It sounds like you have done a fair amount of research, and I think this is very important when it comes to the area of lower lid rejuvenation. There are many ways to rejuvenate the lower lid, and you will receive many different opinions. The most important thing is to understand why your surgeon is performing his/her technique that particular way.
The two basic variations, as you may know, are to address the lower lid blepharoplasty from an external subciliary approach or from a transconjunctival approach. There is a risk of ectropion when approaching from the external aspect due to the violation of the orbital septum, as mentioned. This is especially important in the face of thin skin or poor lower lid tone. One important part of the examination is to address the lower lid tone by performing a “snap-back” test: the lower lid is pulled from the globe of the eye, and the time for the relapse of the lid back to the globe is assessed. If it is, for example, greater than 2 sec., there is a greater risk of ectropion. In these situations, the surgeon may opt for a transconjunctival approach. If the surgeon opts for an external subciliary approach, he/she may supplement the procedure with a canthapexy or canthoplasty (a strengthening procedure at the lateral canthus of the eye to help prevent ectropion). Sometimes these supplemental procedures can slightly effect the lateral corner of the eye or the shape of the lower lid.
If I am performing a transconjunctival blepharoplasty (removing the fat through the inner aspect of the eyelid), I will commonly supplement this with a skin pinch blepharoplasty. The skin pinch incision is normally placed slightly lower than the subciliary incision, and it removes only skin. This lowers the risk of any scarring upon the orbital septum (ectropion). In certain situations, this may be a safer approach than the external subciliary approach which does violate the orbital septum to remove the fat. Keep in mind, that even with a transconjunctival blepharoplasty, you can also perform a lateral canthopexy/plasty to support the lower lid tone.
Finally, with the advent of fillers, a non-surgical approach to lower lid rejuvantion is using products such as Juvederm or Restylane to fill in the “groove” of the lower lid.
Having a detailed discussion with your surgeon regarding all of the options, risk, and benefits will help clarify what procedure will best rejuvenate your lower lid.
Edward Park, M.D.
Board Certified by the American Board of Plastic Surgery