Incisional Hamra technique, where should you have it done? Choose based on whether they assess lower-lid laxity

With the incisional Hamra technique, the basic approach is to choose a clinic that examines lower-lid laxity, position, and excess skin before surgery and explains whether incisional correction is right for you[1]. With skin-incising methods, complications have been reported in which the lower lid descends and the white of the eye becomes more visible; how well this is addressed varies among surgeons[2]. In young people with minimal skin excess, a non-incisional approach may also be considered[1].

Does the preoperative consultation assess lower-lid laxity?

What you should first confirm is the detail of the preoperative consultation. Before lower-lid surgery, it is recommended to examine eyelid position, skin, fat prominence, under-eye hollowing, and dry eye[1].

Horizontal laxity of the eyelid, laxity of the canthus ligament (the tendon supporting the eyelid), and cheek height are also listed as points to assess[1]. These factors are relevant to whether the lower lid will descend after surgery. A useful sign is whether the surgeon physically grasps or retracts the lower lid with a finger during examination.

Is incision right for you? The dividing line between incisional and non-incisional approaches

For people with significant skin sagging (sagging [skin laxity]), an incisional method is necessary[1]. In contrast, for young people with minimal skin excess and prominent fat bulging, an approach from behind the eyelid is more suitable[1].

There is no fixed answer as to which method is absolutely best[1]. Selecting appropriate candidates, sufficient training, and meticulous technique lead to consistent results[1]. Ask whether the surgeon will explain the specific reason why incision is right for you.

How should lower-lid descent be prevented?

With incisional methods, lower-lid descent has been reported to occur in 15–20% of cases[2]. The range extends from mild increased visibility of the white of the eye to a state in which the lid turns outward (ectropion)[2].

In one such report, among 265 patients treated with conservative skin excision and protective techniques such as preserving the eyelid muscle nerve, only 3 patients (1%) showed increased white-of-eye visibility[2]. Note that the follow-up period was a median of 120 days, which is relatively short, and longer-term results are not available[2]. Ask what preventive measures the surgeon employs to avoid lower-lid descent.

What special precautions apply to fat-repositioning surgery?

The Hamra technique not only removes under-eye fat but also repositions it into hollows to smooth contours[1]. Complete fat removal can result in a sunken appearance under the eye[1].

Fat-repositioning surgery can result in lower-lid ectropion, injury to the eye muscles causing double vision, fat necrosis, hematoma, and infection[3]. Bruising, dry eye, pigmentation changes, and asymmetry have also been reported[1]. It is reassuring to choose a clinic that explains in advance how such complications would be managed.

What about revision if needed?

It has been reported that most complications of lower-lid surgery can be resolved through observation or revision surgery[4]. A review of 36 papers found no reports of serious complications affecting the eye or vision[4].

However, the quality of research is not yet sufficient, and few studies compare methods head-to-head[4]. Retaining pre- and postoperative photographs is also helpful for later comparison of progress[1].

Where to have it done? Guidelines if you are uncertain

During your consultation, ask the following:

Preoperative examination: Will the surgeon assess eyelid laxity, canthus ligament, and cheek height?[1]

Rationale for method: Will the surgeon explain which approach—incisional or non-incisional—is right for you?[1]

Measures against lower-lid descent: What preventive techniques are used?[2]

Approach to revision: Is there a plan for managing complications, and will progress be tracked with photographs?[1][4]

Whether the incisional Hamra technique is right for your under-eye area and how much skin to remove cannot be decided from an article alone. At your consultation, have the surgeon examine your lower-lid laxity, skin excess, fat prominence, and hollowing, and decide on the approach together.