Background:  Aging of the eyes takes on many predictable changes and one of those is the development of herniated fat. As the name implies, this is fat that has been historically believed to be once was under the eye that has relocated out onto or bulges over the lower orbital rim. Known as eye bags, it is associated with an aging and tired appearance. Since most human eye contact ends up on the face, their development can not be missed and they usually make an undesired impression.

The anatomy of lower eyelid fat is perceived to be three distinct fat pads that come from an intraorbital location. Recent anatomic studies, however, have evaluated this belief and have come up with a different anatomic explanation of their origin. These cadaver studies have shown the lower eyelid pads are discrete fat compartments that are not in continuity with the more posterior intraorbital fat. Rather they may be more accurately described as being both partially intraorbital and partially extraorbital in location. This may seem like a trivial difference in anatomic description but has relevance when considering their removal.

Removal of bulging lower eyelid fat can be done from either inside or outside of the lower eyelid. The choice of approach depends on whether lower eyelid skin needs to be removed and tightened and the concurrent management, if any, of lower eyelid wrinkles.

Case Study: This 42 year-old female wanted to improve her tired looking eyes. She was bothered by the bulges (bags) that had formed on her lower eyelids. She felt they made her older and more tired than what she was. Her darker and thicker skin allowed for few wrinkles despite having the bag.

Under general anesthesia, a transconjunctival approach was taken to her lower eyelid bag problem. Through the inner eyelid, the medial central and lateral fat pockets were identified and removed. No sutures were used to close the transconjunctival incisions. No external skin or incision was used

Her recovery was very rapid with no bruising but some swelling. By two weeks after surgery all swelling was gone and improvement was seen. By six weeks after surgery, she looked great and no longer had a tired appearance.

Blepharoplasty of the lower eyelid most commonly is done through a transcutaneous approach. (external skin incision) With this exposure all contributing aging factors can be treated including skin and fat removal and, in some cases, tightening of the tendon at the outer corner of the eye. But in some younger patients or in those who have few wrinkles or excessive loose skin despite their age, this cosmetically bothersome orbital fat can be removed from inside the eyelid . By placing the incision below the tarsal plate, the fat pads can be exposed and removed. This not only eliminates any external scar but results in a faster recovery with little risk of causing a lower eyelid sag. (ectropion)

Case Highlights:

1) One of the most common signs of aging around the eyes is the development of lower eyelid protrusions or fat.

2) Lower eyelid bag are herniated fat pads that can either be removed alone or in combination with a traditional lower blepharoplasty in which excess lower eyelid skin is removed as well.

3) Removing lower eyelid bags can make a dramatic difference in making the eyes look less tired.

Dr. Barry Eppley

Indianapolis, Indiana

The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.

While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.

While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.

Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.

Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.

Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Background:  The eyes are very good indicators of how the face is aging being the first to show its signs. Aging first starts around the eyes and continues to progress as one gets older. The frequent movement of the eyelids and the thinness of the skin makes for an often early onset of wrinkles. Eventually the thin eyelid skin develops excess skin or skin rolls that can hang down onto the upper eyelid lashes and below the lower eyelid lash line.

The one tissue component of eyelid aging that can be overlooked, literally, is the underlying fat. This is particularly relevant in the lower eyelid where various fat pockets can come forward as herniations through the orbital septum. This herniated eyeball fat presents as puffiness or bags of the lower eyelids which is often a bigger aging problem than that of excess skin. Lower eyelid fat herniation can become quite severe in the patient who has a natural proclivity for this anatomic derangement as evidenced by having puffy lower eyes even when they were young.

Correction of the puffy eyes requires blepharoplasty or eyelid surgery. The term blepharoplasty represents a spectrum of progressively invasive eyelid techniques from the skin down to the fat and canthal tendons. In its fullest expression, which is needed in the more advanced aging patient, blepharoplasty surgery must encompass skin and fat removal and orbicularis muscle suspension and lateral canthal tightening.

One of the concerns of women undergoing blepharoplasty is that they will have an overly tightened and unnatural look. They can point to numerous celebrities that have that ‘look’. Conversely plastic surgeons are focused on not removing too much tissue, particularly of the lower eyelid, and risk developing postoperative lower eyelid sag. (ectropion)

Case Study: This 62 year-old female wanted to improve her tired look that she had had much of her life. Even as a much younger woman she had always had lower eyelid ‘bags’. As she had gotten older the bags became bigger and the loose skin around the eyes became greater. She had put off blepharoplasty surgery until now because of a lifelong fear of anesthesia and not wanting to look like she had had ‘plastic surgery’.

Under general anesthesia, she underwent upper and lower blepharoplasties. A fair amount of skin was removed from the upper eyelids with a small strip of orbicularis muscle. More skin was removed from the outer aspect than from the central and inner 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 every blepharoplasty patient, she developed a significant amount of swelling and some bruising of the lower eyelids. It took about two weeks before she looked non-surgical and a full three weeks until she looked perfectly normal. The redness of the eyelid incisions took six weeks to become unnoticeable. It was a full two months until her eyelids looked really naturally relaxed, an observation that probably only a plastic surgeon would observe.

Removal of lower eyelid lid is a key component of the puffy eye patient. Large amounts of herniated lower eyelid fat seen during surgery usually represents a fat herniation problem that started long before significant aging began. While concerns abound about too much lower eyelid fat removal in contemporary blepharoplasty surgery, the extremely puffy lower eyelid requires a more aggressive approach to obtain a better contoured lower eyelid shape.

Case Highlights:

1) Aging of the face always affects the eyes initially and becomes progressively worse with time. Puffy eyes are the result of excessive and protruding fat of the eyelids, particularly that of the lower eyelid.

2) The puffy lower eyelid becomes very significant when the patient naturally as a congenital herniation of lower eyelid fat since they were young.

3) Successful correction of the puffy eyes requires substantial lower eyelid fat removal and skin from both the upper and lower eyelids.

Dr. Barry Eppley

Indianapolis, Indiana

Undereye bags are a well recognized facial entity. Everybody has seen lots of people who have them and eventually many people will see them on themselves as they age. For some few people they will have them even when they are quite young before they have any significant aging. Lower eyelid bags in the aging face are made up of several tissue components including loose skin and muscle as well as protruding fat. In the younger patient who just has bags or puffy lower eyelids the issue is one just of protruding fat. But in either the young or old, where does the fat in lower eyelid bags come from and why is it there? This is known as herniated lower eyelid fat that wss originally under the eyeball. Fat under the eye acts as a cushion, which is why you can push back on your eye and it gives in a little. The fat around and under the eye cushions it from impact. This fat is normally contained to the under the eyeball due to a ligament in the lower eyelid known as the septum. But as we age this ligament weakens, allowing the fat to come spilling out creating the puffiness or bags.  In the younger patient with bags, this ligament is naturally or congenitally weak allowing the fat to prematurely bulge out. In essence bulging lower eyelid fat is the result of a weakness or hernia in the lower eyelid ligaments. This heriated lower eyelid fat has three distinct pockets of fat known as temporal,central and medial or nasal fat pockets. Interestingly, while fat is well known to have a yellow color the nasal fat pocket is white and no one knows why.  Herniated lower eyelid fat can be removed exclusively in a transconjunctival lower blepharoplasty or as part of a more complete open lower blepharoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

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: 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