Lower Eyelid Surgical Anatomy and the Implications for Blepharoplasty Surgery: A Systematic Review of Anatomic Studies in the Literature

Lower eyelid blepharoplasty is a procedure to address issues arising from age-related anatomic changes of the lower eyelid. These include excess skin, fat herniation, tear trough hollowing, and midface descent. Unlike the well-defined structures of the upper eyelid, the lower eyelid's anatomy, including the retractors and surrounding ligaments, is less distinct and understudied. In addition, lower eyelid blepharoplasty has an unfavorable complication profile compared with that of the upper eyelid. This review examines relevant studies on lower eyelid anatomy, focusing on age-related structural changes and the variability of key structures involved in blepharoplasty surgery to minimize the risk of complications and achieve desirable outcomes. A literature search for relevant publications on the topic was performed through Medline and PubMed, with the appropriate data extracted, identifying 54 relevant studies. These studies demonstrate how degenerative changes to the supporting structures of the lower eyelid contribute to prolapse of the orbital fat pads, and highlight the relevant ligamentous structures, blood supply, and innervation to avoid complications during transcutaneous or transconjunctival orbital fat repositioning. With detailed knowledge of the anatomy of the lower eyelid as outlined in our review, surgeons can improve and optimize outcomes whilst minimizing complications.