There are 3 main factors of environmentally induced periocular aging change:
1. photo aging
2. gravitational force
3. facial expression
Aging change under the eye and occur mostly from gravitational force. On the lower eyelid, changes can be evidenced as baggy eyelid and double convexity deformity.
1. Baggy eyelids are caused by prolapse of orbital fat pad.
With aging, the orbital septum stretches, bulges, or dehisces, allowing fat to prolapse anteriorly. Lower eyelid orbital fat pad volume also increase with age make baggy eyelid more prominent.
Baggy eyelid can be managed by lower blepharoplasty. Repositioning and occasional excision of bulging fat are the main step of the lower eyelid blepharoplasty.
Transcutaneous approach was traditionally used but the transconjunctival approach is now preferred by most cosmetic surgeons. In the transconjunctival approach, there is less likely to be complications, such as eyelid retraction. Additionally, no skin scarring is another advantage of the transconjunctival approach.
2. Double convexity deformity is the combination of baggy eyelid and descending midface.
Drooping malar fat pad produce the skeletonization of the inferior orbital rim. Hollowness of the inferior orbital rim between prominence baggy eyelid fat and bulge of descending malar fat develops deep orbital sulcus called double convexity deformity.
Lysis of orbitomalar ligament and midface lift can be performed concurrently with lower blepharoplasty. Orbital fat transposition or liposuction with fat injection procedure will alleviate deep orbital sulcus and smoothen lower lid-cheek junction area.
What is lower blepharoplasty
Lower blepharoplasty is the operation to correct mid-face aging. There are 2 type of surgical approach
Transcutaneous approach: through skin
Transconjunctival approach: through conjunctiva
How can baggy eyelid be correct without skin incision?
Old way lower blepharoplasty focus only on remove the excessive fat under the eye but current concept of surgery including correction of under eye circle by cutting the orbitomalar ligament and re-position the under eye fat to create uniformly round midface. This new technique is prove to be better, last longer and can be perform through conjunctiva with no skin incision.
Transconjuctival approach not only benefit cosmetic concern of the patient but also cause less complication namely eyelid retraction and ectropion after the operation. Only limitation of this approach is it is a more difficult technique with steep learning curve for non-experience surgeon.
Example cases of transconjunctival approach lower blepharoplasty: before and after operation
Figure show orbitomalar ligament which cause baggy eyelid
Surgical technique of fat transposition to prevent recurrent of baggy eyelid