Key points
- Lower blepharoplasty addresses a range of changes in the lower eyelid, such as bulging under-eye fat, loose skin, the tear trough, and eyelid laxity [1].
- When fat bulges without loose skin, an incision inside the eyelid (on the conjunctiva) is usually used; when skin needs to be removed, an incision on the skin is usually used [1, 2].
- Rather than only removing fat, recent approaches emphasize moving fat to fill under-eye hollows and the tear trough [1, 3].
- Lower eyelid surgery can lead to serious complications, so outer-corner support (canthal suspension) is used as a preventive measure in cases such as a lax eyelid [3, 4].
- The degree of age-related change differs from person to person and calls for an individualized plan, so an examination by a specialist is important [5].
Why do lower eyelids look older with age?
An aged look under the eyes comes from several overlapping causes, not just one. Changes in the skin, the orbital fat, the muscle around the eye (orbicularis oculi), the soft tissue of the midface, and the tear trough all play a part; their extent varies from person to person, and they develop against a background of overall volume loss in the face [5].
As a result, lower blepharoplasty addresses many different issues. It aims to correct loose skin, bulging fat (steatoblepharon), tear trough deformity, eyelid laxity, and excess skin (dermatochalasis), reducing hollowness under the eyes and smoothing the junction between the eyelid and cheek [1]. An evidence-based review likewise summarized lower eyelid surgery as addressing the eyelid-cheek junction, the tear trough, and the forward bulging of fat around the eye (pseudoherniation) [3].
Incision inside the eyelid vs. on the skin
Lower blepharoplasty falls into two main approaches: the transconjunctival approach, which uses an incision in the conjunctiva on the inside of the eyelid, and the transcutaneous approach, which uses an incision in the skin just below the lashes. The literature notes that lower eyelid surgery can be performed safely with either method [3].
One review summarized that the transconjunctival approach is mainly used for younger patients who have no excess skin but prominent bulging fat, and the transcutaneous approach for patients who need skin removed [1]. Another review also considered the transconjunctival approach the first option when the eyelid is not very lax and fat is bulging [2].
The reviews also note that the transcutaneous approach has absolute and relative contraindications [5]. Which approach suits you should therefore be decided after examining how much excess skin you have, how firm your eyelid is, and the state of the fat.
From fat removal to fat repositioning
In the past, the main approach was to trim and remove the three pads of orbital fat, but recent practice also emphasizes moving fat to correct under-eye hollowness [1]. Lower eyelid surgery is described as being based on selectively removing and repositioning fat, and as involving the release of deeper structures than in upper eyelid surgery [3].
Through the transconjunctival approach, fat can also be moved to create a smooth transition between the eyelid and cheek and to fill the tear trough [2]. For the skin approach, moving fat to preserve volume has been described, and transconjunctival fat repositioning and fat grafting using your own fat were also presented as alternatives [5].
However, surgical techniques vary so widely that a meta-analysis, which pools multiple studies for statistical comparison, could not be performed [1]. In other words, there is not yet enough evidence to say for certain that one method is better.
When the midface also needs to be considered
If the under-eye changes extend down into the cheek, aging of the midface may also need to be assessed. Midface aging is described as a complex problem that requires an individualized, multifaceted surgical approach [6].
Midface lifting has evolved from the traditional technique of pulling sideways to lifting in a more vertical direction, and this approach builds on lower blepharoplasty techniques [6]. Whether to treat only the under-eye area or the midface as well is something to be judged during the examination.
Complications to watch for and outer-corner support
An evidence-based review cautioned that while complications from upper eyelid surgery are uncommon, lower eyelid surgery can lead to serious complications [3]. Malposition of the lower eyelid, where it is pulled downward or turns outward, is known as a major concern.
Outer-corner support (canthal suspension) is used to help prevent this. It is described as especially important when the lower eyelid is very lax, when the eyes are relatively prominent, or when the cheek sits behind the eyeball (a negative vector) [4]. Even small adjustments in this area can change the shape of the lower eyelid considerably, so a careful approach is needed [4].
The options for support include the following [4].
- Canthopexy: the most conservative option, supporting the lower eyelid in the short or long term
- Orbicularis sling: avoids complex surgery at the outer corner of the eye, but may not be suitable when no skin incision is needed or when there is a history of dry eye
- Modified canthoplasty: mainly used when laxity is pronounced, a degree of laxity that is relatively rare in cosmetic patients
What to ask during your consultation
There is no secret to successful lower eyelid surgery; it is stressed that an accurate examination and a plan grounded in anatomy come first [2]. Even when the concern under the eyes seems the same, the cause and degree differ, so it is a good idea to check the following points.
- The main cause of your under-eye changes (bulging fat, loose skin, hollowness, or eyelid laxity)
- Whether the approach inside the eyelid or on the skin suits you, and why
- Whether fat will be removed, moved, or added
- Whether outer-corner support is needed
- Any history of dry eye, and the expected recovery and complications
Frequently asked questions
- If I only have puffy under-eye fat, can the surgery be done from inside the eyelid?
- When there is no excess skin, little eyelid laxity, and the fat is bulging, the transconjunctival approach is usually considered [1, 2]. However, what looks like bulging fat may come with hollowness or skin changes, so the cause should be confirmed through an examination before choosing a method.
- Can the shape of my eye change after lower eyelid surgery?
- It can. The lower eyelid is an area where even small adjustments can change its shape considerably, so a careful approach is described as necessary [4]. In cases such as a lax eyelid, outer-corner support may also be considered to help prevent complications [4].
References
- Bhattacharjee K, Ghosh S, Ugradar S, et al. Lower eyelid blepharoplasty: An overview. Indian J Ophthalmol. 2020.PubMed 32971612DOI
- Pack S, Quereshy FA, Altay MA, et al. Transconjunctival Lower Blepharoplasty. Atlas Oral Maxillofac Surg Clin North Am. 2016.PubMed 27499473DOI
- Drolet BC, Sullivan PK. Evidence-based medicine: Blepharoplasty. Plast Reconstr Surg. 2014.PubMed 24776550DOI
- De Silva DJ, Prasad A. Aesthetic canthal suspension. Clin Plast Surg. 2015.PubMed 25440744DOI
- Jacono AA. Transcutaneous Blepharoplasty with Volume Preservation: Indications, Advantages, Technique, Contraindications, and Alternatives. Facial Plast Surg Clin North Am. 2021.PubMed 33906757DOI
- Sclafani AP, Dibelius G. Transpalpebral midface lift. Facial Plast Surg Clin North Am. 2015.PubMed 25921571DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
