Lower Lid Love

by Ann Jayaram, MD
Mar 16th, 2017

Many people have issues with the appearance of their lower lids.  However, because each problem is unique, there must be a personalized approach to addressing lower lids, and this is usually best done through an in person consultation with your eyelid surgeon.

First, let’s take a look at the most common lower lid problem in younger patients—the dark circle.

Most commonly in patients under 40, the true problem with the under eye area is dark circles. The unfortunate truth about dark circles is that there is no surgical cure all.  Why do we get them? The most common reason is lack of sleep, however other etiologies include heredity, thinning of skin as we age, allergies causing the dilation of blood vessels, excessive eye rubbing or inflammation, eczema or other skin disorders, iron deficiency leading to insufficiently oxygenized blood, crying, and excessive smoking, drinking, caffeine, or drug abuse.

The best and most effective way to combat under-eye pigmentation is an effective concealing regimen.  When dark circles are severe enough, a simple coat of concealer isn’t enough.  The perfect under-eye regimen consists of an eye moisturizing cream, a color corrector to offset the undesired pigment, a concealer, and a skin brightener to top it all off. Yep, it’s a commitment, but this regimen is sure to make a difference.  Here are the products I have come to love for myself.

  1. Eye cream: Clinique All About Eyes Rich, $32
  2. Color corrector: Becca Backlight Targeted Color Corrector ,$30
  3. ConcealerMaybelline Instant Age Rewind Eraser, $7.99
  4. Eye brightener: Becca Undereye Brightening Corrector, $30

If dark circles plague you, you will likely always need a lid regimen like the one detailed above, coupled with getting enough sleep, drinking enough water, and making sure you address any underlying skin problems.

Half the battle with dark circles is combating the shadowing that contour abnormalities can cause.  Sometimes, a small amount of strategically placed filler (ex: Restylane or Juvederm) in the tear troughs may also help. Evening out the peaks and troughs of the lower lid with filler and remove these contour abnormalities and get rid of those shadows, producing a brighter, more luminous effect.

Maybe your lower lids aren’t dark, but rather puffy…or something like that.

Well this is not as easy to assess as you may think. Are they puffy? Is there a true lower lid bag? Or is that part of your lower lid normal and the surrounding area is actually just hollow?  These are questions that an in person physical evaluation is usually necessary to answer.

How does your doctor tell?  You aren’t really able to examine your lower lids during upgaze, but luckily your surgeon can.  Oftentimes, when you look up, the movement of the eyeball muscles will cause a true fat bag to protrude, indicating that someone is a good candidate for a lower lid blepharoplasty.

A true “lower lid bag” is simply lower eyelid fat that has prolapsed through the orbital septum, which is the thin, film-like structure that is intended to hold the contents of the orbit—including orbital fat—back in place. As we age this structure gets weaker and thinner, and fat is more likely to prolapse through.  This is an extremely common problem in women in their 50’s and above, however can happen at a younger age when hereditary factors are at play.

Lower lid blepharoplasty (lower eye lift) is a surgery in which the surgeon makes either an external incision just below the lower eyelid margin or chooses to flip the lower eyelid and make the incision on the inside moist surface of the lower eyelid called the conjunctiva to avoid scar formation. In either case, the septum is opened, the fat is identified and trimmed/cut/sculpted till desired. Often times, surgeons will also talk about fat repositioning or fat transfer.  This refers to an attempt to remove the fat from behind the septum and place it in another location, most often draped over the inferior orbital rim in order to fill out some of the lower lid hollow areas.  To address hollow areas post surgery, some surgeons choose to add a bit of filler to the lower lid tear trough area, to achieve the perfect result of sculpted fat bag and filled trough hollowing.

Maybe you don’t have true lower lid fat bags. What else can cause lower lid fullness?

A common finding in the lower lid is a “hypertrophied orbicularis” or a particularly robust lower eyelid muscle. If this is the case, it is essential to differentiate this from a true fat bag, because lower lid blepharoplasty will not fix this!  A fat bag will usually be inferior to or below a hypertrophied orbicularis, which is one common way of telling these two conditions apart. Unfortunately there is no great fix to a hypertrophied orbicularis, because excising some of that muscle often leads to scarring between overlying skin and underlying structures. In this case, a small amount of lower lid filler can improve the contour and make patients happy. Of note, filler in this area usually lasts about 1-2 years, so can be a really good investment.

Are there any other conditions that can affect the lower lids?

One of the more common other problems in the lower eyelids is eyelid laxity or looseness.  With aging, we lose the elasticity of our skin, and the lids don’t appear as tight anymore.  This can also be secondary to constant tugging from contact lens placement, rubbing from irritation or allergies, or trauma.  There is a surgical correction for this—one can have a lower lid tightening procedure called a canthopexy.  In this procedure, the eyelid is disinherited from the orbital bone and reattached at a tighter position. It is usually a quick 30 minute procedure, however you should know that this procedure can cause a few months of swelling and inflammation at the surgical site. While this usually subsides and produces a nice cosmetic result, it is important to factor in a few months of healing for this procedure.

If you are unhappy with the look of your lids in any way, have a consultation with your eyelid plastic surgeon—chances are, there is a personalized and unique solution that can solve your problems!



Ann Jayaram, MD is a a Bay Area Oculoplastic Surgeon specializing in upper and lower lid blepharoplasty, botox, and filler injectables. She is also a board certified ophthalmologist. She practices in Menlo Park, CA, and in her spare time enjoys good views and great wine.


Original artwork © Chedly Bouzouaya redrawn for Prime Journal; Available at: https://www.prime-journal.com/mini-incision-lower-eyelid-blepharoplasty/

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