Everything you’ve wanted to know about Lower eyelid blepharoplasty (aka eye bag removal surgery)
Lower eyelid blepharoplasty is a surgical procedure focused on improving the appearance of the lower eyelids; in most cases the surgery addresses lower eyelid “bags”. Lower eyelid blepharoplasty is an outpatient procedure, and it can be performed under local or general anesthesia. The procedure itself usually takes 45 to 90 minutes, and it can be performed concurrently with other procedures, like upper eyelid blepharoplasties, endoscopic brow lifts, and facelifts.
Usually, lower eyelid “bags” are caused by the expansion and prolapse (bulging forward) of lower eyelid fat. Bags can also be associated with redundant lower eyelid skin, but this is less frequent in my experience.
Lower eyelid bags associated with fat expansion and prolapse can be addressed in several ways, including fat excision, fat transposition, fat grafting, and combinations of these three techniques. In fat excision, lower eyelid fat is simply cut out with scissors or cautery. In fat transposition, lower eyelid fat is mobilized with cautery, pulled down into the cheek, and sutured into place. This helps to fill in the tear trough and add volume to the anterior aspect of the cheeks. In fat grafting, fat is harvested from another area of the body (often the lower abdomen) and injected into the cheeks. Similar to fat transpositioning, fat grafting can help to fill in the tear trough and add volume to the cheeks. Fat grafting can likely add more volume than fat transpositioning. That being said, not all patients require fat grafting.
The type of lower eyelid blepharoplasty performed depends on each patient’s anatomy. I don’t want anyone to fall asleep before the end of this, so I’ll limit discussing the anatomical analysis that goes into this decision.
In addition to improving the appearance of lower eyelid bags caused by fat prolapse, excess lower eyelid skin can also be addressed during lower eyelid blepharoplasty surgery. Excess skin can be removed with a scalpel or scissors, or it can be resurfaced with a CO2 or Erbium laser. Recently, the “skin pinch” procedure has gained popularity. For the right patient, a skin pinch can work really well, but not all patients are good candidates for a skin pinch. Although I perform skin pinch surgery for some patients, my biggest concern with the current popularity of the skin pinch procedure is that it will probably lead to long-term lower eyelid retraction and ectropion for some patients, especially those who are younger (under 45) and live in very sunny locales. With prolonged sun exposure, our skin can shrink and contract. When this takes place in the lower eyelids, this can lead to an eyelid that is pulled down (retraction) or pulled out (ectropion). Both conditions can lead to significant dry eye and require corrective surgery, often with a skin graft. I don’t mention this to dissuade readers from getting a skin pinch, but I do encourage everyone to consider the possible risks, especially the long-term risks that can affect your activities of daily living during your golden years.
Complications are otherwise rare in lower eyelid blepharoplasty. General risks include bleeding, infection, and the possible need for additional procedures in the future (these are risks for all types of surgeries, anywhere in the body). Risks more specific to lower eyelid blepharoplasty include damage to the eye, loss of vision, and double vision. Eye damage and vision loss are very, very rare. Temporary double vision happens in a small percentage of patients but usually resolves in days to a week after surgery. In the rare event that double vision does not resolve, additional surgery may be required (far less than 1% of patients).
Oculofacial plastic surgeons who are members of the American Society of Ophthalmic Plastic and Reconstructive Surgery are unique in that we all completed an ophthalmology residency (3 years) prior to our training in oculofacial plastic surgery (2 years). Thus, we have an intimate understanding of eye, eyelid, and orbital anatomy. Oculofacial plastic surgeons specialize solely in eyelid and facial plastic surgery. If you choose to have your lower eyelid blepharoplasty performed by an oculoplastic surgeon, I recommend checking to make sure that they completed a 2-year ASOPRS (American Society of Ophthalmic Plastic and Reconstructive Surgeons) accredited fellowship.
