By: Robert Yoho, MD

Some of the latest approaches to lower eyelid surgery let Los Angeles cosmetic surgeons correct under-eye “bags” without any external incision at all, avoiding visible scarring and the problems associated with stitches. But is this approach really effective for all patients?

In general, I would say yes, for two reasons:

1. No Scarring / Faster Recovery

Most lower-lid “bags” are caused by enlarged pockets of fat between the “tear trough” and the lash line. In the old approach to lower eyelid surgery, a Los Angeles area cosmetic surgeon would remove the fat through an incision just below the eyelashes, then pull the skin back to remove the fatty patch. In the internal approach the surgeon removes the fat through a small incision inside the eyelid, directly behind the fatty patch. This approach is more direct and doesn’t require stitches, so most surgeons agree that it offers a number of advantages for the right patient.

2. Less Risk of Complications

The internal-approach incision poses significantly less risk of over-tightening the lid because of the lower risk of scar formation. An external incision poses increased risk of scar tissue forming at the incision site, which can pull the lid downward and allow the eye to dry out. With the inner-lid approach I am able to leave the orbital septum (the delicate membrane that tends to scar and tighten) intact. This reduces the risk of internal scarring.

3. Lax Skin Can Be Addressed Nonsurgically

Where I differ from some other surgeons is in recommending this approach for all lower-eyelid surgery patients. The internal-incision technique is extremely well suited for eyelid sagginess that results from fat, but in cases where loose skin complicates the problem, many cosmetic surgeons will recommend an external-incision approach as a way remove excess skin and fat at the same time.

For me, this argument doesn’t necessarily hold water, because the fact is that we have plenty of nonsurgical methods to address loose skin – laser treatments and injectables, to name two. Or, a little bit of skin can be clipped out below the lash line without entering the deeper structures – an approach which seldom leads to the lower lid “pulldown” that is common with the lower-lid incision used in the larger operation. While it’s true that enlarged orbital fat is not always an issue, in cases where it is part of the problem, it should be approached in the way that’s most effective and comfortable for the patient.

When a person comes to my office presenting with both loose eyelid skin and periorbital fat, the internal approach allows for practically immediate laser or injection treatments, so instead of having to wait a few weeks while their stitches heal, the patient can enjoy much faster skin tightening without the risks of extra surgery.

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