Lower Blepharoplasty Surgery
Step-by-step lower blepharoplasty
Dr De Silva prefers to use hidden incision (termed trans-conjunctival blepharoplasty) in most lower eyelid cases as the surgery, although technically more challenging, avoids a scar in the skin. The figure shows an incision being made on the inside lining of the eyelid with a specialised instrument (CO2 laser or monopolar electrocautery machine) this technology prevents bleeding instantaneously, thereby reducing swelling and speeding up recovery. The soft tissues are then supported both superiorly and inferiorly to enable the fibrous septum to be seen in the lower eyelid.
A fibrous layer known as the orbital septum is opened, this reveals the orbital fat pockets, the fat pushes forwards resulting in the appearance of bags beneath the eyes. There is controversy between surgeons whether the fat should be removed or repositioned, known as tissue-sparing, removal of excessive fat may result in a hollowed appearance that is unsatisfactory and difficult to treat. Dr De Silva utilises both techniques depending on the individual patient, no two people have identical eyes and facial ageing is dependent on many individual factors. Dr De Silva’s preferred technique is conservative approach to transpose fat immediately below the eyelid at the cheek, termed fat transposition. In patients where there is a large volume of fat prolapsing forward both transposition of some fat and excision of the remaining fat may be the preferred option.
Dr De Silva uses state of the art technology including a US-manufactured CO2 laser or monopolar electrocautery to establish meticulous control of bleeding, key to reducing bruising and preserving vision after surgery.
Dr De Silva often utilises a supporting stitch during the healing period to improve the final result. In the figure above, a canthopexy support stitch has been used to support the lower eyelid to the bony orbital rim this stitch is completely hidden and dissolvable, the stitch dissolves a few weeks after surgery.
All our patients are able to see immediately after the surgery and able to return home thirty minutes after the procedure is completed. No patients require overnight hospital admission with the Dr De Silva’s techniques.
Facial procedures with blepharoplasty
Eyelid changes occur as a consequence of genetic and environmental factors and affect multiple layers of the face, including the skin, the soft tissues and the underlying bone. A lower blepharoplasty restores soft tissue changes in the lower eyelid. To give a patient a natural rejuvenation, Dr De Silva often combines lower blepharoplasty with other procedures to give a fully rejuvenated natural looking result.
- Skin Resurfacing. The skin around the lower eyelids often has wrinkles, lines and changes in colour as a consequence of accumulated sun damage. Fine wrinkles may be smoothened, skin quality improved, and the skin tightened slightly with skin resurfacing techniques. Dr De Silva tailors the type of skin resurfacing to the individual and includes the use of trichloroacetic acid (TCA chemical peel) and controlled laser resurfacing.
- Volume replacement. One of the commonest changes associated with facial ageing is loss of facial volume, this can result in a sunken depression between the eyelid and the cheek, giving the appearance of a dark circle under the eye. Dr De Silva uses fat grafting as an effective technique to rejuvenate the appearance of the lower eyelid at the same time as blepharoplasty.
- Facelift surgery, often ageing changes around the eyelids are mirrored with changes in the jaw line and neck. Dr. De Silva tailors a deep plane facelift to rejuvenation a patient’s appearance
- Rhinoplasty is a common procedure Dr De Silva completes at the same time as blepharoplasty.
Revision Eyelid Surgery (lower eyelid retraction)
There are a variety of causes for lower eyelid retraction including trauma, eyelid tumours and the commonest internal scarring after a lower eyelid blepharoplasty. Lower eyelid retraction is often the result of a combination of factors including too much removal of skin tissue in lower blepharoplasty and damaged to the lower eyelid resulting in scarring and lower lid being pulled downwards. The lower eyelid has an intricate anatomy with three fine anatomical planes, damage to any of these structures may lead to scarring and lower lid retraction. The results can be devastating to the patient as scarring changes the shape of the eye resulting in compromised cosmetic result, tearing and discomfort.
Dr De Silva’s preferred technique for lower eyelid surgery involves a hidden incision on the inside lining of the eyelid, this preserved the natural anatomy of the eyelid and avoids this complication. The more traditional method that is used by surgeons practicing older surgical techniques is termed trans-cutaneous blepharoplasty, and involves making an incision immediately below the eyelid.
Dr. De Silva sees and treats many revision blepharoplasty patients who have had surgery elsewhere. The treatment of lower eyelid retraction is challenging and dependent on careful evaluation and identification of the cause. The techniques require tailoring to the individual and include:
- Skin grafting for shortening of the lower eyelid skin
- Use of fillers to prevent recurrent scarring
- Elevation of the mid-face
- Tightening of the lower eyelid to the bony rim with canthoplasty
- Use of material (termed spacers) to elevate the lower eyelid
- Use of graft (hard palate from roof of mouth) to elevate the lower eyelid
- Post-surgical use of lower lid elevation
- Post-surgical use of anti-inflammatory agents
Depending on the cause of the lower eyelid retraction, severity and previous surgery, Dr De Silva utilises a combination of different approaches to elevate the lower eyelid and prevent recurrence. Lower eyelid retraction is a challenging eyelid condition to treat, although the eyelid position can be improved, Dr De Silva discusses with each patient what are realistic expectations that can be achieved through surgery.