What is Lower Blepharoplasty?

Lower blepharoplasty is the surgery that seeks cosmetic improvement of the lower eyelid. It is the surgery that corrects the fat bags and furrows of the lower eyelids, as well as the laxity, folds and wrinkles. Eyelid bag surgery must be very individualized since there are different techniques and we must select the most appropriate one according to the characteristics of each patient.

Lower Blepharoplasty by Dr. Nieto
Schematic representation of lower transconjunctival blepharoplasty Transconjunctival incision, dissection down to the fat pads and removal of excess fat.

Transconjunctival or external?

There is no doubt today that the The best access route for the treatment of fat pads is transconjunctival route. The main advantage of this route is that we can treat the fat pads . without having to manipulate the orbicularis muscle that supports the eyelid.

When the surgery is performed externally, we must open the orbicularis muscle and this increases the risk of possible complications derived from the weakening of this muscle, such as palpebral retraction or ectropion. In other words, the transconjunctival pathway allows access to the fat pads without the need to touch important structures in the eyelid.
A second and obvious advantage is the absence of scars and external stitches. If the patient needs to treat skin laxity, we can make an additional incision just below the eyelashes, but it will be very superficial and will not affect the orbicularis muscle.

How to treat skin laxity?

This will depend on the degree and type of laxity. When there is significant laxity, lower eyelid skin can be safely removed. For this we usually use the “pinch” technique which is minimally invasive and leaves invisible scars very close to the eyelash line.
In cases of minor laxity it is sufficient to treat the skin with a chemical peelat the same time as the surgery. It renews and shrinks the skin without the need for incisions.

It must be remembered that expression wrinkles cannot be completely eliminated, and large amounts of skin should not be removed as this will cause the eyelid to retract.

Remove the bags or replace them?

In most cases we perform a fat redistribution over the orbital grooves. This has several advantages. On the one hand, it avoids the excessively sunken look, but it also improves the grooves and the eyelid-cheek transition. In addition, its result is more stable over time, since the natural evolution of aging usually causes a greater visibility of the furrows by descent of the cheek, and having covered the furrows with the fat of the bags slows that process.
Some patients have little fat and are not good candidates for this technique, and others are have very pronounced pockets and need fat removal. The individual examination determines which technique is best in each case.

Lower blepharoplasty by transconjunctival route and with redistribution
Schematic representation of lower blepharoplasty with transconjunctival fat redistribution.

Do I need a canthopexy?

We often perform canthopexy during lower blepharoplasty. Not necessarily to alter the shape of the eyelid, but to reinforce the support of the eyelid in patients who undergo this surgery and present tendon laxity.
Some patients request a tear in the gaze or the correction of a drooping eyelid and this can be achieved by canthopexy.
However, one must have realistic expectations regarding this procedure. Canthopexy achieves moderate effects, not major stretching or modification of the patient’s natural shape.

Complementary techniques: Lipofilling and Nanofat

When the patient presents prominent grooves or significant volume loss in orbital grooves and cheeks, he or she may be a candidate for volume replacement through micro-lipofilling techniques, which improve the grooves and eyelid support.
El uso de Nanofat, por otro lado, estaría indicado para mejorar la calidad de la piel en casos de significativo deterioro o pigmentación.

Before the intervention you will have a first visit with Dr. Nieto in which you will discuss the characteristics of your anatomy, the possible options and the objectives to be achieved. This visit lasts between 30 and 45 minutes. Before the visit we will ask you to fill in a short questionnaire about your health, eye problems or previous surgeries. It is important for us to know about pre-existing medical problems, as well as the existence of drug allergies and the patient’s usual medications. At the same visit we will perform a complete eye exam to ensure your good eye health. Dr. Nieto is an expert ophthalmologist trained in the best hospitals in the country and abroad, so your eye health is in good hands. It is especially important to detect dry eye problems (low tear production), since in these cases we tend to perform more conservative surgeries in order not to aggravate this problem. Having had laser eye surgery, cataract surgery, glaucoma surgery, or retinal surgery is not an impediment to having this surgery, but it is important that these problems are controlled and stabilized prior to surgery. Before the lower blepharoplasty you must have a general analysis with coagulation and an electrocardiogram, which you must bring with you to the anaesthetist.

You must go to the clinic accompanied and about 30 minutes before your surgery taking with you the necessary documentation as we have indicated, as well as the preoperative tests. Once in the operating room, the team of nurses will make sure you are comfortable and relaxed, and then the anaesthetist will introduce himself, check your vital signs, and give the go-ahead to start the operation. We perform this surgery with local anesthesia and sedation. The drugs used in sedation today are eliminated very quickly from the body, so recovery is very fast and without “hangover”. The surgery is always performed on an outpatient basis, without admission. The surgery usually takes about 45 minutes, but if it is performed in conjunction with a lower blepharoplasty or brow lift it can take up to 2 hours. In any case, thanks to sedation and anesthesia, it is a painless surgery. After the surgery, you will remain under observation for about an hour while we apply cold and anti-inflammatory drugs to stop the initial inflammatory process.

The post-operative period after a lower blepharoplasty is painless, so much so that the vast majority of patients do not need any pain medication. There may be some tightness in the corners of the eyes when a canthopexy or canthoplasty is performed. Bruises and swelling appear to a greater or lesser extent in all patients, and are mostly reabsorbed during the first week. After a week the recovery is not complete, but most patients have no problem restarting their ‘social’ activities at this point. During the first days it is important not to make vigorous physical efforts to avoid possible bleeding and shorten recovery. We recommend frequent application of cold during the first 2-3 days and antibiotic-anti-inflammatory eye drops if a transconjunctival approach has been performed. If there are stitches, we will also apply an antibiotic ointment twice a day, and eye lubrication with artificial tears in eye drops is also recommended. The first check-up is done a week after the operation. Before the first check-up, Dr. Nieto will contact you in person by phone to learn about your progress. In case of any problem or doubt that may arise, you will always have direct contact with him. Recovery after a lower blepharoplasty is usually complete one month after the operation, when we perform the second post-operative visit. Sometimes full recovery can take a little longer. The results of a lower blepharoplasty are long lasting, it is very rare that we perform this surgery a second time in the same patient. It is true that over many years, laxity may appear in the eyelids, but fat pads do not usually reappear.

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