Illustrated representation of a transconjunctival lower blepharoplasty. Transconjunctival incision, dissection down to the bags, and removal of excess fat.

What is a lower blepharoplasty?

A lower blepharoplasty is a surgery that aims to cosmetically improve the lower eyelid. It is a surgery that eliminates the bags in the lower eyelids, and in some cases can also improve the dark circles under the eyes. The surgery on the eyelid bags must be highly personalized due to the existence of different techniques; we must select the best one according to each patient’s individual characteristics.

Who is a candidate for a lower blepharoplasty?

A lower blepharoplasty is performed on patients who have one or more of the following problems:

    • Eyelid bags: They can be more or less pronounced and appear at different ages.
    • Eyelid laxity: Appears with age and is due to the stretching of the tendons and muscle that support the lower eyelids, causing the eyelid to be too lax. It is important to correct this laxity with canthopexy/canthoplasty when planning to eliminate the pockets to prevent the eyelid from retracting.
    • Laxity and wrinkles in the eyelid skin: Wrinkles can be fine or deep, sometimes looking like true folds.

[/list] Patients who predominantly display a pronounced groove under the eyes without bags and eyelid laxity are usually not good candidates for a lower eyelid surgery. They can, however, benefit from non-surgical treatments that seek to add volume to reduce these grooves. The patients who undergo a lower eyelid lift are generally over 30, although in some cases eyelid bags can be present from 20 years of age. Like any cosmetic surgery procedure, having reasonable expectations is important. In other words, this surgery will improve your appearance and can make you feel better about yourself, but it cannot achieve drastic changes in your appearance and its effect is limited to your lower eyelids. Any preexisting medical condition must be checked before this type of surgery, especially hypertension and diabetes. There is no medical condition that prevents this surgery from being performed, as long as the condition is well controlled. See more below.

What does a lower blepharoplasty involve?

A lower blepharoplasty must always be highly customized to the patient. Below, you will find a general idea of how we approach each situation in the lower eyelids. A patient may require one or several of the following techniques to achieve the best possible result.

    • Eyelid bags: We always treat these bags internally (using a transconjunctival approach). Depending on the patient’s characteristics, we remove the excess fat or redistribute the fat without removing it in order to improve the grooves and prevent the eyelid from having a sunken look. This is a very important concept that has evolved in recent years, since experience has shown that fat removal is not advisable in all patients because of the aforementioned risks of hollowing. Fat redistribution achieves an apparent disappearance of the bags and furrows without reducing the volume of the eyelid.
    • Eyelid laxity. Canthopexy and canthoplasty. These are two techniques that we use when necessary to tighten the lower eyelid when there is significant laxity. Both techniques are performed using a small incision. Canthopexy is used when eyelid laxity is slight or moderate, and it reinforces the eyelid tendon using a suture. We use canthoplasty in cases of severe eyelid laxity and it involves shortening the tendon in order to hold the eyelid in place more firmly. Sometimes, we may perform a canthoplasty for solely cosmetic reasons (without laxity) when the patient wishes to have more slanted eyes, but this is uncommon. In addition to the tendons that hold the eyelid in place, there is a second fundamental structure that supports the lower eyelid: the orbicular oculi muscle. Its function is so important that when it is damaged by facial paralysis, trauma, or carelessly performed surgeries, the lower eyelid retracts(ectropion) and the eyelid tendon is insufficient for holding the eyelid properly in place. When we perform canthopexies and canthoplasties, it is very common that we also perform a suspension of the orbicularis muscle, which is carried out through the same incision. This tightens the muscle, further improving eyelid support and its appearance.
    • Wrinkles and skin laxity. In cases of fine skin wrinkles, we generally perform chemical peels, while in cases of deeper wrinkles or folds it may be necessary to surgically tighten the skin. This is done by making an incision just below the eyelashes and must always be carried out in conjunction with a canthopexy or canthoplasty, and orbicularis suspension, to strengthen eyelid support.

Before a blepharoplasty

Prior to the procedure, you will have a consultation with Dr. Nieto during which you will discuss the features of your eyelids, the possible options, and the goals you wish to achieve. This visit lasts between 30 and 45 minutes. Before the visit, we will ask you to complete a brief questionnaire about your health, ocular problems, and previous surgeries. It is important for us to know about preexisting medical problems, as well as allergies to medications and any medications you are currently taking. During the same visit, we will perform a complete eye exam in order to verify that you are in good ocular health. Dr. Nieto is an expert ophthalmologist, with training in the best hospital in the country and abroad, which is why your ocular health is in good hands. It is especially important to detect dry eye problems (reduced tear production), since in these cases we usually perform more conservative surgeries to avoid aggravating this condition. If you have previously had laser, cataract, glaucoma, or retina surgery, this is not an impediment for undergoing this procedure, but it is important that these issues are controlled and stabilized prior to surgery. Before the lower blepharoplasty, you must undergo lab tests with a clotting analysis and an electrocardiogram, which you must bring with you on the day of your surgery and submit to the anesthesiologist. In special cases, a visit with the anesthesiologist may be necessary prior to surgery.

The day of the surgery

You must come to the surgical centre, accompanied by another person, about 30 minutes before the surgery, bringing the necessary documentation that we have requested from you, as well as the preoperative tests. Once you are in the operating room, the team of nurses will ensure that you are comfortable and relaxed; then the anesthesiologist will, check your vital signs, and give the go-ahead for the procedure to begin. In most cases, we perform this surgery with local anesthesia and sedation, although it can also be performed with only local anesthesia if necessary for medical reasons or if preferred by the patient. The medications used in for sedation nowadays are very quickly eliminated from the body, which is why recovery is very speedy and there is no subsequent “hangover.” The surgery is always done on an outpatient basis, without admittance. The surgery usually lasts approximately 45-60 minutes, but if performed along with an upper blepharoplasty or a brow lift, it can last up to 2-3 hours. In any event, thanks to sedation and local anesthesia, it is a painless surgery. After the surgery is finished, you will remain under observation for about an hour while we apply cold and anti-inflammatories to slow the initial swelling process.

Recovering from a lower blepharoplasty

The post-operative process following a lower blepharoplasty is painless – so much so that the vast majority of patients need no pain medication. There may be some tightness at the corners of the eyes if a canthopexy or canthoplasty has been performed. Bruising and swelling occur to a greater or lesser degree in all patients; for the most part, these effects go away after the first week. After one week, recovery is not yet complete, but most patients do not have any problems resuming their “social” activities at this point. During the first days after surgery, it is important to refrain from vigorous physical activity in order to avoid possible bleeding and to shorten recovery. We recommend applying cold frequently for the first 2-3 days and using antibiotic/anti-inflammatory drops if a transconjunctival approach has been used. If there are sutures, an antibiotic ointment will also be applied twice daily. Using eye drops to lubricate the eye is also advisable, since symptoms of dry eyes may appear due to the fact that normal blinking is reduced during these early days. The first follow-up check is done one week after the procedure. Before this first check-up, Dr. Nieto will personally contact you by phone to ask after your progress. Should any doubt or problem arise, you will always have direct contact with him. Recovery is usually complete by one month after the procedure, when we conduct the second post-operative appointment. Sometimes, complete recovery may take a little longer. The results of a lower blepharoplasty are long-lasting. It is very uncommon for us to perform this surgery a second time on the same patient. However, after many years, laxity may appear again in the eyelids, but the eyelid bags do not usually reappear.

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