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Lower lid bleph

Dr. Zoumalan is an eyelid plastic surgeon and exclusively performs cosmetic eyelid surgery. Every patient that he examines for cosmetic eyelid surgery presents with variations in eyelid aging, and each surgery has to be customized and tailored to that specific patient.

When evaluating each patient, Dr. Zoumalan examines for the following

Amount of excess lower lid fat (also termed ‘prominent orbital fat’). Excess fat will likely have to be removed in order to rejuvenate the lower lid’s appearance. The type of surgery that Dr. Zoumalan performs to remove the excess lower lid fat is called a lower lid blepharoplasty.
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Excess lower lid fat pockets
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Notice the improvement after removal of lower lid fat pockets through a lower lid blepharoplasty.

Volume loss along the lower lid and cheek area. Volume loss appears as hollowing, which is usually seen along the infraorbital rim, which is the bone below the lower eyelids. This hollowing is located below where the prominent lower lid fat occurs.

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This is a patient with BOTH prominent lower lid orbital fat and infraorbital rim hollowing. Black dotted line denotes the infraorbital rim. Prominent fat pockets are seen above that. Double asterisks denote the “tear trough deformity,” and single asterisk denotes the “lid-cheek junction.”Both the tear trough and the lid-cheek junction are part of the infraorbital rim.

Patients that have both excess lower lid fat AND hollowing along the infraorbital rim can benefit from a lower lid blepharoplasty with fat repositioning.

Amount of excess skin. In addition to remove excess lower lid fat pockets, lower lid blepharoplasty should also address the excess lower lid skin. Some patients may have mild excess skin which often ablative resurfacing through a chemical peel or laser resurfacing can help tighten the skin and improve the appearance. Patients that have significant amount of skin will likely require excision of the skin through either a skin pinch or a skin-muscle flap blepharoplasty approach. Dr. Zoumalan will examine you and determine what you are a best candidate for.

Transconjunctival versus transcutaneous lower lid blepharoplasty

Dr. Zoumalan performs his lower lid blepharoplasty through either a transconjunctival approach OR a transcutaneous approach. Dr. Zoumalan will perform a complete Oculoplastic examination and determine what approach will better serve you and your surgery goals.

Transconjunctival blepharoplasty:

This is an advanced scarless technique that Dr. Zoumalan uses in many of his patients. The incision is carefully made inside the lower lid so that the skin is not directly cut and hence no visible scars. The transconjunctival approach allows for direct access to the prominent fat pockets. Excess fat pockets can be removed or repositioned through this approach. Fat pockets are removed through heat-induced sculpting while repositioning actually involves moving the excess fat to help fill in the under eye hollows that people have with aging. Dr. Zoumalan will determine if you are a candidate for fat repositioning.

The fine wrinkles or excess skin cannot be improved with a transconjunctival procedure alone; usually Dr. Zoumalan will recommend either a chemical peel or a laser to help improve the fine wrinkles or excess skin underneath the eyes. Both are effective and can provide a tightening effect to the skin and also help reduce the fine wrinkles. Either laser or a chemical peel can be applied to the lower lids at the same of your transconjunctival lower lid blepharoplasty. Botox can also be used to relax the crow’s feet in the corners of the lids which laser or chemical peel cannot treat.

Transcutaneous blepharoplasty:
This is a well-described lower lid cosmetic surgery procedure, which involves directly removing excess lower lid skin at the same time as removing excess fat. A transcutaneous blepharoplasty is performed in cases where there is excess skin and weakened muscle in the lower lids that a chemical peel or a laser alone may not adequately treat. Excess fat pockets can still be removed or repositioned with this procedure

This procedure not only rejuvenates the lower lids by removing the puffiness and dark circles, but can also help tighten the lower lid muscle and skin where a laser or chemical may not do as well. Dr. Zoumalan is well regarded as an expert in the skin muscle flap blepharoplasty, which is an advanced, minimally invasive transcutaneous technique that tightens the excess skin and underlying weak muscle. Dr. Zoumalan will examine you and determine if you are a candidate for this procedure. Dr. Zoumalan has published his latest findings in advanced lower lid blepharoplasty and continues to speak at conferences about his expertise in this topic.

Fat repositioning
Fat repositioning is a technique that Dr. Zoumalan performs in patients that have BOTH excess lower lid fat pockets and hollowing along the infraorbital rim. The excess fat pockets are identified at the time of surgery and carefully prepared as fat pedicles. They are then trimmed to the desire size and repositioned into the areas along the infraorbital rim where hollowing is noted.Fat repositioning allows for a more natural looking appearance while preserving the patient’s volume during surgery. Fat repositioning can help prevent hollowing after lower lid blepharoplasty. However, some patients may still have hollowing despite lower lid fat repositioning, and in that case, Dr. Zoumalan will recommend if you may need further procedures such as injectable fillers to better improve the hollowing after surgery. The injectable fillers that Dr. Zoumalan uses around the eyelid area are composed of hyaluronic acid and can be performed in the office using topical numbing cream.

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This figure shows two fat pedicles that are repositioned along the infraorbital rim to fill in the hollowing. The white line is the infraorbital rim. The arrows along the fat pads show the direction of where the fat pockets are directed.

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This is a side view illustration of how the fat pocket is repositioned to fill in the hollowing. This is all done without an open direct incision and through an incision that is not visible.

Combined cosmetic procedures
Eyelid surgeries and Brow lifting procedures

A lower lid blepharoplasty can be performed with other cosmetic surgeries at the same time. The most common combined procedure with a lower lid blepharoplasty is an upper lid blepharoplasty, where excess skin and fat pockets in the upper lid are removed. Dr. Zoumalan commonly performs both procedures at the same setting. Endoscopic brow lift or a temporal-based brow lift can also be performed at the same time to help rejuvenate the brows in patients that have droopy and low set eyebrows.

Other combined surgeries with other specialty plastic surgeons
Dr. Zoumalan routinely works with his colleagues in combined cosmetic surgeries to help achieve his patients’ comprehensive cosmetic goals. If you desire to undergo other cosmetic surgeries to be performed at the same time as your lower lid blepharoplasty such as Rhinoplasty, Facelift, Necklift, Breast or Body work, Dr. Zoumalan and his staff will help you in achieving your goals. Dr. Zoumalan exclusively performs eyelid surgery, but he works with a multi-specialty plastic surgery team comprised of board-certified plastic surgeons and facial plastic surgeons, which all together can help address your cosmetic needs.

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    Procedure performed:Lower lid fat prolapse.

  • pre-brow-lift-face-lift-blepharoplasty

    Preoperative diagnosis:Upper and lower lid dermatochalasia, upper lid mild ptosis, mild upper lid ptosis, facial aging, and lower lid fat prolapse.

    Procedure performed:Upper and lower lid blepharoplasty and periorbital fat grafting, ptosis repair. Deep plane face lift (facialplasty), brow lift, and periorbital fat and facial fat grafting performed by Dr. Richard Zoumalan.

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    Preoperative diagnosis: Mild upper lid excess skin, lower lid fat prolapse.

    Procedure performed:Upper and lower lid blepharoplasty, periorbital and lower lid fat grafting.

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    Preoperative diagnosis: Bilateral upper lid mild ptosis, upper and lower lid dermatochalasia (excess skin) and fat prolapse.

    Procedure performed:Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty, periorbital and lower lid fat grafting.

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    Preoperative diagnosis: Upper lid excess skin and lid ptosis (droopy lid)resulting in difficulty seeing well and a tired appearance, lower lid bags and excess skin.

    Procedure performed:Bilateral upper lid blepharoplasty, upper lid ptosis repair, and lower lid blepharoplasty.

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    Preoperative diagnosis: Bilateral upper lid and brow ptosis, upper and lower lid dermatochalasia (excess skin) and fat prolapse.

    Procedure performed:Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty, and upper lid external browpexy.

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    Preoperative diagnosis above: Upper lid ptosis and upper and lower lid dermatochalasia.

    Procedure performed:Upper lid ptosis repair, upper lid blepharoplasty and lower lid blepharoplasty using a lower lid orbicularis suspension flap (skin-muscle flap) technique. Note how well the scars have healed. They are virtually undetectable even four months out from surgery.

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    Preoperative diagnosis: Upper and lower lid dermatochalasia and lower lid fat prolapse.

    Procedure performed:Upper and lower lid blepharoplasty and periorbital fat grafting. Deep plane face lift (facialplasty) and periorbital fat and facial fat grafting performed by Dr. Richard Zoumalan.

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    Preoperative diagnosis: Bilateral upper lid ptosis, upper and lower lid dermatochalasia (excess skin) and fat prolapse.

    Procedure performed:Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty, lower lid chemical peel (TCA 30%).

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    Preoperative diagnosis: Bilateral upper lid ptosis, upper and lower lid dermatochalasia (excess skin) and fat prolapse.

    Procedure performed:Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty, lower lid chemical peel (TCA 30%).

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    Preoperative diagnosis: Bilateral upper lid ptosis, upper and lower lid dermatochalasia (excess skin) and fat prolapse.

    Procedure performed:Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty, lower lid chemical peel (TCA 30%).

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    Preoperative diagnosis:Bilateral upper lid ptosis, upper and lower lid dermatochalasia (excess skin) and fat prolapse.

    Procedure performed:Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty, lower lid chemical peel (TCA 30%).

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    Preoperative diagnosis:Bilateral upper lid ptosis and brow ptosis, lower lid excess fat pockets.

    Procedure performed:Bilateral upper lid ptosis repair (blepharoplasty) and external browpexy, lower lid blepharoplasty.

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    Preoperative diagnosis:Bilateral upper and lower lid excess skin, lower lid aging changes with excess fat pockets.

    Procedure performed:Bilateral upper lid ptosis repair (blepharoplasty), lower lid blepharoplasty with fat repositioning, chemical peel to lower lids.

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    Preoperative diagnosis: Bilateral upper and lower lid aging changes

    Procedure performed: Bilateral upper and lower lid blepharoplasty, chemical peel to lower lids.

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    Preoperative diagnosis: Bilateral upper lid ptosis, lower lid retraction, lower lid excess fat pockets.

    Procedure performed: Bilateral upper lid ptosis repair, lower lid retraction repair using Alloderm graft and canthoplasty, and lower lid blepharoplasty.

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    Preoperative diagnosis: Bilateral upper lid ptosis and brow ptosis, lower lid excess fat pockets

    Procedure performed: Bilateral upper lid ptosis repair, upper and lower lid blepharoplasty with fat repositioning to lower lids, and left external brow pexy

Lower lid blepharoplasty Recovery

IMMEDIATELY AFTER

You will have some early bruising and swelling in the lower lids. Soreness and some discomfort is normal; the doctor should be notified if you experience sudden or severe pain. It is important for you to immediately start icing after surgery to help with the svvelling and bruising

1 WEEK

If you have any stitches, they usually are removed by the doctor at your one-week post surgery visit. You should start to see your swelling and brusing improving by now.

2 TO 3 WEEKS

Majority of your swelling and bruising improves by the second or third week after surgery. You can start putting on makeup at this time and also start wearing contact lenses so long as the doctor has cleared you to do so. You can also start resuming your normal day to day activities usually by two weeks.

1 MONTH TO 6 WEEKS

Most if not all your swelling should be improving by this time and you should start seeing the final result of your procedure.

What do we usually see with aging eyelids?
Excess fat pockets occur as a result of herniated fat pockets. They result in the appearance of having under eye bags or dark circles. Excess skin or wrinkles are also commonly seen. Volume loss around the eyelids can also result in a hollowing effect. All these can be addressed with lower lid surgery. You and Dr. Zoumalan will sit down and go over your wishes and desires. Dr. Zoumalan will then perform an in-depth eyelid examination and determine the best recommendation for you that fits your desires, the doctor’s goals, while maintaining a natural and rejuvenated result.

How does Dr. Zoumalan perform his lower lid cosmetic surgeries?
There are several advanced surgical techniques that Dr. Zoumalan uses to effectively rejuvenate the lower lids. After a careful and thorough examination, Dr. Zoumalan will recommend you the best option that fits your desires and your eyelid and facial appearance. Dr. Zoumalan uses the latest techniques to promote rapid recovery.

Where is the incision made in the lower lids if I need a transcutaneous bleopharoplasty?
Dr. Zoumalan makes a hairline incision right below your eyelashes and will carefully close the wound using very fine sutures which are removed usually in 5-6 days. The incision heals very well since it is right below the eyelashes. The corner incision is tucked into your crows feet and heals within your natural crow’s feet.

Can fat grafting or injectables be performed at the same time of my lower lid surgery?
Not only do we gain excess fat and skin in the eyelids with aging, but we lose volume (fat) in the midface area–which is right below the eyelid. This can often result in a hollowing effect of the lower lid that surgery alone may not help. During your consultation with Dr. Zoumalan, he will examine your midface and rest of your face in order to determine if you require volume augmentation in addition to lower lid surgery. Fat grafting or hyaluronic acid fillers (facial fillers) can be used for volume augmentation. The midface area can often have a loss of volume and worsen the lower lid dark circles. Oftentimes, moving (or repositioning) the excess fat to fill in some of the hollowing can help but oftentimes the doctor will recommend injectable fillers. Injectable fillers can either be fat grafting which is taken from your belly fat or hyaluronic acid fillers (such as Restylane or Juvederm). Dr. Zoumalan will go over these options with you and determine what you will be the best candidate for.

Why choose Dr. Zoumalan?
Dr. Zoumalan is a board certified Oculoplastic Surgeon that exclusively performs eyelid surgery. He is one of a handful of surgeons in the country with this level of expertise. Dr. Zoumalan has presented his techniques at conferences and published his latest findings in advanced cosmetic eyelid surgery in the most prestigious journals of plastic surgery. Dr. Zoumalan also teaches his advanced techniques to young doctors undergoing their surgical training at the Keck School of Medicine of USC.