Lower Blepharoplasty

Q: Dr. Eppley, I would like to enquire about lower blepharoplasty. I am a 45 year old male and have been suffering from eye bags getting worse over the last five years or so. (particularly the last year) I have been to see three plastic surgeons about this, but am confused as to the approach to take. All three plastic surgeons have confirmed it is herniating fat and not a tear trough or other problem that is causing the bags. 

The first surgeon preferred a transcutaneous approach, though said I may benefit from a tiny skin excision, it may not be needed. The other two both said skin removal was not needed and both recommended the transconjunctival approach with no fat transfer or redraping. Now, since I have done quite a bit of research on this I realize that a transconjunctival approach is regarded to be less risky, due to not cutting through the lower eyelid muscle, especially since a skin excision is not required it seems a needless risk.

However, where the last two surgeons differ is that one said they rather be repairing the lower orbital septum, (he called it Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty) and that this would involve a miniscule fat removal as the septum would hold the fat pads in a more natural position. He said this would not only give better long term results in terms of preserving eye shape and lid level, but also prevent a common problem of a skeletal look that can arise from a basic transconjunctival approach, he even claimed that this marginally would improve the upper eye skin look, as the eye would be sitting more naturally in its socket – looking at before and after pictures I can see this is indeed a happy side effect.

What I would like to ask is:

1) Which approach would you take (I am happy to send in more photos)

2) Is it common with a basic transconjunctival approach to have a skeletal look long term or is this always simply caused by excess fat removal?

3) Would a transconjunctival approach, with septal suture repair produce more inherent risks or recovery time, and if so would the results be that much better that (2) such that the risk is worth it?

A: In looking at your pictures and your age, it is clear that you don’t need skin removal. Thus a transconjuncival approach to your lower blepharoplasty should be done rather than a transcutaneous one. Your debate is in how to handle the herniated fat pads…either subtotal removal or retrograde repositioning. (septal reset) The simple answer to this debate is if you can keep your fat and it can be brought back in (like a hernia repair) this is always better long term. However it is much more technically challenging than fat removal through the transconjunctival approach.

Dr. Barry Eppley

Indianapolis, Indiana