Lower blepharoplasty

What it is

Under-eye bags form when the supports of the lower lid weaken and the fat around the eye pushes forward (PMID 39585706). At the same time the cheek descends, which shows the bony rim of the eye socket and deepens the groove below the eye, the tear trough (PMID 10697189).

Lower blepharoplasty treats each part of that picture: the bulging fat, the groove, loose skin and the support of the lid (PMID 21278622). It is done mainly for appearance, for people who see bags or circles under the eyes, a tired look or a flat face (PMID 37531619).

The lower lid is less forgiving than the upper lid: its supporting structures are less distinct and its complication profile is less favorable (PMID 39585706).

Where it came from

The customary operation went through the skin just below the lashes and raised a flap of skin and muscle (PMID 7568479). Fat was removed through the front of the lid, an approach with a reported potential for a pulled-down lower lid of 15% to 20% (PMID 18434828). Removing the fat could also leave a hollow lower lid, the operated look (PMID 7624408).

In 1989 Baylis reported removing the fat through the inside of the lid instead; his series had no lid retraction, the most common complication of the skin approach, and no ectropion (PMID 2771349). In 1995 Hamra released the septum where it attaches to the bony rim and advanced the fat over the rim instead of removing it, to hide the rim (PMID 7624408). In 2000 Goldberg moved the fat on its blood supply through the inside of the lid into a pocket on the cheekbone (PMID 10697189), and in 2004 Hamra reset the septum itself over the rim for a firmer lower lid (PMID 15253208).

In 2011 Rohrich published a five-step method: add volume to the deep cheek fat, keep the lid muscle, remove little or no fat, release the ligament at the lid-cheek junction, support the outer corner and remove minimal skin (PMID 21278622). Lower lid surgery moved from skin-muscle flaps and fat removal to blending the lid into the cheek (PMID 29787515). By 2018 most oculoplastic surgeons surveyed repositioned fat and supported the outer corner of the lid (PMID 28151825). Very large bulges still need some fat removed, now paired with repositioning (PMID 41051496).

Who it suits

• Bags from fat, little loose skin. Fat removed through the inside of the lid leaves no skin scar and avoids lid retraction (PMID 2771349).
• Bags with a groove below them. When a deep groove runs along the rim, moving the fat over the rim is preferred to removing it (PMID 10697189).
• Loose, crepey lid skin. A skin pinch removes a strip of skin without lifting the muscle and did not change lid height (PMID 18209632).
• Very large bulges. Selective removal of the deep fat combined with repositioning corrects them (PMID 41051496).
• A lax lower lid or an outer corner that tilts down. A downward-tilting corner was linked to white showing below the iris after surgery (PMID 41677016); patients with poor lid tone may benefit from support at the outer corner (PMID 18434828).
• Heavy excess skin or festoons. These patients are advised more traditional techniques than a midface lift through the inside of the lid (PMID 22859542).
• A cheek that has dropped. The lid operation is chosen together with the facelift, by how far the midface has descended (PMID 33657627).

How it is done

Incision inside the lid

The surgeon reaches the fat through the lining of the lower lid (the conjunctiva), so there is no skin scar (PMID 2771349) and the lid's middle layer stays intact (PMID 18434828). Its main shortfall in Baylis's series was fat left behind, in about 7 in 100 patients (PMID 2771349). A CO2 laser used for this incision caused less swelling of the eye surface than electrocautery and no granulomas (PMID 36723988).

Incision below the lashes

An incision just below the lashes allows the surgeon to remove skin and work on fat and muscle; in a left-right comparison, this approach and the inside approach graded alike at 6 months (PMID 7568479). Moving fat on its blood supply is probably easier through the skin (PMID 41415593). Current skin techniques protect lid position: suspending the lid muscle kept the lid where it was a year or more later, with no ectropion (PMID 41677016), and a tension-releasing cut in the lid retractor layer produced no ectropion in a consecutive series (PMID 40952103). Keeping the muscle cut within a mapped safe zone below the lashes preserves its nerve and prevents thinning of the muscle along the lash line (PMID 37384881).

Skin pinch

A fold of loose skin is pinched and trimmed without lifting the muscle; an average of about 8 mm of skin came out (PMID 18434828). Combined with fat work through the inside of the lid, it leaves the lid's middle layer intact and allows laser resurfacing at the same sitting (PMID 18434828).

Fat: remove, move or graft

• Remove. Bulging fat is trimmed; on its own this risks a hollow lid (PMID 7624408).
• Move. Fat stays attached to its blood supply and is drawn over the rim into a pocket on the cheekbone, held by a stitch (PMID 10697189), or the septum is reset over the rim (PMID 15253208).
• Graft. Fat removed from the bags is placed back along the rim as free pieces (PMID 30418468, PMID 41150997). Minced fat grafts and fat moved on its blood supply gave equal results (PMID 37463504), and grafting may be the easier way to blend the lid-cheek junction (PMID 41415593).

Support for the outer corner

Tightening the outer corner of the lid (canthopexy) guards against a pulled-down lid; a superficial lateral retinacular canthopexy kept the corner in its place (PMID 31985628). After skin pinch or laser resurfacing alone, subtle retraction appeared that corner support prevented (PMID 31444052). Some surgeons add it only when the lid needs it (PMID 40952103).

Results and how long they last

Most patients see the bags and the groove corrected. After deep fat removal with repositioning, about 9 in 10 had both fully corrected (PMID 41051496), and patients judged that they looked about 3 years younger (PMID 41051496). In a randomized trial, fat removal and fat transposition both improved appearance and self-esteem at 6 months (PMID 22124642).

Releasing the ligament under the lid and grafting fat along the rim also improved how the lower lids look when smiling, with no white showing below the iris at a mean of nearly 2 years (PMID 41150997). Repeat surgery is uncommon, under 1 in 100 in pooled data (PMID 30084870).

How long the result lasts is poorly documented: published photographs beyond 2 years after surgery are rare (PMID 30084870). Repositioned fat shrinks somewhat but stays alive (PMID 10697189).

Risks and how surgeons lower them

• Lower lid pulled down (retraction, ectropion). Ectropion occurred in about 1 in 400 in pooled data (PMID 30084870). Surgeons lower the risk with the inside approach (PMID 2771349), support at the outer corner (PMID 31444052) and muscle suspension when going through the skin (PMID 41677016). Evidence for the various holding stitches and splints is weak (PMID 40907566). Repair of a retracted lid depends on how long ago the surgery was, how prominent the eye is and how much scarring there is (PMID 1390423).
• Uneven contour or undercorrection. After fat grafting or repositioning, contour problems or undercorrection occurred in about 1 in 16 (PMID 39158343), and about 2 in 100 had another operation (PMID 39158343). Free fat grafts carried fat necrosis in about 3 in 100 (PMID 41150997).
• Double vision (strabismus). A strabismus diagnosis followed about 2 in 100 lower blepharoplasties within three years, more often than after upper lid surgery (PMID 38346431). Surgery to correct it was rare (0.15%) (PMID 38346431).
• Swelling of the eye surface (chemosis). Persistent chemosis was more common after the skin approach with a canthoplasty and with radiofrequency tools (PMID 38610858); a CO2 laser caused less than electrocautery (PMID 36723988).
• Bleeding behind the eye (orbital hemorrhage). About 1 in 2,000 after cosmetic eyelid surgery (PMID 15599241). Permanent loss of vision from it is rarer still, about 1 in 22,000 (PMID 15599241).
• Scars. Raised scars are rarely reported, and no keloid has been reported after cosmetic eyelid surgery (PMID 36797842). Botulinum toxin injected at closure narrowed the scar below the lashes in Asian patients (PMID 34128526).

Most complications after lower blepharoplasty settle with conservative care or a revision (PMID 40995580).

Recovery

• Tranexamic acid injected under the lid skin at surgery reduced bruising on the day of surgery and at one week (PMID 38624153).
• When fat is repositioned, the holding stitch comes out after 3 to 5 days, and the contour settles over 1 to 2 months (PMID 10697189).
• Swelling and chemosis are more likely when the outer corner is tightened or suspended (PMID 18434828, PMID 38610858).
• Temporary white showing below the iris after a skin pinch settled with lid massage (PMID 18434828).
• Bleeding behind the eye is most likely in the first 3 hours after surgery (PMID 15599241).

With a facelift

• Blepharoplasty is the procedure most often added to a facelift, and adding procedures raised the odds of a complication (PMID 32459769).
• Hamra kept and advanced the lower lid fat in every composite facelift (PMID 7624408) and later added the septal reset to that operation (PMID 15253208).
• A midface lift done with lower blepharoplasty added volume to the tear trough whether the fat was left alone, moved or removed (PMID 36719989).
• A deep-plane midface lift through the inside of the lid had no significant complications at a median of about 5 years (PMID 22859542).
• The facelift type and the lower lid method (skin pinch with fat removal, or fat transposition) are chosen by how far the midface has dropped (PMID 33657627).
• Fat moved or added, ligament release, septal reset and deep cheek filler can be combined to blend the lid into the cheek (PMID 29787515).

Questions to ask a surgeon

• Will you remove my under-eye fat, move it into the groove, or both? (PMID 41051496)
• Will the incision be inside the lid or below the lashes, and why for my eyes? (PMID 41415593)
• Do I need skin removed, and can a skin pinch do it? (PMID 18209632)
• How will you support the outer corner of my lower lid? (PMID 31985628)
• How will you treat the groove between my lid and cheek? (PMID 29787515)
• How often do your patients have a pulled-down lid or need a revision? (PMID 30084870)
• Should my lower lids be done with my facelift, and does that change my risk? (PMID 32459769)
• Can I see your patients' lower lids 2 years or more after surgery? (PMID 30084870)

Open questions

• Which incision is best for keeping fat: both are safe, and reporting is too weak to rank them (PMID 41415593).
• Fat moved on its blood supply or free fat grafts: results were equal in one comparison (PMID 37463504), and free grafts carry a small risk of fat necrosis (PMID 41150997).
• Routine or selective support of the outer corner: one series skipped it selectively without ectropion (PMID 40952103), corner surgery is linked to lasting chemosis (PMID 38610858), and routine canthopexy kept the corner in place (PMID 31985628).
• How long results last: long-term photographs are rare (PMID 30084870).
• Why strabismus is more frequent after lower than upper lid surgery (PMID 38346431).
• Fat grafting and repositioning had high complication rates in pooled data, led by contour problems and bruising or swelling (PMID 39158343).

Terms

• Transconjunctival approach: incision on the inner surface of the lower lid, no skin scar (PMID 2771349).
• Transcutaneous (subciliary) approach: incision just below the lashes with a skin-muscle flap (PMID 7568479).
• Skin pinch: removal of a fold of loose lid skin without undermining (PMID 18434828).
• Arcus marginalis: the attachment of the orbital septum at the bony rim, released to move fat over the rim (PMID 7624408).
• Fat repositioning (transposition): moving orbital fat on its pedicle over the rim instead of removing it (PMID 10697189).
• Septal reset: advancing the orbital septum over the rim to smooth the lid-cheek junction (PMID 15253208).
• Tear trough: the groove along the bony rim below the eye (PMID 10697189).
• Orbicularis retaining ligament: the ligament that tethers the lid-cheek junction; released in some techniques (PMID 21278622).
• Canthopexy: a stitch that tightens and supports the outer corner of the lid (PMID 31985628).
• Scleral show: white of the eye visible between iris and lower lid (PMID 41677016).
• Ectropion: outward turning of the lower lid (PMID 40907566).
• Chemosis: swelling of the conjunctiva (PMID 38610858).
• MRD2: distance from the corneal light reflex to the lower lid margin (PMID 18209632).

Papers