Written by Dr. Julian De Silva
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.