What are the risks of lower eyelid surgery?

Cosmetic lower eyelid surgery lower eyelid blepharoplasty is amongst the most popular cosmetic surgical procedures performed throughout the world the appearance of puffy eye bags that are present all the time is due to bulging fat and is commonly genetic in origin as well as being associated with facial aging the genetic aspect of this condition is why many younger people have under-eye bags the most effective and longest lasting procedure for puffy eye bags is lower eyelid surgery to sculpt the fat responsible for the under eye bags

The popularity of lower eyelid surgery can make it appear to be a generic procedure in actuality it’s anything but generic many surgeons performing this category of surgery use a one method fits all approach resulting in many people needing corrective procedures by specialists like myself the lower eyelid is a complex structure and the art is in creating the optimal strategy to get the most satisfactory result with minimal risk for complications I’ll discuss how I assess my patients and how I customized the procedure to minimize the risks related to lower eyelid surgery

I’m Dr. Amiya Prasad I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon I’ve been in practice in Manhattan and Long Island for over 20 years as an oculoplastic surgeon who specializes in cosmetic eyelid surgery I routinely perform lower eyelid blepharoplasty as well as eyelid revision surgery for complications after surgery originally performed by other doctors I’ve observed throughout my career that a lot of complications after lower eyelid surgery occur because the surgeons performing this procedure are not fully aware of the ways to avoid compromising the support structures intrinsic to the lower eyelid anatomy one of the more common risks of lower eyelid blepharoplasty is lower eyelid retraction the degree of eyelid retraction can be such that the eyes look rounded after surgery and the patient loses the characteristic shape of their eyes I’ve seen patients who had this problem after surgery and their original surgeon denied that the patient had a rounded appearance of their lower eyelids it seems that there’s been a normalization of rounded lower eyelids similar to the normalization of high arched eyebrows and overfilled lips

This is why during consultations patients will often express their disdain for the look of some famous people who they feel look like they’re a deer in headlights so what is the cause for this eyelid retraction problem well the most commonly performed surgical technique to address fat under the eyes which causes puffy eye bags is called transcutaneous blepharoplasty this technique involves making an incision in the lower eyelid right below the eyelashes to access the fat pockets responsible for puffiness the transcutaneous blepharoplasty technique is often performed by general plastic surgeons this approach has the potential to compromise the strength of the eyelid structure by separating the layers which are stronger when intact in addition there is potential compromising of the function of the orbicularis oculi muscle which works like a belt supporting the lower eyelid this can lead to the lower eyelids sagging or pulling downward making the eyes look rounded instead of retaining their original shape and it’s referred to as lower eyelid retraction

The lower eyelids may also rotate inward causing irritation from the eyelashes known as entropion or avert outward causing irritation from exposure known as ectropion further worsening this compromise of the integrity of the lower eyelids is caused by the common practice of eyelid skin removal as a strategy to improve the appearance of fine lines and wrinkles

A common misconception held by many surgeons and the general public is that the fine lines and wrinkles are the result of excess lower eyelid skin so many surgeons excise skin when performing transcutaneous bluffing this removal of skin often leads to the lower eyelids retracting even further and can lead to a more rounded look and worse a skin shortage where the eye is not adequately protected this can cause the tears to not be evenly distributed over the eyes to maintain proper eye health in some situations there can even be a limitation in high closure when sleeping I approach lower eyelid retraction ectropion and aunt ro beam with one guiding principle restoration of anatomy eyelids that look good function well this means for eyelid retraction in order to restore anatomy I have to use tissue grafts such as dermis cellular matrix graft and even skin grafts to reconstruct and provide vertical support

I also have to repair the anatomic structural connection to the bone called the lateral canthal tendon each patient situation is unique and requires proper evaluation I use advanced wound healing technology such as PRP or platelet-rich plasma and a cellular matrix to improve my patient tissue healing and consequently their outcomes it’s often the case that lower eyelid fat prolapse is associated with the deficiency in the projection of the cheek bone and bone structure under the eyes the paradox is that there is excess fat pushing forward while deficient bone is not projecting forward enough I usually recommend placement of hyaluronic acid filler at the bone level to address bone volume deficiency some doctors advise fat repositioning with lower eyelid surgery where a small extension of fat still connected to the eye is stretched and bent over the bone to try to address this deficiency this pedicle of fat is usually too small to address hollowing and the blood supply is kinked over the bony orbital rim resulting in prolonged swelling irregularities or the fat just dying from the blood vessels being bent and compressed to provide adequate volume as well as a more predictable result

I use hyaluronic acid fillers such as Restylane and Juvederm to address hollowness in the lower eye area as well as the cheek bones I bring to my patients attention the relationship between the bone structure around the eyes and the eyes themselves so they can look their best it is of course much better to completely avoid lower eyelid retraction of other complications than it is to need extensive and expensive revision surgery so many people opt for cheaper lower eyelid surgery to save money without understanding why the surgery is being done so cheaply quality and cheap simply don’t go together so opting for cheaper lower eyelid surgery can be much more expensive to fix not to mention the cost of time off work and the expenses of travel

So how do I minimize the risk of lower eyelid retraction I start with the approach of preserving the lower eyelid support structures such as the lower eyelid skin and the orbicularis oculi muscle I preserve lower eyelid Anatomy by using a specialized technique called transconjunctival blepharoplasty transconjunctival blepharoplasty involves no external incision because the fat pockets responsible for under eye bags are sculpted from behind the eyelid the lower eyelid skin and the orbicularis oculi muscle are completely preserved and the results look natural since there is no scar from an external incision and there is no compromise in the support structure I also avoid skin removal because under eye wrinkles and fine lines are an issue of skin quality not excess skin quantity for under eye wrinkles I improve the quality of the skin by stimulating collagen production and resurfacing the skin collagen can be stimulated using a laser or radiofrequency device to induce collagen production collagen is the protein that gives skin its strength

In addition the application of heat also makes the skin contract and tighten to further stimulate collagen production and blood supply in the lower eyelid skin without heat I use platelet-rich plasma platelet-rich plasma also called PRP is a concentration of wound healing and growth factors present in the blood which are activated when you have a cut if there is redundant lower eyelid skin or a fold I’ll perform a skin pinch excision I still focus on maintaining the natural shape and the character of the lower eyelids I perform lower eyelid surgery under local anesthesia with Lite IV sedation so patients don’t have to deal with the stress of general anesthesia as well as the side effects of general anesthesia patients are comfortable throughout the surgery and what is generally referred to as a twilight state of consciousness they walk out of our office alert and happy soon after surgery

Most of our patients have little to no bruising and return to work in about a week like any surgery there are always risks risks can be minimized through the experience expertise and techniques used by the surgeon coming from an ophthalmology background and having an understanding of how to maintain the shape and retain the healthy function of the eyelids has been invaluable for my ability to help my patients undergoing lower eyelid surgery

I hope you found this information helpful thank you for your question