Consultation and Physical Exam


We have outlined below what you can expect from your lower eyelid surgery consultation. Read carefully, as there are many suggestions that will save you time, clear up questions, and help you convey to Joseph T Cruise, MD what it is you want to accomplish.

Health History

All cosmetic surgery consultations begin with a thorough health history. This is especially true if general anesthesia is being used but also applies to local anesthesia. Prior to meeting with the plastic surgeon you will be given a health history questionnaire. There are five areas of your health you will be asked about. Be sure to answer it with detail so that your surgery and anesthesia can be optimized for you.

General Health

General health problems are important to discuss so that your surgery is as safe as possible. Be sure to mention any chronic illness. Of particular concern are high blood pressure, diabetes, heart problems, liver and kidney disease, stroke, cancer, bleeding problems, and wound healing problems.

What if I Have Medical Problem?

In short, he will make sure your health is optimized as much as possible to ensure your safety. This may mean referring you to your private physician.

If you have a health problem or are over 60 years of age you can often save yourself time by getting a letter from your private physician prior to your cosmetic consultation stating what the problem is, how it is being treated, and whether or not you are able to tolerate general anesthesia safely.

If you are seeing any specialist (cardiologist, kidney doctor, psychiatrist, etc. ) be sure to bring a letter from them stating you are able to tolerate surgery.

If you are not able to tolerate general anesthesia it may be possible for your procedure to be done under local anesthesia. This must be discussed with your plastic surgeon. Often, lower eyelid surgery can be done under local.

Past Surgical History

On your questionnaire you will be asked about previous surgeries. Of particular concern are previous surgeries in the area that you wish to change. Be sure to identify any problems you may have had with anesthesia.


Be sure to list all medications including aspirin and over-the-counter medications. These are important as they may increase bleeding and affect your surgery. It is extremely important to stop taking aspirin and aspirin containing products at least 10 days before surgery. Tylenol is a good alternative. Here is a partial list of aspirin containing products and other products to be avoided prior to surgery.

Allergies to Medications

Information about medications that cause allergies is very important so that these medications can be avoided. Of particular importance is the reaction you had, especially if you had trouble breathing. Be sure to include this information! Nausea is not an allergy but it is important to mention as well.

Smoking, Drinking and Drug Use

These will certainly affect your surgery and MUST be mentioned so that your surgery can be optimized. Smoking causes a profound decrease in wound healing and will lead to worse scarring and a less favorable result. With large procedures such as a face lift, neck lift, tummy tuck, and breast lift smoking must be stopped at least 2-3 weeks before and after surgery. Otherwise, the results could be disastrous leading to non-healing wounds, poor scarring, and/or infection. With smaller procedures such as eyelid surgery, nose surgery, breast augmentation, and liposuction smoking will hurt the overall result but this may or may not be noticeable. In this case smoking cessation is strongly advised but is not mandatory.

Specific Eye Issues

During your consultation you must be very accurate with your eye problems. These include glaucoma, lazy eye, retinal problems, and cataracts. Of particular concern is Dry Eye. Dry eye is characterized by frequent blinking, red eye, itching and burning. It is important because it can made worse by eyelid surgery especially if proper measures such as canthopexy or canthoplasty are not taken.

Patients with thyroid disease must be particularly careful with eyelid surgery as it can cause dry eye and/or persistent swelling if it is not controlled. Therefore, it is important to bring documentation of your last thyroid function test to your consultation if you have thyroid disease as this will be a requirement prior to surgery.

Physical Exam

The exam can be broken up into 5 anatomic parts that make up the lower eyelid. I know earlier we mentioned 4 parts. The fifth part is the position of the lower lid and this is determined by a combination of all 4 parts.

During your consultation your plastic surgeon will examine each part individually and determine which of them needs to be changed to obtain the desired result.

  • Skin

Do you have an excess of skin? Usually, this will result in wrinkles. If so, then skin removal may be needed.

How is your skin texture. If you have dark circles or age spots then some type of textural rejuvenation will be necessary such as laser or a chemical peel. Often, proper skin care with Retin-A and/or glycolic acid will help tremendously. Other types of treatment such as IPL, and micro-dermabrasion are helpful but often take many treatments. They will not obtain the significant improvements that laser and chemical peeling can but they also do not have as much, if any, down time.

Example of lower blepharoplasty that required skin excision to diminish wrinkles from excess skin.

The orbicularis oculi muscle is right under the skin. It is responsible for the wrinkles around the eye that occur with smiling. As we age this muscle sags and give a tired appearance often leaving circles under the eyes. When this is present, resuspension of this muscle is necessary. The woman above had muscle resuspension in addition to skin excision.

The above picture dramatically shows why muscle resuspension is often necessary.

There are two types of fat related to the lower eyelid. The first is located just under the eyelid. During aging this fat often bulges out and causes bags. If bags are present there are two ways to get rid of them. The most common way is to map out exactly where they are and cut them out during a lower blepharoplasty. If the bags are not severe then they can be flattened by resuspension of the orbicularis muscle.

Youthful eyes - muscle view

Youthful Eyes. Muscles around the eyes are circular in shape.

Aging eyes - muscle view

Aged Eyes. Notice how the muscles and the lateral canthus sags.

Example of bags caused by bulging fat. Fat excision combined with muscle resuspension effectively diminished the problem.

The second fat related to the lower eyelid is the cheek fat. This fat often descends with aging. This leads to loss of cheek height and the characteristic signs of cheek aging. As the fat descends it causes the nasolabial folds to get bigger. Correction of this problem is accomplished either by a face lift or by a cheek lift performed through the same incision as the lower blepharoplasty. A cheek lift is done by elevating the orbicularis muscle and cheek fat as a unit back up to where they once were.

A third modification of lower eyelid fat can be performed by fat transplantation. This is done by harvesting fat, usually from the abdomen, and injecting it directly where it is needed. This is described in more depth in the section fat transplantation.

The underlying facial skeleton has a profound effect on facial appearance as well as eyelid position. Bone modification can be performed by implants. The most common implants are silicone. Cheek implants are very effective in cheek augmentation. They can dramatically heighten cheek bones creating an elegant triangular facial structure.

Diagram of a youthful lower eye and cheek

Cheek fat in youth is located high underneath the lower eyelid. This prevents the formation of the lower eyelid crease that is characteristic of an aged face.

Diagram of an aging lower eyelid and cheek

Aged Eyes. Notice how the cheek fat has descended creating a deep lower eyelid crease and a deep fold above the lips.

Example of how fat transplantion can add the necessary volume to fill in crease underneath lower eyelid

Lateral view of same patient.

The fifth part of the lower eyelid exam is the position and laxity of the lower eyelid. This is extremely important.

Diagram of ideal, youthful eyelid

In the attractive, youthful lower eye lid, the lateral canthus should be higher than the medial canthus. The lower lid should just touch the colored part of the eye.

Normally the lower lid position is just touching the colored portion of the eye (the iris). If it is below this then lower lid support is necessary by tightening it via a canthoplasty.

Performing a lower blepharoplasty on a patient with laxity of the lower lid without tightening the lower lid (i.e. canthoplasty) can be disastrous.

Lower lid tightening is necessary to prevent the lower lid from descending so that it no longer touches the iris. Plus, it is a powerful technique to creating an elegant, almond-shape eye. This is especially true in patients with a descended lateral canthus.

Lateral view of same patient.

Example of how elevating the lateral canthus in addition to lower blepharoplasty can create an attractive, almond-shape appearance

Laxity can be determined via the snap back test. This is done by pulling the lower eyelid away from the eye ball. Without blinking the lower eyelid should snap back against the eye. If it takes a few seconds or does not occur until you blink then you know that lower eyelid tightening is necessary.

Putting it all together

As you can see, lower blepharoplasty is not simple. This is why it is imperative that you have it done by an experienced Board Certified Plastic Surgeon. All the factors above must be taken into consideration in order to achieve the desired results safely and to prevent complications.

Typical Incisions

Typical incision for lower eyelid surgery

Lower blepharoplasty incision runs just under the eye lashes until it gets to the lateral canthus. It then cants downward. It becomes hidden in a natural skin crease with time.

The incision remains red for about 6 weeks but then becomes essentially unnoticeable unless there are wound healing problems.