10.4.1 Relevant Anatomy

The lower eyelid consists of seven layers (Fig. 10‑2), the composition of which depends on the level within the eyelid. From anterior to posterior, these are skin, orbicularis oculi muscle, orbital septum, orbital fat, lower eyelid retractors, tarsus, and conjunctiva. Near the orbital rim, all layers are present except for tarsus. More superiorly, the septum and retractors condense and insert into the tarsus. There is no orbital fat present above this condensation. Moving more superiorly, near the eyelid margin, only skin, orbicularis, tarsus, and conjunctiva are present.

The lower eyelid skin, like the upper eyelid skin, is the thinnest skin of the body. With age, it loses elasticity. The orbicularis oculi is the primary eyelid protractor. It is a circumferentially oriented muscle that is responsible for voluntary and involuntary eyelid closure. The orbital septum is a thin, but firm, connective tissue, which originates from the arcus marginalis at the inferior orbital rim and combines with the capsulopalpebral fascia just inferior to the tarsus such that they insert together onto the inferior tarsal border. It is an important landmark, in that it separates the anterior eyelid structures from the posterior orbital structures. Orbital fat lies just posterior to the septum, and is divided into three distinct fat pads (Fig. 10‑3, Fig. 10‑4). The medial and central pads are divided by the inferior oblique muscle, whereas the central and lateral pads are divided by the same muscle’s arcuate expansion. Posterior to the orbital fat are the eyelid retractors: the capsulopalpebral fascia, which is analogous to the levator palpebrae superioris in the upper eyelid, and the sympathetically innervated inferior tarsal muscle, which is analogous to Müller muscle in the upper eyelid. The tarsus is a dense connective tissue that confers structural support to the eyelid, and the most posterior layer is the conjunctiva, which is contiguous with the conjunctiva of the globe itself.

10.4.2 Indications

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  Specific indications:

  
  
  
  
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    Herniation of orbital fat (“bags” under the eyes).

    
    
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    Excess or sagging lower eyelid skin.

    
    
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    Descent of the mid-face tissues (Fig. 10‑5).

  
  
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  Overarching considerations:

  
  
  
  
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    Patient should desire aesthetic enhancement or rejuvenation of the lower eyelids.

    
    
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    Patient and surgeon should agree on intended aesthetic outcome.

    
    
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    Surgeon must reasonably believe that the intended outcome may be achieved surgically.

    

10.4.3 Contraindications

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  Absolute contraindications:

  
  
  
  
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    Patients with unrealistic expectations:

    
    
    
    
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      The only true measure of success in a cosmetic procedure is the patient’s satisfaction.

      
      
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      Failure to align patient and surgeon views of an optimal result preoperatively virtually guarantees an unhappy postoperative patient.

  
  
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  Relative contraindications:

  
  
  
  
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    Overly picky, demanding, critical, or particular patient:

    
    
    
    
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      Extreme care should be taken preoperatively to review goals, risks, and plan for addressing postoperative dissatisfaction.

    
    
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    High bleeding risk (intrinsic coagulopathy, patient in whom it is unsafe to discontinue anticoagulation):

    
    
    
    
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      Given the potentially devastating consequences of intraorbital hemorrhage, caution should be exercised in these patients.

10.5.1 Operative Setting

The procedure may be performed in an ambulatory surgery center or in the office setting. It is important to note, however, that manipulation of fat is painful, and as such, discretion in patient selection is advised if choosing the office setting, with careful attention to both the personality of the patient and the intended surgical plan. If fat repositioning is to be employed, an ambulatory surgery center is recommended. If the office setting is chosen, the surgeon should consider preoperative treatment with oral pain medication and anti-anxiolytic agents.