Compared with upper eyelid surgery, the lower eyelid tends to be more complicated and if not performed well is associated with more complications. Part of the reasons is the contribution of various anatomical structures that the surgeon needs to address. Not surprisingly, there are many more surgical techniques for the lower than the upper eyelids because of the relative importance of each anatomical structure. It is unlikely that a single technique is sufficient for all aesthetic problems of the lower lid and some inexperienced surgeons avoid doing the lower lid altogether.
The different techniques for lower eyelid include:
- simple fat excision (usually performed from behind the eyelid ie transconjunctival lower blepharoplasty)
- simple fat excision with lower lid skin excision (transcutaneous lower blepharoplasty)
- lateral canthal tightening suspension with limited fat and skin excision
- fat transposition
- release of retaining structures to abolish the tear trough
- lower lid bony augmentation with implantation
Very often the above techniques are used in combination to treat the different aspects of the lower lid blemishes. For example a patient with fat herniation, tear trough and lower lid laxity will need fat excision or transposition, release of retianing structures and lateral centhal tightening.
The photo of this young patient is a good example of the complexity of the lower lid anatomy. The surgeon need to analyse the importance of each anatomical structure contributing to the lower lid blemish in order to get good aesthetic results.
a = orbicularis oculis (the muscle under the skin), in some
patient this may be prominent and may be mistaken for eyebag;
b = herniated fat that eyebag usually refers to;
c = tear trough this is a groove marking the attachment
of the muscle to the underlying bony structure.