Hollowing or tear troughs of the lower eyelid are a common aesthetic periorbital concern. Numerous treatment approaches are used ranging from hyaluronic-acid based injectable fillers to the placement of synthetic implants. One autologous approach is the use of a lower eyelid blepharoplasty technique known as fat transposition. By relocating herniated lower eyelid fat into the tear trough area, a volumetric fill is achieved.

The lower blepharoplasty fat transposition method is a fairly simple technique. The herniated fat is close by and it is easily teased out and moved over the lower orbital rim. Fixing the relocated fat by sutures is done to the surrounding periosteum. An interesting question is whether the fat should be placed above or below the periosteum.

In the May 2011 issue of the journal Facial Plastic and Reconstructive Surgery, an article was published entitled ‘

Transconjunctival Lower Blepharoplasty With Fat Repositioning: Retrospective Comparison of Transposing Fat to the Subperiosteal vs Supraperiosteal Planes’. Over a two-year period, 40 patients (27 women, 13 men, average age 58 years old) operated on by a single surgeon were retrospectively evaluated of which 20 patients had transconjunctival lower blepharoplasty with fat repositioning to the subperiosteal plane and the other 20 patients to the supraperiosteal plane. The aesthetic results and complications between the two techniques were compared.

They reported that the subperiosteal technique was more meticulous and less disruptive of normal anatomy and resulted in less bleeding. Supraperiosteal fat transposition surgery was faster but lead to more bruising, swelling, and with more evident temporary contour irregularities along the orbital rim. All patients had a high level of satisfaction. No differences were seen in the overall aesthetic results. The paper’s authors concluded that transconjunctival lower blepharoplasty with fat repositioning can be performed safely and effectively, whether fat is translocated to the subperiosteal or the supraperiosteal plane. Aesthetic results were similar between the two transposed fat locations.

Filling the tear trough with fat from the lower eyelid is an effective approach that has few complications, particularly without lower eyelid skin manipulation. (transconjunctival approach) While the subperiosteal location is a bit more tedious to perform, it offers better camouflage to the fat and a better place to engage suture fixation.

Dr. Barry Eppley

Indianapolis, Indiana

Background: The aging process around the eyes is classic. The near continuous motion of the eyelids creates loose skin and, with enough time and motion, the eyebrows will fall over the supraorbital rims and sag downward.. For many patients today, they have eyelid surgery early in life and never progress to see the extreme aging changes that can occur around the eyes.

But in its most extreme form, eyelid aging will develop hooding where the loose and excessive skin will fall down and even over the eyelashes. The eyebrow can even lie completely under the brow bone further accentuating the hooding effect of the loose upper eyelid skin. While such severe changes are usually seen in the elderly, it can occur in younger patients due to their natural genetics.

When there is a large amount of loose upper eyelid skin, it is tempting to think that a dramatic change can occur with its excision alone. But this does not take into account the powerful negative effect of a low brow position and its influence on obscuring the vertical space between the lashline and the brow. Without such a space a supratarsal fold can not be created no matter how much eyelild skin is removed.

Case Study: This 57 year-old female wanted to improve the aging appearance of her eyes.  She has severe upper eyelid hooding, a low eyebrow position and significant obstruction of her upper visual field. While she initially resisted the idea of a browlift with her blepharoplasties, she eventually resigned herself to the fact that failing to deal with her eyebrow position would limit how much of a blepharoplasty result would be seen.

Under general anesthesia, a pretrichial (hairline) browlift was initially performed with a beveled incision along the frontal hairline. Eleven mms of forehead tissue was removed from the center of the hairline tapering out into the temporal area. The browlift was secured into position with suture fixation through outer cortical skull bone holes and sutures to the galea. An upper and lower blepharoplasty was then done, removing skin only in the upper eyelid and skin and fat from the lower eyelid.

Her postoperative course had the typical swelling and bruising around the eyes which ensues with some expected temporary foehead and frontal scalp skin numbness. She looked fairly normal at three weeks after surgery and completely normal by 6 weeks after surgery. She not only looked more refreshed by had a dramatic improvement in her field of vision.

With severe periorbital aging, oen has to consider a more comprehensive surgical approach around the eyes. This would include a browlift as well as the four eyelids. the choice of browlift is based on the existing length of the forehead and the degree of brow ptosis.

Case Highlights:

1) Severe upper eyelid hooding and brow ptosis produces an combined aesthetic and functional obliteration of the eyes.

2) When the brow is low, even aggressive upper eyelid skin removal will not produce an adequate result.

3) A combined browlift and 4-lid blepharoplasties is needed to open up the eyes in severe aging changes.

Dr. Barry Eppley

Indianapolis, Indiana

Background: Aging affects all areas of the face but not more profoundly than the periorbital (eye) area. Because of the thin tissues of the eyelids, they are prone to display wrinkles, loose skin and lower eyelid bags even early in the aging process. Because most human conversation is done by looking in the eyes, and they are the first thing we usually look at in the mirror, aging changes in the eye are very noticeable and usually disturbing.

The male periorbital area ages just like that in females and responds equally well to blepharoplasty (eyelid tuck/lift) surgery. But there are several unique aspects of a male blepharoplasty. Men tolerate aging changes better than women and as a result they often appear later in the aging process with more profound eyelid tissue issues. The upper eyelids usually have significant hooding and the lower eyelids have bags. Usually the lower eyelid bags are of a bigger concern because they contribute more to a tired and aging look.

The aging lower eyelid bag is caused by a combination of herniated fat, excess skin and sometimes a lax or loose lower eyelid. The biggest anatomic contributor is the fat component. The fat is the result of a protrusion or displacement from its normal under the eyeball position. Normally held into position under the eyeball by ligaments between the eyelid and the bone, aging or a genetic weakness in them allows the fat to come forward creating the ‘bag effect’. This is known as a herniation, much like that of a defect in the abdominal wall.

Case Study: This 48 year-old male wanted to improve his tired looking lower eyes. He had fairly pronounced bags, loose skin and wrinkles. What bothered him the most were the protruding bags which was worse in the morning and after eating salty foods. He had a fair amount of hooding on the upper eyelids but this was not a concern to him.

Under general anesthesia, a transcutaneous approach was used with an incision under the lashline with an extension into a crow’s feet skin crease. A skin-muscle flap was raised down to the lower eye socket rim. A large amount of protruding fat was found and the three fat pockets (medial, central and lateral) were reduced back behind the orbital rim. The lower eyelid skin flap was elevated in a superolateral direction and redraped up over the eye. A pilot cut was made at the lateral canthal area and a 5mm to 6mm skin trim was done along the lashline and a triangle of skin removed over the lateral canthal area. Orbicularis muscle suspension sutures were placed and the skin closed with dissolveable sutures. No dressings was applied at the conclusion of the surgery other than some antibiotic eye ointment along the incision lines.

At one week after surgery he had the typical eyelid bruising and swelling but the elimination of the bags was already evident. By three weeks after surgery all swelling and bruising was gone. When seen at three months after surgery, he had no bags, no lower eyelid malposition and he looked perfectly natural.

Lower eyelid bags are an undesireable aging feature that no topical or laser therapy is going to improve. Even if they could produce a mild improvement in lower eyelid bags the male patient is usually interested in a more efficient and effective therapy. Lower blepharoplasty surgery is the most effective treatment known and the only question is whether it is done with a transcutaneous (outer eyelid incision) or a transconjunctival (inner eyelid incision) approach. This depends on how much loose lower eyelid skin is present.

Case Highlights:

1) One of the common aging concerns for the middle-aged male are lower eyebags.

2) Lower eyelid bags are the result of herniated fat from under the eyeball that sticks out beyond the lower orbital rim.

3) A transcutaneous lower blepharoplasty can very effectively remove herniated fat and loose skin from the lower eyelid, creating a less tired look.

Dr. Barry Eppley

Indianapolis, Indiana

Background: The constant movement of the eyelids and their thin skin makes for early and inevitable signs of aging. The eyelids almost always shows the signs of age first. It is also easily observed since the eyes are the fundamental focal point of human conversation. The signs of periorbital aging are always associated with such patient complaints as ‘I look tired’, ‘I look older than I feel’ and ‘My eyes feel heavy’.

Despite the relatively small amount of upper eyelid skin that naturally exists, it is incredible how much excessive and loose skin can be created. Often it appears that there is at least twice as much skin present than would normally exist in the upper eyelid as one ages. The amount of fat that comes sticking out (herniated) from below the eyeball to make up the lower eyelid bags can be equally impressive.

Case Study: This 55 year-old female wanted to improve the appearance of her tired and aging eyes. She had so much upper eyelid skin that it had fallen down onto her lashlines, partially obscuring her vision. Her lower eyelids had large bulging bags and wrinkled skin with numerous brown spots.

Under general anesthesia, a large amount of upper eyelid skin was removed. More skin was removed laterally (near the outer corner of the eye) than medially. (near the inner corner of the eye) On the lower eyelids, a skin-muscle flap was raised and the protruding medial, central and lateral fat pads were removed. The lower eyelid skin was conservatively trimmed of excess skin and the orbicularis muscle and skin resuspended out laterally.

Her postoperative course was typical for eyelid surgery with substantial swelling and mild bruising for the first ten days after surgery. Sutures were removed at one week after. By two weeks she looked nearly normal and by three weeks after the procedure she looked completely normal and non-surgical in appearance. Her last follow-up at three months after surgery showed a refreshed and rejuvenated periorbital appearance.

Blepharoplasty surgery has one of the highest patient satisfactions of all the rejuvenative facial plastic surgery procedures. Despite the small size of the eyelids, comparatively small amounts of skin and fat removal can make for a dramatic change in appearance. Every blepharoplasty patient’s goal is to look refreshed, maintain a natural appearance and avoid complications. This is done by not removing too much eyelid skin, particularly on the lower eyelid.

Case Highlights:

1) Aging of the eyes occurs by hooding of the upper eyelid skin and bulging of lower eyelid fat. Both eyelids develop increased wrinkles and skin rolls.

2) An upper blepharoplasty removes excess skin and recreates an upper eyelid crease and sulcus

3) A lower blepharoplasty removes or relocates herniated fat and removes a conservative amount of skin with corner of the eye tightening.

Dr. Barry Eppley

Indianapolis, Indiana

Background: Some of the earliest signs of facial aging affect the eye area. The frequent sphincteric closure of the eyes and their thin skin ensures that aging will appear first on one’s face.  One of the inevitable eye changes is the development of extra skin on the upper eyelid. Due to the constant opening and closing of the upper eyelid, which moves a lot more than the lower eyelid, the development of stretched out skin is inevitable.

When it becomes significant enough, the extra skin will hang over the natural crease of the eyelid and eventually can hang down onto the lash line. This is known as upper eyelid hooding. The removal of this hooded upper eyelid skin is the primary objective of upper eyelid blepharoplasty, also known as eyelid tucks or lifts. With this skin removal, the overhang is removed and the natural crease or inward fold of the upper eyelid is seen again. While part of the underlying orbicularis muscle has historically been part of an upper blepharoplasty, contemporary techniques now seek to preserve it and to only remove skin.

Given the small area that eyelids occupy, it is not an uncommon request to ask if it can be performed under local anesthesia. While the use of local anesthesia for a blepharoplasty does not shorten one’s recovery from the swelling and potential bruising of the surgery, it does save anesthesia fees and the short-term issues related to having been put to sleep. The infiltration of local anesthesia can penetrate the thin tissues of the eyelid very effectively for a profound numbing and vasoconstrictive effect.

Case Study: This 50 year-old female wanted to remove her excessive upper eyelid skin. It was making her eyes feel heavy and gave her a tired appearance. She was happy with how her lower eyelids looked and only want the upper eyelid skin removed. She had numerous surgeries perform in the past under local anesthesia, including her first breast augmentation, and felt comfortable with a local anesthetic approach for the much smaller eyelid area.

In a surgical suite setting, markings of the amount of skin to be removed were done with her opening and closing her upper eyelid to ensure that the complete skin overhang would be removed. Then 1cc of 2% xylocaine with 1:100,000 epinephrine solution was injected into each upper eyelid. Ten minutes was allowed to achieve its maximal effect which is evident by skin blanching. The marked skin was then excised, removing just a very small strip of muscle with it. Closure was done with a combination of dissolevable and permanent sutures. Only antibiotic ointment was used for dressing.

She experienced some swelling and no bruising. Her sutures were removed a week later and she missed only a few days of work. When seen at one month after surgery, she had a more open and refreshed look to her eye area.

Blepharoplasty surgery can be very successfully done under local anesthesia. But it can not be so effectively used on the lower eyelid because of constant eyelid movement with the inability of the patient to not look at the ongoing surgery. Upper blepharoplasty is done with the patient’s eyelid closed and done from above or to the side of the patient, both maneuvers which prevent the patient from potentially seeing what the surgeon is doing. Thus lower eyelid surgery or combined upper and lower blepharoplasty surgery is best done under sedation or general anesthesia.

Case Highlights:

1)      A blepharoplasty (eyelid lift) is very effective for eliminating hooding and skin overhang of the upper eyelid.

2)      An isolated upper blepharoplasty can be comfortably done under local anesthesia for many patients.

3)      Recovery from upper blepharoplasty can be very rapid and one looks reasonable in 7 to 10 days after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

There are many signs of facial aging but most people are usually concerned with what happens around the eyes first. The classic presentation of periorbital aging is a progression of tissue changes including excess lower eyelid skin, protruding orbital fat (bags), lower eyelid instability and the falling of the adjacent cheek tissues. (malar descent) While the upper and lower eyelid ages similarly in any person, the scope of the lower eyelid is actually bigger if you include the surrounding cheek regions. Thus the lid-cheek region is a frequent target for facial rejuvenation efforts.

Traditionally, these aging changes were managed by a standard lower blepharoplasty operation which involved an elongated lower eyelid incision and removal of skin and fat. While this basic operation still works well for many lower eyelid concerns, it is known to have potential lid malpositioning problems with risks of ectropion (lid sagging) and separation of the globe-lid intimacy. The precarious suspension support of the lower eyelid is prone to being disrupted by incisional placement, delamination of the lower eyelid tisues with lack of orbicularis muscle integrity near the lid margin, unrecognized weakness of the lateral canthal tendon and over-resection of lower eyelid skin.

One lower eyelid rejuvenation trend that has become commonly used over the past decade, partially as a response to the risk of ectropion, is the transconjunctival approach. Avoiding skin resection and an external lid incision, herniated orbital fat can be removed or repositioned through button hole sized incisions on the inside of the lower eyelid. While protruding orbital fat was once uniformly removed, it is now frequently being preserved and used as a filler for tear troughs, nasojugal grooves and creating rim augmentation to smooth out the lid-cheek junction. Because the blood supply to the overlying lower eyelid skin is preserved, skin resurfacing for wrinkles can be done with lasers or chemical peels.

One evolution of lower eyelid rejuvenation, which is the opposite of a transconjunctival blepharoplasty, is the extension into simultaneous cheek rejuvenation as well. These so-called cheek or midface lifts are a collection of procedures whose technical differences can be as diverse as the surgeon who performs them. Lifting up sagging cheek tissues through a full lower blepharoplasty incision and securing to some location along the zygomaticorbital bone, or even higher to the temporal and forehead regions, allows them to sit back up or higher on the cheek bone. But because it is a more invasive and extensive procedure with much wider tissue dissection than a lower blepharoplasty, it ironically has an even higher risk of ectropion and lower lid scarring problems if not executed to technical perfection.

While it can cause it, these cheek lifts can also be used to treat lower eyelid retraction problems as well. Lifting and supporting the surrounding cheek tissues can relieve the tension on the repositioned lower eyelid at the lateral orbital wall. Releasing the lower eyelid scar, retightening or remaking the lateral canthus and some cheek tissue release and resuspension can be very effective for getting the outer aspect of a retracted lower lid back up against the globe.

Dr. Barry Eppley

Indianapolis, Indiana

Blepharoplasty or eyelid lifts are one of the most common types of anti-aging facial surgery. Their results are usually so significant that they have earned the moniker of best ROI (return on investment) in the face. Changing that tired look to a refreshed one can be a significant change which just makes one look more alert and fresher. While the procedure usually causes some significant swelling and bruising, there is usually little pain other than some tightness.

But unlike tightening the neck and jawline, removing excess skin and fat around the eyes and tightening them always runs the risk of causing some eye symptoms. The eyelids do play a vital role in eye protection and lubrication which is easily overlooked…until some change in their closure function occurs. Eyelid lifts do temporarily interfere with eyelid closure, particularly when all four eyelids are done simultaneously, and this can cause some decrease in their lubrication function.

While dry eyes are a known risk in blepharoplasty surgery, how frequent does it usually occur? Such was the focus of a study published in the  October  2012 issue of the Archives of Facial Plastic Surgery from a large blepharoplasty population out of one surgeon’s practice in Indianapolis Indiana. From nearly 900 patients who had eyelid lifts done over a 10 year period, the incidence of dry eyes both before and after surgery was followed. Around 25% had some degree of dry eyes after surgery and another quarter of the patients also reported swelling of the lining of the eyelids known as chemosis. Often these two occurred together in patients who had all four eyelids done together as opposed to just uppers or lowers eyelids. Most of these eye side effects were temporary and routinuely managed by eye drops and/or ointment.

This study shows that dry eyes are not rare after eyelid lift surgery and is a direct result of disrupting the blinking action caused by the orbicularis muscle. When the blink reflex is decreased, particularly when eyelid closure may be incomplete, the cornea lacks adequate protection from the inadequate spread of the tear film. This results in dry eye symptoms and swelling of the eyelid lining (chemosis) as it strives to regain competence of globe protection.

Dry eyes do not happen to everyone after blepharoplasty surgery and some patients have signs of increased risk beforehand. A loose or lax lower eyelid surgery is the most recognizeable one as well as anyone that reports a history or active dry eye problem. This study interestingly showed that the risk is higher in patients on hormone replacement therapy although the exact reason is unknown.  (more women over 50 have the procedure than men)  Aggressive surgery can also cause the problem when too much skin is removed from the lower eyelid, internal canthal suspension procedures are done or aggressive midfacial lifting techniques are simultaneously performed.

While dry eyes after blepharoplasty is usually a temporary problem, it is not pleasant when the patient is going through it if it is significant. Avoidance is always the best treatment and that comes with recognizing the high risk patient and avoiding aggressive lower eyelid surgery which is almost always is the culprit. This may mean less skin removal on the lower eyelid or using an inner eyelid approach (transconjunctival) instead.

Dr. Barry Eppley

Indianapolis, Indiana

Background:  The eyes may be the window to the soul but there are also good indicators of how the face is aging externally. Aging first starts around the eyes and continues to progress as one gets older. This occurs because of the frequent motion of the eyelids and the orbicularis muscle that surrounds them. It develops quickly not only because of the muscle activity but also because the skin is thin and not very resistant to wrinkling and loss of elasticity.

The aging changes seen in the eyelids are classic with the development of excess eyelid skin and hooding, protruding lower eyelid fat and skin rolls and wrinkles that radiate outward in the crow’s feet area. These aging periorbital features are no different between men and women with the exception that men can develop more upper eyelid hooding due to thicker skin and more significant lower eyelid fat herniation.

While how the eyes age may not be gender different, when they appear for surgical correction frequently is. Men tend to appear much later in the aging process and at an older age. Thus their eyelid aging changes are frequently more advanced. Women tend to appear in the 40s and 50s when the eyelids aging is more moderate. Conversely, men appear more frequently in their 50s and 60s with more severe manifestations.

One of the great fears of men undergoing any facial rejuvenation surgery is that they will appear unnatural or have an operated look. They all seem to point to certain celebrities, such as Kenny Rogers, for how they do not want to look like after surgery. They are very interested to know how that postoperative look/problem is going to be avoided.

Case Study: This 65 year-old male wanted to improve his tired look. He had thick Mediterranean skin with few wrinkles and little sagging. But his eyes look heavy with excessive upper eyelid skin and a large amount of herniated fat in the lower eyelids. His lower eyelids were very puffy and were more swollen in the morning or if he was very tired. He only wore reading glasses and did not wear contacts.

Under general anesthesia, he underwent upper and lower blepharoplasties. A fair amount of skin was removed from the upper eyelids with a small strip of orbicularis muscle. More was removed from the temporal aspect than from the central and medial aspect of the eyelid. The lower eyelids were treated by aggressive removal of the medial, central and lateral fat pockets which had significant protrusion. Only a few millimeters of lower eyelid skin was removed with suspension of the orbicularis muscle at the lateral canthal area. All dissolveable sutures were used with the exception of the lateral canthal extensions of the upper and lower eyelid incisions.

Like most men he developed a significant amount of swelling and bruising, particularly of the lower eyelids. It took about two weeks before he looked non-surgical and a full three weeks until he looked perfectly normal. The redness of the eyelid incisions took six weeks to become unnoticeable.

The key to a natural look in male blepharoplasty is to avoid over-resection of tissues, particularly skin. Too much skin removal creates a tight look and is prone to lower eyelid retraction. (ectropion) It is much better and more natural looking if there is still a few wrinkles left behind and a little aging present. This approach also lowers the risk of dry eyes in the older male patient who is at a greater risk for this problem.

Case Highlights:

1)      Aging of the face first begins around the eyes and progresses eventually to upper eyelid hooding and herniated lower eyelid fat pads.

2)      Men frequently delay eyelid rejuvenation surgery until the process is advanced with severe lower eyelid bags and very heavy upper eyelids.

3)      Successful and natural-looking eyelid surgery in men avoids over-resection of tissues and a wide-eyed surprised look.

Dr. Barry Eppley

Indianapolis, Indiana

The eyes are always the first area of the face that begins to show the effects of age. They are also the most easily perceived as they are continuously viewed in conversational interactions. But of the many aging eye features that will develop, which is best treated by surgery and which are better treated by the numerous non-surgical treatments methods now available. For crow’s feet wrinkles consider Botox injections and fractional laser resurfacing. For dark circles and under eye hollowing (tear troughs), the addition of volume through hyaluronic-based fillers can be very helpful. For small amounts of undereye wrinkles and loose creepy skin, chemical peels (TCA) or light fractional laser treatments can tighten up some loose skin. But for a lot loose skin and wrinkles and large undereye bags, a surgical blepharoplasty is far more effective. Not surprisingly, age plays a major role in the line between  non-surgical vs surgical eyelid rejuvenation. Injectable fillers and skin resurfacing have a much bigger role in those patients under 50 years of age. In addition, unlike the lower eyelid, the upper eyelid can only largely be treated by surgery.

While women used to be the dominant gender that had eyelid surgery, more and more men today are opting for it. Looking less tired and more alert casts a better image to others which is important from social interactions to one’s vocation and job opportunities. While getting good sleep, avoiding excessive sun exposure and not smoking are all extremely helpful, there is only so much one can do to prevent excess eyelid skin, lower eyelid bags and wrinkle lines from developing as time progresses. 

Men age just as much around the eye area and, in many cases, may actually age worse than women. Men are particularly prone to excessive and hanging upper eyelid skin because their brows are often lower relative to the brow bone. Men tolerate lower brows so upper eyelid skin redundancy is often exaggerated. Men often develop large and prominent lower eyelid bags due to fat herniation. While historically men would not undergo blepharoplasty surgery until they have visual field obstruction, they are much prone today for earlier interventions before they develop functional issues.

While most of the technical aspects of blepharoplasty surgery are the same in men as women, there are noticeable variations between the two that should be considered. These include the aggressiveness of the eyelid surgery, the concomitant consideration of browlifting, avoiding postoperative lid retraction and dry eyes and the extent of recovery.

While men may exhibit more significant periorbital aging and often wait until later than woman to have surgery, this does not mean they want a dramatic change in appearance. Aggressive eyelid skin removal and tightening can potentially feminize a man’s face and, at the least, create a drastic change in appearance. Most everyone is familiar with the ‘Kenny Rogers’ result and I have to meet anyone that thought that was a favorable change. In men, less is more. While every man wants the best bang for their dollar, they also prefer to be discrete and will accept a modest improvement while still looking like themselves 

For some men a  browlift may be considered with their blepharoplasty surgery. A low brow in men poses challenges due to the frequent lack of a stable or existing frontal hairline, thus limiting effective browlift choices. In addition, too much of a browlift can radically change a man’s appearance. Most men can really only have a transpalpebral approach using periosteal suturing or an endotine device for tissue fixation. The good news is that such an approach only produces a modest elevation and falls into line with the less is more approach for men.

Due to thicker tissues and the common prevalence of high blood pressure in men, they will frequently have more swelling and bruising. They are also at higher risk of hematoma formation right after surgery due to spikes in blood pressure. Such swelling and bruising around the eyelids can be very noticeable for weeks. Men tend to be more impatient than women and should be counseled accordingly about the length of visible changes around the eye area. Pre- and postsurgical use of Arnica oral supplements and aggressive use of icing the first night of surgery can be very helpful.

The most common complication after blepharoplasty surgery involves the lower eyelid, regardless of whether it is a man or a woman. Avoiding any amount of lower lid retraction (ectrropion) requires good lateral canthal and orbicularis muscle support and minimal skin resection. While many older men have large amounts of excessive lower eyelid skin, it is important to resist the temptation to take too much. It may look fine on the operating table in the horizontal position but can turn out to be quite different after surgery as healing and scar retraction sets in. It is not important to try and make the lower eyelid wrinkle-free nor does it look natural that way either.    

Dr. Barry Eppley

Indianapolis, Indiana