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Aging of the Lower Eyelid

You may not think of your lower eyelid very often, but it’s an integral part of maintaining a youthful appearance. The youthful lower eyelid is described as having smooth and firm skin, a smooth contour as it transitions to the cheek, lacks shadows or hollows and has a short distance between the eyelash (top of the lower eyelid) to the top of the cheek—this is called the eyelid–cheek junction, which is characteristically short in young eyes. Fat pads lay over the lower or-bital rim, which creates a soft fullness under the eyelid as it transitions to the cheeks. The upper cheeks are characteristically full and convex, supporting the lower eyelid position. All of these characteristics define a youthful, refreshed–looking lower eyelid.

Starting in the late 30s and early 40s, the lower eyelid region is one of the first parts of the face to show the signs of aging. The development of loose skin (dermatochalasis), bulging fat pads or “bags” (pseudoherniation of fat), skeletonization of the lower orbital rim and elongation of the eyelid-cheek junction are the changes that result in the tired, hollowed and aged lower eyelid.

We can not talk about the lower eyelid aging process and its subsequent rejuvenation without mentioning the importance and ubiquitous loss of the fat surrounding the lower eyelid. The malar fat pad and SOOF (subobicularis oculi fat pad) begins to diminish with age, leading to the outline of the bony lower orbital rim and tear trough deformity. The loss of the fat pads in the upper cheek cause a deflated, sallow look that leaves the eyes looking tired, less healthy and drawn.

Is Rejuvenation of the Lower Eyelid Region Right for Me?

Rejuvenation of the Lower Eyelid Region could be your best option if you’re looking to:

  • Eliminate bags under the eyes
  • Eradicate sagging around the eyes
  • Restore a youthful and natural–looking appearance
  • Revive fullness and volume around the eyes

Advantages of Lower Eyelid Rejuvenation

  • Natural–looking
  • Truly refreshed appearance
  • No change to shape of the eye
  • Consistency and reliability
  • Low complication rate
  • Long–lasting results (10+ years)
  • Performed under local anesthesia with IV sedation; no need for general anesthesia
  • Two week downtime
  • Ideal balance between excellent and natural results, low risk and brief recovery

Complementary Combinations to Achieve a Comprehensive Rejuvenation

The goal of any lower eyelid procedure is to create a refreshed and youthful appearance. In nearly every case where there is excess skin or bulging fat effecting the lower eyelid, there is volume loss happening below the eyelid. The malar fat pads and cheek fat pads begin to diminish, causing the outline of the lower orbital rim to become prominent and skeletonized. The hollowing in the upper and middle cheek further give the eyes a deflated and tired look. The fat loss exacerbates the aging appearance of the lower eyelid. In nearly every case, replacement of the lost volume is essential to lower eyelid rejuvenation.

Fat Transfer This is a treatment that complements our surgical procedures and is done with essentially every rejuvenation case (approximately 350 cases per year). This results in long–lasting and natural volume restoration.

Adding volume is the most effective and important way of rejuvenating the eyes. Without it, the skin and sagging may look better, but the eyes will never have that refreshed and youthful look.

Skin Resurfacing The skin can often look crepey, thin, and wrinkled. In these cases, a chemical peel using a Jessner’s/35% TCA or erbium:YAG laser resurfacing can eliminate these surface changes and create a smooth lower eyelid skin appearance.

Procedures and Anesthesia

Perhaps one of the biggest advantages from a safety standpoint is that these procedures can be performed under local anesthesia with IV sedation. With this technique, patients are comfortable, moderately sedated and without any discomfort. Most patients choose this method to avoid any of the risks associated with general anesthesia. For those patients who do prefer general anesthesia, our facility is fully–equipped for general anesthesia.

Procedures are performed in our accredited and certified (JCAHO and Medicare) surgical center, Carmel Valley Surgical Center, located within the suite. The center offers the highest level of safety and state regulations for outpatient surgery. Highly–trained and experienced surgical techs, medical assistants, nurses and a Board Certified Anesthesiologist (for general anesthesia cases) all work together to create the safest and most comfortable experience possible. Carmel Valley Surgical Center hosts two state–of–the–art surgical suites and a recovery center. The rooms are equipped with only the best equipment and instruments, and the center also has a separate entrance and exit from the main office, which allows our patients to undergo procedures in privacy. Your comfort is always our priority during these surgical procedures.

Post-procedure care

Following surgery, ointment is applied to the incisions. Patients return to the comfort of their home or hotel room. A cool compress is used to reduce swelling for the first two days following surgery. Lubricating drops are used during the day and ointment is used at night to help keep the eyes moist and protected from drying. Antibiotic ointment is used on the incisions for one week. At one week, sutures are removed in the office. At this point, swelling is starting to resolve rapidly. Follow–up appointments are made at one month, three months, six months and one year to monitor healing and make sure all questions are answered.


Recovery is primarily related to swelling. Bruising is not commonly seen in our patients, although it is a possibility. The typical recovery takes between 7–14 days, depending on the combination. We recommend planning two weeks off of work or social engagements to allow sufficient time to heal. Although healing is not completely finished by two weeks, most patients are sufficiently healed and can return to work and other social occasions. Minor swelling continues to improve steadily for up to one year following the procedure. Exercise is resumed between two to four weeks following surgery, depending on the nature of the activity and the degree of swelling involved.

What to expect: results

There are a variety of positive results you can expect from your Lower Eyelid Rejuvenation, including:

  • Restored youthful, bright–eyed appearance
  • Natural–looking fullness and volume around the eyes
  • Elimination of bags and dark circles under the eyes
  • Eradication of excess skin around the eyes

Why choose Dr. Karam for your lower eyelid rejuvenation?

An average Board Certified Plastic Surgeon performs approximately 20 eyelid procedures annually. Dr. Karam, on the other hand, performs over 350 every year. Extensive experience translates to more natural results, more consistency and less variability, plus a distinct knowledge of different ethnicities and facial types and how to change the techniques to best suit the particular facial structure. Dr. Karam’s careful and intentional approach ensures that no one changes their identity, but simply looks refreshed and youthful.

Dr. Karam’s comprehensive technique, which involves combining these procedures with others, results in synergistic effects. The entire face looks naturally and vibrantly youthful, rather than hosting a single, unnatural element. In his textbook, Rejuvenation of the Aging Face, Dr. Karam describes his approach to facial rejuvenation and eye rejuvenation in order to teach the ingenious techniques to other surgeons and colleagues. Dr. Karam’s expertise in the subject has also prompted him to write a number of book chapters and scientific articles on facial plastic surgery topics, including upper and lower eyelid blepharoplasty, fat transfer and rejuvenation of ethnic–specific (for example, Asian) groups. And perhaps most importantly, Dr. Karam’s caring demeanor, good patient communication skills and responsive and knowledgeable staff ensure you’re always comfortable and informed. It’s these particular attributes that have earned Dr. Karam the trust to perform these procedures on his medical colleagues and their families.

Planning your consultation

During the consultation, your expectations will be discussed and a personalized treatment plan will be proposed after careful examination and discussion of your goals. The basic criteria for timing of this procedure is dependent on two factors: first, whether there is enough sagging and deflation to justify the procedure, and the patient’s readiness to move forward. The average patient defines the changes seen in their 40s as a point where comprehensive eye rejuvenation would make a positive difference. In general, the earlier the better. The advantages of performing the surgery sooner are that the changes are less dramatic and more subtle, and the results last longer. More and more patients are utilizing these procedures as a way to maintain their appearance and prevent aging.

Before & After

Dr. Karam, who is board certified by the American Board of Facial Plastic and Reconstructive Surgery and American Board of Otolaryngology, offers services in San Diego County including San Diego, Del Mar, Carlsbad, Carmel Valley, Encinitas, Rancho Bernardo and La Jolla in Southern California.

If you are ready to schedule an appointment with Dr. Karam, contact us today.

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