Lower eyelid and midface rejuvenation.

Lower eyelid blepharoplasty is one of the most common procedures in aesthetic plastic surgery. Although patients desiring lower eyelid blepharoplasty typically describe their problem as "bags in the lower eyelids," there are many anatomical imperfections that should be assessed. With aging, the youthful single convexity of the lower lid separates into a double convexity with a valley at the intersection of the lower lid and midface. Midface descent further drags this intersection inferiorly, leading to a vertically lengthened lower eyelid. This article discusses how to clinically evaluate lower lid deformities, how to formulate a surgical plan, the preoperative assessment, and surgical markings. The rationale and anesthetic technique for outpatient versus in-office surgery is reviewed, and a detailed step-by-step approach with accompanying figures for lower lid blepharoplasty via a transconjunctival or transcutaneous incision is given. An approach to vertically supporting the lower eyelid is presented.