Stitches in the eyelid are usually removed in five days. When midface lifts are done in conjunction with blepharoplasty, 10 days to two weeks are needed for swelling and bruising to resolve. Subtle swelling can persist for up to a month.
Is this surgery covered by insurance? Lower eyelid surgery is covered by insurance only for severe lower lid laxity, ectropion, or problems with tear drainage. If the surgery is designed only to improve appearance, it is considered cosmetic and not covered.
To arrange a consultation, please call Aesthetic Surgery Associates at (254) 526-5106 or toll-free 1-866-232-0469