Lower eyelid lift Surgery are considered one of the most effective cosmetic operations to restore the original appearance of the face and give a more fresh and youthful touch to the eyes in particular and the surrounding tissues. The eye and the tissues surrounding it are the most influential organ when expressing feelings, but it is also the mirror of the face that reflects age, gender, and the extent of the beauty and youth of the face.
The sensitive nature of the lower eyelid area in particular makes it more vulnerable to external stimuli such as ultraviolet radiation, light, and visual repetition of moving visuals.
Lower eyelid lift Surgery are the third most common plastic surgery in the world, with about 204,000 operations annually, according to 2012 statistics issued by the American Society of Plastic Surgeons, and this number increased by about 10-17% during the five years up to 2017.
These statistics do not include non-surgical operations that are performed. It does not require skin incisions such as injections of inorganic substances, phototherapy, and chemical peels.
The goal of lower eyelid lift surgery
Diversity in methods to restore the vitality and appearance of the lower eyelid between surgical and non-surgical methods requires accurate knowledge of the anatomy of the eye, eyelid, and all surrounding tissues involved in the operation, and how to avoid any problems resulting from these procedures.
In the lower eyelid lift, the surgeon aims to remove excess and sagging skin, make the muscles under the eye flat evenly with the rest of the facial skin, and tighten the skin supporting these areas if needed, and remove the accumulated fat to reconcile the eyelid with the cheeks.
The lower eyelid lift procedure through the skin depends on the incision of the outer skin in conjunction with the surgical skill that achieves these goals. Although this procedure is for patients seeking to restore the freshness and vitality of the skin under the eye, it differs from one patient to another, and therefore the anatomy of each patient and the structural problems of the eyelid and eye must be determined.
There is no such delicate balance between structure and function in any plastic surgery as there is in the lower eyelid and how to adjust it. This balance is due to the sensitive nature and complex structure of the eyelid and its very important vital role in protecting the visual system and the efficiency of vision.
For this reason, the eyelid should be handled with complete care and accuracy in regards to the fragile tissues and their complex structure. Therefore, the doctor must focus on the anatomy of the lower eyelid for each patient individually before proceeding to perform the lower eyelid lift operation.
We must put the eye and the efficiency of vision in the first place before addressing the installation of the lower eyelid. The edge of the eyelid touches the line separating the eye from the eyelid incision, which makes the operation a very precise matter so that the visual vision is not damaged as a result of dealing with eyelid fat.
It is also important in the operation to determine the area of the lower bulge under the eye and the wrinkle line in this bulge very accurately and its connection to the tissues of the eye muscle and the surrounding nerves. In most cases, the center of this wrinkle, which is in the middle of the eyelid bulge, is at a distance of 5-6 mm from the edge of the lower eyelashes.
Preoperative assessment of the patient
One of the most important requirements that the doctor must consider when planning a lower eyelid lift operation from a technical point of view is all the questions that concern the patient that require clarification. Once both the patient and the doctor can reach a common understanding of all aspects of the technical and surgical process, in this case it is possible to develop an integrated plan for the operation.
This scheme is built according to the patient’s desires and aspirations for the results of the operation based on some anatomical considerations of the patient’s face and the doctor’s observations about the limitations and problems of the operation specific to the patient as an individual case.
The initial consultation is performed as a starting point for the patient’s preoperative surgical assessment. During this consultation, the doctor examines the patient completely and investigates his medical, medical and health history based on clear reports.
These tests pertain to blood, heart efficiency, breathing, diabetes, pressure, liver disease, thyroid gland, some anatomical examinations of the patient’s face, the structure of the lower eyelid, and determination of the paths of blood vessels and nerves in the area under the operation.
The doctor examines the patient’s surgical history, especially surgeries related to the eyes and face, as well as examining the visual capabilities of the eye and its relationship to the degree of eyelid laxity.
After completing the examination of the patient’s medical history, a complete review of the vision system should be done, including checking the amount of tearing or dryness of the eye, the number of eye blinks, the extent of redness and itching, and whether the patient uses contact lenses or eyeglasses.
All these considerations make the doctor need to take into account the eye’s vision system in terms of muscles and nerves and how to avoid any influences that may harm the vision of the eye.
Dry eyes in particular should receive special attention and discover its causes from basic issues such as insufficient production of tears or excessive evaporation of eye fluid. There are some other complaints that the doctor considers such as eye itching, foreign body sensation in the eye, blurry vision, pain and eye fatigue.
Statistics from the American Society of Plastic Surgeons show that 12% of men and 17% of women have dry eye symptoms, and this percentage is considered high among patients. If the patient suffers from this type of dry eye, the plastic surgeon will have to refer him to an ophthalmologist to examine the condition and prescribe the appropriate treatment.
The doctor is also supposed to note the allergies that the patient may have, the patient’s alcohol and smoking intake, and all current medications, including nutritional and herbal supplements. The patient’s intake of aspirin and blood-thinning medications should also be monitored and how to regulate these medications if the situation requires their use urgently. High blood fluidity may increase the problems of the operation, although it is an elective surgery that can be waived if the disease cannot be performed.
Physical examination of the patient before lower eyelid lift surgery in Turkey
The anatomical and structural examination of the patient’s face, especially the eye area and eyelids, is considered one of the factors for the success of any cosmetic operation performed in the facial area. A good drawing of the anatomy of the eye socket bone area, the circular muscle, and the nerves left in this area must be a detailed explanation in order to avoid any impairment that may result from the operation. The doctor must have a deep understanding of the factors of facial aging, the anatomy of what is around the orbital area or the eye circle, the edges of the bones, the amount of excess fat in the eyelid, how to deal with it, and whether the removal of this fat will affect the functioning of the eye apparatus and its surroundings after the operation.
Factors of facial youth depend on the ability of the skin to stretch and ductility in its tissues and the absence of any defect in the pigmentation of cells, as well as how fat supports the appearance of the face.
On the other hand, the visible signs of aging in the lower eyelid include some secondary changes in the ability of the skin to metabolize, which appear in different degrees of wrinkles, the development of keratoderma and different degrees of skin pigmentation and color.
In general, if there is no excessive amount of fat and loose skin in the lower eyelid that needs to be tightened, performing the operation in this case may lead to malposition of the eyelid.
The structural structure supporting the lower eyelid is closely related to aging factors and the extent of fat in the eyelid, and the tarsal and lateral ligaments of the eye become less flexible, causing a stiff appearance and lower eyelid position falling.
The circular muscle of the eye and the nerves surrounding it also become weaker and more stretched, allowing the eyelid to drop and fat to accumulate in this area. The degree of this relaxation in the eye muscle and nerves is reached by following the scale of comparison with the images available to the patient in earlier times.
Or through the eyelid retraction scale, which is a method that relies on gently lifting the lower eyelid up and calculating the period of time that the eyelid needs to return to its normal position. If more than two seconds have passed since the eyelid retracted, then in this case the test is positive and the patient’s condition is required to undergo the operation.
There are also some quantitative tests that can be performed for the lower eyelid, including the clinical test of the eyelid, which is by measuring the distance between the circular edge and the eyelid. for the tensile process.
If it is confirmed that there is significant looseness in the skin of the lower eyelid, then it is necessary to perform an additional operation in the lifting operation plan in order to flatten the skin and camouflage it with the rest of the facial skin.
Steps to perform a lower eyelid lift in Turkey
The techniques of performing a lower eyelid lift differ from the upper eyelid lift in several respects, as the anatomical structure of the lower eyelid differs, especially in how fat accumulates, the pattern of skin sagging, and the distribution of muscles and nerves under the eye.
The doctor first makes illustrations of the fat sacs, the position of the end of the lower eyelashes, and the distance of this fat from the eyelashes. Usually, the operation is performed using 3 surgical techniques, which are the opening through the mucous lid of the eyelid, the muscular skin flap, and the skin flap.
Most of the doctors prefer the traditional method through the eyelid mucosa because it gives great results in more than 90% of the patients.
This safe method depends on reducing the opening area and also makes the chances of problems such as eyelid turnover and misplacement much less than other techniques. First, the appropriate patient for this technique must be carefully selected, and the patients suitable for this technique are:
- The elderly who have large amounts of fat, bags under the eyes, and loose skin are suitable patients for this technique.
- This technique can also be performed for young patients, on the condition that there are hereditary swellings and old sagging in the lower eyelid area.
- This technique is ideal for patients who do not want to make a visible incision in the eyelid and hide the traces of the operation.
- Patients with edema, a condition in which wounds enlarge and become apparent after healing.
- People who have darker skin and those who may have increased skin pigmentation in the surgical areas.
Many plastic surgeons have noticed the rare occurrence of problems associated with lower skin tightening when using this technique in the short and long term compared to the muscle skin flaps and skin flaps.
Some doctors prefer to combine the lower eyelid lift with the mucous lid technique with some means of removing excess skin by surgical methods or laser eyelid lift , which we will provide a detailed explanation of its methods and techniques.
Preparing for a lower eyelid lift
The patient sits in an upright position while looking up to reveal the fat bags that are supposed to be dealt with. The doctor then makes the outlines and determines the location of these fatty cysts and areas of sagging skin with a thin surgical pen so that the definition is more accurate.
After that, the patient is placed in a horizontal position to start the first steps of the operation. The doctor places two drops of 0.5% tetracaine hydrochloride solution in the lower inner region of the eye, which is a local anesthetic solution that does not cause allergic reactions.
This instillation is done before the local anesthetic is injected to help reduce the feeling of pain. Also, before local anesthesia, the doctor injects some analgesics and sedatives through intravenous injection, consisting of midazolam and meperidine hydrochloride in the form of Demerol with 10 mg of dexamethasone to reduce ascites after the operation.
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The local anesthetic is a mixture of equal amounts of 0.25% bupivacaine and 1% lidocaine with 1:1000 epinephrine dissolved in sodium bicarbonate solution and then injected into the mucous membrane of the lower eyelid with a fine needle.
The needle is inserted into the mucous membrane until it reaches the bulge that precedes the edge of the eye socket bones from the lower side. The doctor slowly injects the anesthetic solution while withdrawing the needle.
The local anesthetic is injected into multiple parts of the lower eyelid so that the solution spreads in the lower, middle and upper eyelids until the patient gets complete anesthesia during the operation.
Surgical opening procedure
After waiting for a full 10 minutes until the eyelid area is completely numbed by local anesthetic, the doctor will hold the eyelid with two long hooks and fix the upper eyelid to ensure that it does not move during the surgical procedure.
The doctor makes a surgical incision with a fine scalpel 2 mm below the lower edge of the eye socket bones. During the incision, this tip is gray in color and is therefore easy to locate securely. The wound is usually 4-5 mm from the lateral end of the eye socket.
Immediately after the surgical opening of the eyelid membrane, a suture is made next to the eyelid vault, which is in a circular shape, for fixation. After that, the two hooks intended for tightening and relaxing the upper and lower eyelids are removed so that the features of the fat bags that must be dealt with become clear. One of the advantages of this technique is that it maintains the non-adhesion of the iris due to the surgical procedure located in the eyelid mucosa.
Removing fat from the lower eyelid
If the operation plan requires removing some fatty bags from the eyelid, it is supposed to make some simple incisions inside the eyelid mucosa so that the surgeon can remove these bags. These fat bags must also be anesthetized with an additional amount of local anesthetic to avoid the patient’s feeling of pain during the fat removal.
This fat is not withdrawn randomly because any unjust removal process will damage the external shape of the eyelid and the texture of the skin, which may distort the skin and cause permanent wrinkles to appear on the surface.
The process of removing fat is done with small surgical forceps, after pulling the tip of the skin on the side of the eyelashes with a surgical hook. The circular muscle stands as a barrier between the middle and central fat, so the position of this muscle must be determined in advance before dealing with any of these fat bags.
As for the lateral bags that determine the shape of the cheeks in terms of the position of the eye, care must be taken when removing fat with it, because it may distort the appearance of the eye when the lower eyelid meets the cheek.
The doctor pulls out the middle bags first very accurately and then examines the external shape of the eyelid. If it is necessary to remove some fat from the side area, it must be gradual. This gradual retraction provides the doctor with space for an aesthetic assessment of the eyelid’s appearance before removing essential portions of the eyelid fat.
After each pull, the bleeding is dealt with by forceps, stopping the bleeding so that no blood or mucous seepage occurs under the membrane. In elderly patients who have excess skin that requires removal, a chemical peel or skin tightening technique may be added until the cosmetic results are more evident. Excess skin is lifted with small 2-3 mm surgical forceps or Brown-Addison forceps prior to removal of the skin.
The surgeon uses sharp scissors, taking care not to disturb the lower eyelashes. After that, the two ends of the skin are joined after the cut and surgical stitches are made according to the area of the removed skin, taking into consideration not to leave any spaces in between.
After completing the closure of the wound and making sure that there is no bleeding inside the eyelid, the doctor examines the appearance of the eyelid from the outside, in order to ensure that the operation was carried out accurately without tampering with any essential fats.
These essential fats determine the shape of the outer eyelid and the way the skin flattens evenly with the rest of the skin of the cheeks and face in general. If the doctor notices that there are some wrinkles in the skin that have developed after the operation, he can combine some non-surgical methods with the operation to implement the required lift without compromising the scope of the operation.
The patient should know that the immediate results of the operation are guaranteed, but there are some long-term results that appear shortly after the operation.
Within a few days after the operation, the eyelid gets the required rest, as the remaining fat inside it spreads and expands to give the expected aesthetic appearance.
Figure 1: Measurement of eyelid disorder by holding both ends of the eyelid downward, a method used to determine the elasticity of the skin and the amount of fat accumulated underneath.
This method is the first step before considering a lower eyelid lift and before determining the type of technique used in the surgical procedure.
Figure 2: The method of measuring the range of movement of the lower eyelid by stretching and showing the inside of the eyelid, which is a measure that also determines the extent of the eyelid’s stability on the eye and the range of the tip of the eye socket.
Figure 3: Using the surgical hook to lift the tip of the eyelid from the side of the lower eyelashes and using the needle with a pointed tip, which is the first step in the surgical opening procedure.
In this step, the doctor inserts the pointed needle into the mucous membrane of the eyelid and determines the available distance to the bones of the eye cavity.
Figure 4: The process of performing the surgical stitch intended to fix the eyelid and prevent it from moving during the surgical opening. In this step, the doctor uses a thin tool with a cotton tip to straighten the place of the surgical opening by expanding the eyelid with the two tension hooks.
Figure 5: Using a metal traction tool to expose the inner eyelid mucosa during the incisional procedure.
Figure 6: After the lift procedure by means of the metal tool, the internal fat is exposed in the lower eyelid, allowing the surgeon to determine how it is distributed, the ability of this fat to be removed, and its association with the circular eye muscle that separates the middle fat from the central fat.
Based on this practical evaluation, the surgeon removes fat from the middle or both sides of the eyelid, according to the supposed aesthetic appearance and based on the available skin area.
Figure 7: This figure shows how to remove midsection fat through clear fat cysts by microsurgical forceps without subjecting the lateral fat to excision.
Figure 8: The method of grasping the excess skin in the lower eyelid to determine the amount of tissue to be removed, which is a step that takes place before drawing lines to determine the skin to be removed.
Figure 9: Removal of excess skin with surgical forceps after locating the target area with a scalpel.
The history of the operation and the extent of its development
The history of eyelid surgery dates back to more than 2000 years ago when the Indian surgeon Sasruta described the primitive operation in his book “Jami Ma’rif Sasruta”, in which he provides a description of the surgical instruments and more than 300 operations and their classifications.
Then, Arab scientists in the tenth century AD performed cauterization of the eyelid tissue in safe surgical ways to give a more youthful appearance to the upper and lower eyelid areas that suffer from swelling and sagging tissue.
In the early 19th century, several physicians described how to remove excess skin from the eyelids, and in 1818 von Graffey coined the term blepharoplasty . Based on all previous contributions, Costa Neres developed a detailed description of the anatomy of inner eyelid fat and how it accumulates, which is what is considered a modern eyelid lift.
The first eyelid fat removal using the muscular skin flap technique was performed by Sir Archibald Maclendo, a contemporary of Costa Neres. This technique has gained wide popularity due to its ability to separate fats in a safe manner.
In the 1970s, Furnas identified the antiaging properties of the lower eyelid, explaining the role of the circular muscle in this process. While the previous techniques focused on the role of these fats in concealing the aesthetic appearance of the eyelid, which affects the youth of the face, “Loeb” interpreted the role of fats, preserving them or transferring them, and not just removing them from the eyelid area.
The continuous increase in the popularity of surgical plastic surgery and the non-surgical procedures associated with it led to a change in the approaches and methods of performing these operations in the nineties of the last century. Surgeons have begun to use laser techniques and chemical skin restructuring in addition to these cosmetic procedures for lower eyelid lift, including the efficiency of the operation and the associated problems.
These studies revealed some of the negative consequences of classical techniques including the role of nerves and how these ancient procedures were damaging eye and eyelid nerves. These studies showed that exposure to violent eyelid skin tightening by traditional methods may lead to severing of the facial nerves and increase the spread of diseases in the face and cheeks area in particular, such as poor positioning and inversion of the eyelid.
In recent years, many lower eyelid plastic surgery techniques have been combined to arrive at a modern technique that is safer and more effective than previous techniques. Where the doctors combined the technique of removing fat and skin from the eyelid area with techniques to preserve this fat so that the eyelid and the surrounding areas do not get damaged over time.
This technique combined the method of removing excess skin and fat with the technique of bonding between the eyelids and cheeks, while avoiding exposure to the facial nerves and the circular muscle of the eye. In other words, the operation has become dependent on the removal of a quantity of fat and skin without removing the entire circular muscle of the eye and the nerves present in the surgical area, in proportion to maintaining the original eyelid position and not harming the eye’s vision device.
In addition, doctors have used autologous fat injection or hyaluronic filler to restore volume in areas that may accept this addition in difficult cases that do not accept modification. Doctors also investigated the extent to which eye vision was exposed to damage, tissue death, deformation of facial contours, and other operation problems that were present in previous techniques, and how to avoid them with modern technology.