The Evolution of Lower Lid Blepharoplasty

After over 40 years of practice in this fascinating field some basic principles remain, but there are also new concepts and technologies to evaluate and incorporate into our treatment regimes. Anatomy remains the foundation and “basic science” of all we do. Lower lid blepharoplasty has changed and yet remained the same.

Early on we almost always approached the lower lid with a skin muscle flap sub-ciliary incision- this meant making an incision under the lower eyelashes and removing fat, skin and muscle.

Later the transconjunctival approach which involved removing fat from inside the lid became popular and was our technique of choice.  To address extra skin we either did a skin “pinch” or tightened and smoothed the skin with laser resurfacing or a peel.

  Now we are again doing more skin muscle flap procedures to address muscle laxity and more precisely transpose fat and lift the depressed cheek (SOOF). There is also a renewed focus on supporting the lower lid with various techniques to prevent lid malposition- the lateral retinaculum suspension suture is most used. 

Lower blepharoplasty has also changed with a recognition of the role played by cheek descent with age in creating an undesirable cheek lid contour. Mid-facelift, fat transposition, or fillers can help repair this deformity.

 We most often choose fat transposition which takes fat that previously would have been removed and “transposes” it to fill a tear trough deformity. Results however with injecting hyaluronic fillers or the patient’s own fat can be almost as good. Mid-facelifts and SOOF lifts can provide excellent improvement but involve much more significant surgery.

 We have over the decades achieved a better understanding of facial aesthetics with aging and have many more techniques – both surgical and non-surgical – to rejuvenate the lower lids.