One of the most apparent signs of ageing is loose skin and wrinkles. As we age, our skin loses its elasticity and tightness and becomes more loose, saggy and redundant. And this is especially apparent in areas where the skin is delicate and thin like the eyelids and under the eyes. 

When the lower eyelids look baggy or buffy, they make you look tired all the time. This lower eyelid bagginess can cause a lot of stress that can impact your life. It can affect how you feel about yourself and make you insecure because everyone thinks you look tired because of this eyelid puffiness. 

Fortunately, there is a solution that can restore your comfort and self confidence, reduce lower eyelid bags, improve your eyelid skin, and result in a tighter, more youthful appearance. 

A simple outpatient procedure called lower eyelid surgery or blepharoplasty can restore your face harmony. 

So, what is lower eyelid surgery or Blepharoplasty? 

It is one of the most commonly performed face cosmetic procedures.  The eye is an important component of facial aesthetics. Lower eyelid blepharoplasty plays a vital role in the perception of ageing. It helps correct loose skin, excess fat, puffy lids and wrinkles in the eyelid area. As we age the eyelid area stretches and the muscles that support it becomes weak.  Symptoms such as tired-looking eyes, excess skin, or circles around the eyes can be corrected by this procedure. So, you don’t have to live with bags under your eyes any longer. 

But why is it done? Is it only for an aesthetic purpose? 

Some people might consider blepharoplasty if their droopy or sagging eyelids keep their eyes from opening completely or pull on their lower eyelids. Besides, it makes your eyes look younger and more alert. 

So, again, who is it for? 

You might consider blepharoplasty if you have: 

• Baggy or droopy lower eyelids. 
• Excess skin of the lower eyelid. 
• Bags under your eyes due to excess fat. 

But, honestly, lower eyelid blepharoplasty is almost always done for cosmetic purposes. 

The good thing that you can undergo this procedure along with other cosmetic procedures such as facelift, brow lift, or laser or chemical skin resurfacing. 

And since no two pairs of eyes are the same, no two blepharoplasties are the same either. It is always tailored to each patient’s cosmetic desire and unique facial features. The doctor also must have an artistic understanding of what the ideal look of eyes is best for each patient. The doctor also should have expert knowledge of eyelid architecture and function. Just because you need a better look, doesn’t mean you have to let go of the best functional quality. 

So, if all the conditions apply, what should we expect from the lower eyelid blepharoplasty? 

Results do vary from one person to another. However, you should expect an improvement in the eyelid appearance. You should see an improvement regarding the bags under the eyes and you should see a smooth transition between the cheeks and the eyelids, just like your facial architecture when you were young. You should look natural and more youthful. 

However, you might not be able to see the final results of your procedure right after it because post-surgical swelling and bruising might obscure this final outcome. Although many patients return to work one or two weeks after the procedure, it might take several weeks for the swelling to subside. You can see the final results of your lower eyelid surgery in about 4 to 6 weeks following the surgery. 

After the surgery you might also experience: 

• Blurred vision from the lubricating ointment applied to your eyes.
• Double vision.
• Light sensitivity.
• Watering eyes.
• Puffy or numb eyelids.
• Swelling and bruising. 
• Pain or discomfort.

Your surgeon will likely suggest some instructions to follow to reduce these symptoms such as:

• Using ice packs on your eyes the night after the surgery for ten minutes every hour. And on the following day, use the ice packs four or five times throughout the day.
• Gentle cleaning of the eyelids and using the prescribed drops and ointments. 
• Avoidance of straining, weight lifting, and swimming for a week. 
• Avoidance of smoking and rubbing the eyes. 
• Not using contact lenses for two weeks after the surgery. 
• Applying cold compresses to reduce swelling. 

And just like any other surgery, there must be some risk of complications.

Some of these risks represent the natural process of healing after the surgery such as swelling, bruising, and blurred vision. They are part of the normal healing process.

More serious risks of lower eyelid surgery include: 

• Infection. 
• Bleeding. 
• Dry irritated eyes. 
• Difficulty closing your eyes. 
• Injury to eye muscles. 
• Skin discoloration. 
• Noticeable scarring. 
• The need for follow-up surgery. 
• Cysts where the skin was sewn together. 
• Death of the fat tissue under the eyes. 
• Blurred vision or loss of eyesight. 
• Numbness. 
• Drooping upper eyelid. 
• Anesthesia complications. 
• Blood clots. 
• Poor wound healing.
• Asymmetry.
• Pulling down on the lower eyelid. 

Your surgeon should discuss all these risks and complications with you before the procedure. But with an expert eyelid surgeon, and extensive training in blepharoplasty surgeries, you will have a lower risk of complications. The more qualified your surgeon is, the fewer and less harmful complications you might face. 

Your surgeon also should prepare you before the surgery. Some examinations and investigations should be conducted to make sure you are totally ready for the procedure. 

Before the eyelid surgery, you will undergo the following examinations: 

• A physical examination. Your surgeon will conduct a physical examination where he examines your tear production and measures parts of your eyelids. 
• Eyelid photography. Your surgeon will take photos of your eyes from different angles so he or she can plan the suitable surgical approach in your case and assess the immediate and long-term effects of the surgery. 
• A vision examination. Your doctor will ask an ophthalmologist to test your vision including your peripheral vision. This is helpful to support your insurance claim if you needed it. 

Some drugs will also be stopped before the surgery- if you are taking them- such as warfarin, naproxen, aspirin, ibuprofen and any other medication associated with increased bleeding. 

Your surgeon will also ask you to stop smoking several weeks before the surgery because it might affect the quality of your wound healing. And, of course, you are asked to arrange for someone to drive you home after the surgery because you won’t be allowed to drive yourself. 

It is highly important to talk honestly with your surgeon before the procedure to tell him what bothers you the most and what outcomes you are expecting. 

Now, let’s talk more about some details of the procedure itself. Let’s start with the type of anesthesia used during the procedure. 

The procedure can be done in the operating room but if minor enhancements are the only modifications to be done, then, the whole process can be performed in the office. The procedure can be done under general or local anesthesia, but mostly, minimal sedation with local anesthetic injections is needed for the procedure. Local anesthesia will give the surgeon the benefit of testing eye muscle movements and, hence, reduce the risk of excessive cutting. However, if you are having more than one surgery, your doctor will recommend general anesthesia. 

There are several surgical approaches for lower eyelid surgery. The used approach usually depends on the goal you want from the procedure and the unique anatomy of the eyes. 

Before the procedure, your surgeon will ask you to sit up so he or she can see your eye bags better and mark them to know where to make the incision. 

Although the sites of the incisions may vary, the general concept of lower eyelid procedures is still the same. The surgeon cuts excess skin and removes excess fat then suture the skin back together to create a smoother, younger, and more natural look. 

And although the procedure will give you good results, you need to understand that you will continue to age after the procedure and your skin will start to appear wrinkled and sagging again after a while. It all depends on your age, skin quality, and how well you take care of your skin after the procedure. 

So, if this surgery’s results won’t last forever, you might be wondering. Are there any alternatives to the lower eyelid procedure? 

Yes, there are other alternatives, but they work on mild or moderate skin sagging. These options are:

• Laser skin resurfacing. It includes exposing the skin to a laser which causes the skin to tighten. However, it is not for everyone. 
• Dermal fillers. Doctors use hyaluronic acid dermal fillers to improve the skin appearance, but the body will eventually absorb the fillers, so they are not permanent. 

I hope we covered most of the frequently asked questions about lower eyelid surgery. But for more information about different surgical approaches and how they are done clinically, today we have Doctor Park who is an accomplished cosmetics surgeon and professor in Seoul, Korea. He is going to discuss Lower eyelid surgery from an experienced point of view.

Interview

For lower eyelid, how do you actually do lower eyelid surgery?

In lower eyelids, as we age, we develop wrinkles and eye bags. So, how will we take care of this? So, for the upper eyelids, we perform incisions, take out the fat, pull, etc. But for the lower eyelids, just removing tissue from the area does not result in improvements. We must find out what is causing the eye bags. One reason could be that the fat from the deeper layers is surfacing outwards. Another could be that the skin has expanded. Third, the skin may have sagged downwards. These are the three causes. We must address all of them. So, we must discuss these issues with the patient.

In what cases would patients decide to have this surgery?

For example, this person. This person has both the upper eyelids and lower eyelids sagging. So, this requires both upper and lower eyelid surgeries. If we just do lower eyelid surgery, the result would be even more noticeable coverage of the upper eyelids overhanging and the eyes would seem smaller. So, we must diminish the lower eyelids, then pull the sagging skin right here upwards while planning the area here. So, we must do three procedures here – namely, upper eyelids, lower eyelids and skin pull right here. OK?

How long would the bruise and swell normally be reduced after surgery?

The very important point of this surgery is that we must avoid this type of bruises. If bruises like this develops, it can lead to embolism and delay recovery. A successful surgery will have almost no bleeding after the procedure. If we look at this patient, we remove the lower eye bags, pull the tissue below it upwards for firmness, then blur this area to be smooth and remove some skin here. After all that, just four days later he looks like this (no visible side effects). It has been only four days, but we can see there are no bruises. Recovery is fast is such successful surgeries. Some my think inflammation is normal, but I say it is not.

Is it different case by case ?

No. The issue is whether there is lots of bleeding or not. Some have bruises after surgery and that is due to bleeding. In order to recover fast, there has to be no bleeding. If we look at this person, she had upper eyelid surgery and lower eyelid surgery, both sides were lifted. It has been 20 days, ad we can barely see a very fine line scar but later even that will disappear. So, the key point during surgery is whether there is bleeding or not. If there is bleeding, recovery is slow. That is the most important point.

Does the patient have to come back for stitch removal?

Yes. There are threads that are absorbed and those that are not. Some say if we use the absorbed threads there is no need to remove the thread. But for that to happen we need many months. And during that time the stitch separates the tissue. So, even if we used an absorbable thread, it is best to remove it. For eyelid surgeries, removal is four days after. In facelift surgeries, five to seven days later it should be removed. In eyelid surgeries three to four days later. Maximum four days later.

OK. Are there any side effects for lower eyelid surgery?

The side effects for lower eyelid surgery, as I said before, is the turning of the lower lid. The reason they turn over is due to bleeding. Blood is absorbed and bruises form. When the bruises form, the eyelid is pulled downwards. Another is when the skin is removed excessively. And in some cases, some people have a facial structure that encourages the eyelids to turn over. If we look at this person, he has almost no bone here (cheeks). This is the most common side effect. In order to avoid this, we must pull the skin, remove only a small portion of the skin, and avoid bleeding. These are the important points.

Lower eyelid surgery is removing unnecessary fats inside the lower eyelid. Will this fat regrow after the surgery?

The fat will not regrow. However, there could be fats deposited inside that may come outwards. Just like a glacier, the fat beneath will keep on coming outwards. So, we distribute the fat to fill the area evenly and lift the mid-face layer. We must pull the part below the eyes upwards like this. Then we must stabilize and that results in a good surgery. This method prolongs the desired results, easily reaching about ten years. So, even with younger people like this one, we should not simply remove the fat here. We have to remove the fat, and also pull here upwards. And one year later, all the sagging skin is lifted upwards and looks like this. Whether the patient is young or old, the surgery’s goal is not to simply remove the fat. We must lower the fat and lift the lower area upwards.

Conclusion

As we age, we develop eye wrinkles and bags. For the lower eyelids, simply removing tissue from the area does not lead to improvements. We should look for the causes that lead to them and discuss them with the patient. Usually it is the fat from the deep layers that surface, so we have to remove it and pull the skin up. The very important point of lower eyelid surgery is to avoid bruising. Successful surgery will hardly be mentioned after the procedure and recovery will be very quick. The removal of the threads will be on the fourth day after the procedure.