Thursday, December 13, 2007

The Benefits and Limitations of Lower Eyelid Surgery

As the aging process continues, many patients have complaints relating to the lower eyelids. As figure 1 shows, there are two general changes that occur in the lower eyelids with aging. The first is the development of soft bulges beneath the lashes – people commonly refer to these as eyelid “bags”. These are mainly caused by the protrusion of fat through the muscles that close the eyes, and can be exacerbated by the retention of fluid in the eyelid skin. These bags can create the impression of fatigue, advanced age, or even illness or allergies. The second type of change involves loosening of the lower eyelid skin. This process is particularly prominent in the patient’s left lower eyelid in figure 1. Sagging of skin is caused by many factors, especially the loss of collagen and elastic tissue, and the effects of gravity. Lower eyelid skin is very thin to begin with, so as it loosens, many fine wrinkles are created.

 Figure 1. Typical aging changes of the lower eyelids are displayed by this patient. 

Treatment Options. The medical term for surgery of the eyelids is “blepharoplasty”, and just as there are two general aging processes of the lower lids, there are also two general approaches in lower eyelid blepharoplasty. The first involves incisions in the “conjunctiva” – the pink, moist tissue on the inside of the lid. Therefore, this approach is called a “transconjunctival blepharoplasty”, and does not leave any scars on the skin. Through these small incisions, a portion of the protruding fat is removed, and the bags are therefore minimized. An example of this result is shown in figure 2. The amount of fat removed must be precise – if too much is removed, the eyes may have a sunken or hollow appearance, and if too little is removed, the bags will persist. Patients should remember that this surgery does not change the wrinkle of the lower lids – it only reduces the bags.

 Figure 2. A transconjuntival blepharoplasty can reduce prominent lower lid bags (left  before; right – after).

If skin wrinkles are prominent, in addition to the bags, then a skin incision is required and excess skin must be excised. This incision is made in an existing skin crease just below the lower lashes, and is referred to as a “subciliary incision”. The thin lower lid skin is then lifted from underlying tissue, and excess skin is trimmed. Protruding lower lid fat can be removed in this manner as well, or can be repositioned to smooth the contour of the lower lid. This approach also requires precision, because if too much skin is removed, the subsequent scarring can pull the lower lid down.

For patients who are not candidates for surgery, certain skin resurfacing procedures are available to smooth lower lid wrinkles. Examples include light peels and laser treatments. An example of improvements to wrinkles of the lower lids is shown in figure 3 – note that not all wrinkles can be removed due to risk of lid retraction.

Figure 3. Lower lid wrinkles can be reduced by skin resurfacing (left – before; right – after).