Lower Lid Blepharoplasty
Why Do Patients Get a Lower Lid Blepharoplasty?
The main reason to get a lower lid blepharoplasty is to improve your appearance. Some patients may have issues with the lid being too loose, in which case it can turn in or turn out. This would cause dryness and irritation and possibly tearing or watery eyes. But for most patients, they are just bothered by the way they look. Also, I have a subset of patients that have been referred to me by other doctors because they’ve had fillers into their lower eyelids with someone else and then are having problems with swelling or redness.
At What Age Do People Get a Blepharoplasty?
In the past, the majority of patients who were getting lower-lid blepharoplasties were between 50-90 years old, with the majority being 60-80. Now, because of Covid and Zoom meetings, I’m doing far more of these surgeries on 20-40-year-olds than I have in the past, and they do really amazingly well.
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What Are the Parts of the Lower Eyelid That Can Be Addressed With a Surgery?
There are 7 parts of the lower eyelids that I commonly address when patients are bothered by their lower eyelids. They are:
The Skin
This is obviously the first layer, and it can have several issues. There can be too much skin, or the texture can be wrinkled and crepey, or both. Sometimes the skin is red, irritated, or inflamed, and sometimes it can be pigmented.
The Orbicularis Muscle and the Crow’s Feet
Actually, I like to call them Smile Lines because it sounds so much better! These are the lines on the sides of the eyes that scrunch up when you smile. Some people get a thick roll of muscle underneath their eyelids when they smile, which is sometimes called a Jelly Roll.
The Fat
This is the yummy stuff – these are the bags under your eyes. We commonly see this in people as they get older because the fat pooches out more. But I see patients all the time now that have had “bags under their eyes” since they were kids or teenagers. There’s nothing wrong with them, but they just have a genetic predisposition to having more fat pooching out.
The Tear Trough
This is the ligament that connects the skin to the bone underneath the fat pads. This is what creates that hollow appearance under the eyes.
Festoons or Malar Mounds
Swelling that occurs in this outside triangle is usually referred to as a Malar mound or festoon. This is just water that collects underneath the eyes.
The Lateral Canthal Tendon
Your eyelid is held up and connected to the bone with a rope called the canthal tendons. The lateral canthal tendon can become loose or stretched out for a multitude of reasons.
Fillers
This is the troublemaker. I’m going to go on record here. I love fillers – I think they’re great, and when used in moderation, they can really help people. My nurse practitioner and I inject them all the time into the cheeks, the temples, and around the mouth – they’re great. But since there are so very few cosmetic oculoplastic surgeons in my area, I wind up seeing a ton of patients who have problems or complications from fillers injected into the lower lids by other providers. These patients come to me months or years later with issues related to previous fillers. The most common issue I see is persistent swelling, but I’ve also seen inflammation and infections on the lower lids even up to 25 years after the filler was injected. So, like I said – I love fillers, but under the eyes, I’m not a fan of fillers except in very specific patients.
What is a Lower Lid Blepharoplasty?
For excess Skin:
Lower Lid Skin Pinch -
When I cut out a strip of skin on the lower eyelid
For crepey lower lid skin
Lower lid Laser Resurfacing -
When I use a CO2 Laser or an Erbium Laser to resurface the lower eyelids. We also use RF Microneedling with or without vital fluids for texture issues on the lower lids.
For Dynamic lines:
Botox -
To address the smile lines or crow's feet.
For the Bags underneath the eyes
Transconjunctival Lower lid Blepharoplasty without Fat Transposition -
This is the surgery when I cut out the fat causing the undereye bags. The goal is to “get rid of the bags” under your eyes.
For hollow tear troughs
Tear Trough filler -
In very select patients, I’ll use Restylane to fill in a hollow tear trough. This is best for patients with thick skin and muscle under the eye, a deep tear trough, no fat pooching out, and just volume loss. In this case, the goal is to soften the deep tear trough.
For Festoons
Direct Festoon Excision -
When people have pretty bad festoons, I’m able to cut them out. For the people who have very prominent festoons that can be pinched together, we cut them out, so the festoon can’t collect as much water.
For a loose Lateral Canthal Tendon
Canthopexy, Canthoplasty -
This is when I tighten the corner of the eyelid to give it more support. In patients that have moderate amounts of laxity, I’ll tighten the eyelid so that it hugs the eyeball a little better to give it more support.
For Filler Problems
Hylenex -
For patients who have had filler anytime in the past 25-30 years, I use Hylenex (Hyaluronidase) to dissolve the fillers. We also use RF Microneedling for patients that have swelling after lower lid fillers in conjunction with Hylenex. This has been life-changing for patients with lots of swelling under their eyes because it can be rather upsetting for people.
What Can Lower Eyelid Surgery Do? What are the Limitations of Eye Bag Surgery?
For excess Skin
Lower Lid Skin Pinch -
The goal is to get rid of *some* of the excess skin that you can pull off your face. I can’t cut out all the skin because if I cut out too much, the eyelid can pull down and not close.
For crepey lower lid skin
Lower lid Laser Resurfacing -
The goal is to smooth out the wrinkles on the lower eyelids.
For Dynamic lines
Botox -
The smile lines or crow's feet should soften when you smile. This is one of the most common cosmetic treatments performed. It works amazingly well, and I get this done myself.
For the Bags underneath the eyes
Transconjunctival Lower lid Blepharoplasty without Fat Transposition -
The goal is to “get rid of the bags” under your eyes.
For the Bags underneath the eyes
Transconjunctival Lower lid Blepharoplasty with Fat Transposition -
Here, the goal is to “get rid of the bags” under your eyes but keep some of the fat and use it to soften the deep tear trough under the bags.
For hollow tear troughs
Tear Trough filler -
We use this technique if you’re hollow and don’t have large bags. In this case, the goal is to soften the deep tear trough.
For Festoons
Direct Festoon Excision - For the people who have very prominent festoons that can be pinched together, we cut them out, so the festoon can’t collect as much water.
For loose Lateral Canthal Tendon
Canthopexy, Canthoplasty - In patients that have moderate amounts of laxity, I’ll tighten the eyelid so that it hugs the eyeball a little better to give it more support.
For Loose Lateral Canthal Tendon
Lateral Tarsal Strip -
In patients whose eyelid is very loose and really not supporting and protecting the eyeball, I’ll use this technique to reattach it to the bone.
For Filler Problems
Hylenex - I use Hylenex to dissolve fillers under the eyes. This has been life-changing for patients with lots of swelling under their eyes because it can be rather upsetting for people.
Do Men Get Lower Lid Blepharoplasty or Eye Bag Surgery?
Interestingly enough, the ratio of men who come in to have eye bag surgery is higher than the ratio of men interested in upper lid surgery – and the age is younger too. I see the full spectrum of men from their 20s to 80s who come in to have their bags addressed, but there is definitely a trend toward younger men getting bags taken out at a significantly younger age. I think these guys just realize in their 20s that the fat is just there, and no amount of exercise is going to help it.
What is the Most Common Referral That Dr. Landmann Gets From Other Plastic Surgeons?
By far, the most common reason a Facial Plastic Surgeon, an ENT, or a General Plastic Surgeon will refer to me is that they did a TransCutaneous lower lid bleph, and the patient developed retraction. There are special procedures that oculoplastic surgeons do to try to correct that, so they will ask me to take over and manage their patients. Fixing Post Blepharoplasty Lower Lid Retraction is a very involved topic, which involves steroid injections, patching, and complex surgeries involving implants and skin grafts.
What is the difference between a Transconjunctival versus a Transcutaneous Lower Lid Blepharoplasty?
TransCutaneous
TransCutaneous means through the skin.
A TransCutaneous lower lid blepharoplasty is an older technique. It is how I was first trained to do lower lid blepharoplasties, but I haven’t done one in years and honestly can’t imagine any circumstance in which I would ever do one. The reason is that the risk of “retraction” – when the lower eyelid is pulled down – is 6-20%, which is really bad odds. And retraction is super frustrating, upsetting, and very difficult to deal with. Patients can develop bad problems with dryness, which makes it feel like there is sand or glass in their eyes. It is also not a normal look – In mild cases, the lower lid looks scooped out, which gives it a plastic surgery look. In bad cases, the lower lid is just pulled down, and it looks like an obvious problem. I never recommend a transcutaneous lower lid blepharoplasty.
TransConjunctival
TransConjunctival means through the conjunctiva or from the inside of the eyelid.
A TransConjunctival lower lid blepharoplasty is a newer technique. The learning curve is much steeper, so older surgeons might not pick it up. The incision is hidden on the inside of the eyelid. The incision heals beautifully, and sometimes I don’t even need to use a suture to close it – it just closes on its own.
I Went to a Facial Plastic Surgeon Who Recommended a TransCutaneous Lower lid Blepharoplasty Because He Could Trim Off a Little Skin at the Same Time.
Let’s rephrase the question. If you got into an Uber and he said, I can get you from Wayne, NJ to NYC in 20 minutes, but I have to drive 122mph. Would you say, “Go for it!” or “No – get me another Uber, and don’t drive like a maniac!”
Honestly, if I could give one piece of advice to anyone out there on the internet about lower lid surgery – it would be to please not get a transcutaneous lower lid blepharoplasty. I see so many patients with complications from this technique. If you get lower lid retraction, it’s a really bad problem, and you can’t just snap your fingers and undo it. The surgeons who say they don’t see this problem with their technique are misguided – because these patients often get second opinions from oculoplastic surgeons and never go back to their original surgeon. The skin should be addressed with a skin pinch or laser resurfacing, or a chemical peel. Most commonly, nothing needs to be done with the skin, and your result will look more natural by taking a conservative approach. If I can’t convince you, just call 10 oculoplastic surgeons (doctors who just do eyelid surgery) and ask what technique they use.
Are Lower Eye Fillers temporary? Is Surgery Permanent?
The clinical effect for most fillers is typically a year or so. The effects of Lower Lid Surgery certainly last longer, but no surgeon would say “permanent.” I’ve also lost track of how many patients I’ve seen who’ve had complications from fillers for 25-30 years. Do not base your decision to have a procedure based on how long it takes to perform or how long the results last – you should do the right procedure for your problem.
Which is Better? Fillers vs Surgery for the Lower Eyelids
This is a super common question because these are confusing topics.
But first, let’s talk about an analogous question, which is better, to color your hair or cut it? Ok, these are two obviously different things. If I bleach my hair blond, I’m gonna have a very different appearance. And if I decide to shave my hair and have a mohawk, I’m also going to have a very different appearance. It’s an extreme example – but the point is this – two different problems are being addressed, two different treatments are being performed, and two different outcomes are expected.
In general, most people that have surgery for their lower eyelids have their bags (which are fat) either removed or trimmed. So, if you have big bulges under your eyes, surgery is the procedure that can address that. Some people just have a big bulge – in which case I just remove it. Some people have a big bulge, but underneath that have a deep hollow area. In that case, I trim most of the fat and then use it to fill in the hollow area by moving it down.
Fillers don’t get rid of pooches of fat. Fillers take up space. They fill things up. So, if the problem is that you are just hollow, you’ve lost volume in your tear trough, then fillers can fill up that void.
Now, a lot of people are in between. They have a little bit of pooching and a little bit of hollowness. In this case, the argument for fillers is that the filler can dampen the disparity between the deep tear trough and the big bulge. I’ve had really great results with that. But, if your pooch of fat is big, and someone tries to match that big pooch with filler, you wind up being overfilled, which we’ve all seen and dread. I would argue that if you have a medium to severe pooch and any amount of tear trough, then you can trim down the pooch and use it to fill in the hollow.
To summarize: Lower Eyelid Fillers take about 10 minutes to do the procedure. It’s a quick procedure, and I never even need to prescribe Tylenol for it. But it can take 30-60 minutes just to explain the procedure and determine if it is the correct procedure for you. The results, for appropriate patients, last about a year. For some patients, they’re ecstatic, and it’s great. Wahoo! Everyone is happy. But… for some patients, I have seen patients who are miserable for years dealing with swelling, inflammation, and then injections and surgeries. I’m not being mean to “lower lid fillers,” but I just want patients to understand that this is considered an implant being injected, and it has risks that should be considered as important and serious as risks to surgery.
What’s the Difference Between Fat Grafting, Fat Transposition, and Fat Excision?
Fat Excision
Simple enough, I just cut out the fat. Sometimes I release the tear trough to help efface the contrast between the cheek and the lids. I do this in patients who don’t have a prominent tear trough. I also do it for patients who’ve had fillers in the past because it produces the least amount of post-operative swelling and the quickest recovery.
Fat Transposition
For patients with a pooch and a hollow area, I trim down some of the fat, and then I use the rest of the fat and slide it underneath the hollow area to lift it up and fill it.
Fat Grafting
Some doctors just take out the fat, and then they do a little liposuction and use that fat to fill in the tear trough.
Both Fat Transposition and Fat Grafting are good procedures, but both have their downsides. In my hands, I’m a minimalist, and I try to do the least amount of surgery possible. So I like fat excision and fat transposition because it takes out the risks involved with operating on a second surgical site.
How long does it take for Dr. Landmann to do a Lower Eyelid Blepharoplasty?
It typically takes me about 45 minutes to an hour and a half. I actually don’t time myself because when I’m operating, I take my time and never rush. If it takes me a few extra moments to get your surgery as perfect as possible, I just take my time and do it.
What Type Of Anesthesia Is Used?
The vast majority of the upper lid surgeries I do are done with local anesthesia (Lidocaine) and an oral relaxing medication, so you don’t feel anxious or nervous. For lower lids, though, it’s very difficult to numb all the fat, so I typically do it with IV sedation or Monitored Anesthesia Care. You get an IV, and an anesthesiologist zonks you out – you are breathing on your own the whole time. It’s not general anesthesia, but you feel very comfortable the entire time.
How is the recovery after a Lower Lid Blepharoplasty?
I would say the recovery is pretty similar to the recovery after a cosmetic upper eyelid blepharoplasty, but there are a few differences:
- I usually put a stitch that holds up the lower eyelid to support it by anchoring it to the upper eyelid. It’s kind of annoying for the first week because your eyelid is a little closed, but I remove it around 5-7 days after surgery, and you feel instantaneously better once it’s out.
- I prescribe an antibiotic drop rather than an ointment.
- When I do an upper eyelid surgery – I tell patients that the swelling is about 6 weeks, in case they have a wedding or a TV appearance. When I do lower lids, I usually say 8 weeks for swelling. Some people are less than 6-8 weeks, but I always like to overestimate the downtime so no one is upset.
Lower Lid Blepharoplasty FAQs
Who is Not a Good Candidate For Eye Bag Surgery?
In addition to the risks factors for upper lid blepharoplasty, the two major risk factors that I look for when evaluating patients for lower lid surgery are:
- Prominent Eyes with poor cheek support. The technical term for this is a “Negative Vector.” The cheek acts like a pillar, supporting the lower eyelid, almost like a Roman Column that supports the roof of a building. So, if the cheek isn’t supporting the lid well, it is a setup for retraction.
- A history of fillers to the lower lids. This isn’t a contraindication for lower lid surgery, but if you’ve had fillers into your lower lids, even if it was 25-30 years ago, it can affect your surgery. After surgery, old filler can get swollen for a prolonged period of time, or it can get inflamed. This can be managed with Hylenex and/or steroid injections, but that sometimes has to be repeated several times postoperatively (we’re talking 2-6 times, at once a month – so it can be very disturbing to your social calendar). I give my patients a heads-up about this, and during the surgery, I do my best to try to dissolve any filler I see.
Is Lower Eye Bag Surgery Painful?
Since I do the procedure with “Twilight” sedation, patients are comfortable during the procedure. Afterward, I’ve never needed to call in narcotics. I tell patients to take Tylenol every 4 to 6 hours after surgery. Most patients will take Tylenol for 2-3 days.
When Can I Return to Work and Normal Activities After Having Eye Bag Removal Surgery?
Since I put a temporary suture that holds the lower lid up, it would be difficult for most people to get a lot of technical work done until the stitch is removed, usually 5-7 days after the procedure. Most people could go to work after that if they wanted, but the vision might be blurry for another week or so.
How Much Does Lower Lid Blepharoplasty Cost in New Jersey?
The average cost of Lower Eyelid Bag Surgery in Northern New Jersey can be around $8850. When comparing prices, please understand that this fee encompasses the surgeon’s, a facility, and anesthesia fees. The surgeon’s fee is the cost of the actual procedure, and for my practice, this includes the preoperative consultation, the surgery itself, and the postoperative visits. If something needs to get tweaked, I also do not charge patients, as my goal is to get it as perfect as possible, and everyone heals differently. The facility fee is the cost of the supplies and the facility itself. Since the vast majority of my cases are done in my office, you’re just paying for the supplies and equipment since so much stuff is disposable, i.e., gauze, needles, sutures, etc. The anesthesiologist fee is to pay for a doctor to be there to provide “twilight” sedation. In most surgery centers and hospitals, the Facility Fee and Anesthesia Fee are billed in increments of 15 minutes. In my office, we just have a flat fee depending on the nature of the procedure. So if I take extra time or if I need extra equipment, you will not get billed for that. There are no surprises!
The following may not apply to everyone: some random fees that patients may have are History and Physical with Primary care doc, blood work, EKG, and Antibiotic Eye drop.
How Long Will My Blepharoplasty Results Last?
The results from upper lid blepharoplasty are very consistent and, for most patients, last a long time. The lower lids are much more variable and depend on a lot of factors. The skin can age rather dramatically. Look at people 10 years younger than you and 10 years older than you. If you’re out in the sun a lot, you’ll have a nice tan, but the sun is the #1 cause of aging skin. The fat can vary too. If you gain or lose a lot of weight, that can affect the bags. Endocrine problems like a thyroid condition or changes in your estrogen levels can also have effects on the fat in your body. So, there’s no solid answer for this one, but if you maintain your health and stay out of the sun, hopefully for a long time!
I Am Interested! How Should I Proceed?
Great! Hopefully, you can tell from the above discussion that I do a ton of these. Lower Lid Blepharoplasty is much more involved than upper lid surgery, but I’m very meticulous, and I think my background in Electrical Engineering helps me take a very systematic approach. I’d be honored to go over your treatment options. Write down your questions and concerns and call Melissa to set up an appointment. I’m looking forward to meeting you! Our number is 201-696-2646.
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