Sagginess of the lower eyelids is in many cases the earliest sign of aging, anticipating many years to other stigmata such as wrinkling, sagging face and neck or eyebrows droopiness.
The anatomy of eyelid rejuvenation (excludes skin aging and wrinkles) is divided into upper eyelids (excludes the eyebrows) and lower eyelids, which do not overlap to each other. Aesthetic aging lower eyelids may show as only sagginess, only bagginess or both at the same time, not necessarily with the same grade of severity.
Lower eyelids sagginess is a simplified way of naming the chalasia or aging overgrowth and flaccidity of the skin at the lower eyelid and the orbicularis oculi muscle portion corresponding to the lower eyelid, which develop excessive tissue overtime and fold under the lower eyelid and even the cheek; in a extreme grade may pull down the lower eyelid and produce ectropion.
Although there are cases of severe lower eyelids sagginess in young or very young people due to familiar hereditary factors, medications, smoking habit, unhealthy lifestyles or certain illnesses which may require corrective treatment, the most common scenario is patients showing a marked degree of lower eyelid sagginess from the 40s, often as the only remarkable sign of facial aging or associated with cheeks aging.
In many occasions the patient is unable to detect certain aesthetic and aging issues located in proximity of the lower eyelids, like the malar crescents, malar mounds or malar festoons, the chronic lower eyelid swelling or the hyperdynamic crow's feet spastic wrinkles, attributing their dissatisfaction to the aging of saggy lower eyelids. In the border region between the cheekbones (facial territory) and the lower eyelid (orbital territory) there is a very clear frontier between a thin, dark and elastic skin that belongs to the lower eyelid and a lighter, thicker and firmer skin that corresponds to the face and cheeks and therefore does not belongs to the lower eyelid.
Some patients call saggy lower eyelids what is really malar crescents, malar mounds or malar festoons, or both problems coexist so we would be before a case of skin excess on the lower eyelid aggravated by the creases at the upper cheek area. It must be borne in mind that the lower eyelids age at a same pace than malar crescents, malar mounts or malar festoons, which may confuse patients and surgeons who are not experienced in facial plastic surgery. In other words, the greater the aging of the cheeks, the more it seems that lower palpebral skin is left over, but it is not the real amount of excess skin on the lower eyelid; the actual amount of excess skin on the lower eyelids is diagnosed with the cheeks in their correct position.
It is very important that the patient receives an exact diagnosis, because under no circumstances should facial skin be removed for misinterpreting that much lower eyelid is in excess, which would cause even greater issues at the lower eyelid, just as you cannot pretend to remove the excess of lower palpebral skin by an aggressive treatment of the cheek, as it would entail a grotesque and artificial appearance or even a functional limitation of lower eyelid closure.
In most cases, the patients suffer at the same time from skin and muscle excess on the lower eyelid along with a greater or lesser degree of cheek aging, so it is usual to simultaneously perform the treatment of both problems.
Best state of the art treatment for the saggy lower eyelids in cases of large amount of myocutaneous (skin and muscle) excess is a subciliary (under the eyelashes) concealed incision lower eyelid blepharoplasty to allow their adjustment and excess removal.