Historically, lower eyelid blepharoplasty has been a challenging surgery fraught with many potential complications, ranging from ocular irritation to full-blown lower eyelid malposition and a poor cosmetic outcome. The prevention of these complications requires a detailed knowledge of lower eyelid anatomy and a focused examination of the factors that may predispose to poor outcome. A thorough preoperative evaluation of lower eyelid skin, muscle, tone, laxity, fat prominence, tear trough deformity, and eyelid vector are critical for surgical planning. When these factors are analyzed appropriately, a natural and aesthetically pleasing outcome is more likely to occur. I have found that performing lower eyelid blepharoplasty in a bilamellar fashion (transconjunctivally to address fat prominence and transcutaneously for skin excision only), along with integrating contemporary concepts of volume preservation/augmentation, canthal eyelid support, and eyelid vector analysis, has been an integral part of successful surgery. In addition, this approach has significantly increased my confidence in attaining more consistent and reproducible results.
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