Lower Blepharoplasty & Tear Trough Correction

Overview

Lower blepharoplasty is surgical rejuvenation of the lower eyelid, addressing the complex structural changes that produce under-eye bags, tear trough hollowing, and lower eyelid skin laxity. It is technically one of the most demanding periorbital procedures because the lower eyelid anatomy is unforgiving — complications in this region are visible, affect function (ocular lubrication and lid closure), and can be difficult to revise.

Contemporary lower blepharoplasty practice has shifted significantly from aggressive fat excision — which produces the characteristic hollow, skeletonised appearance of over-operated patients — toward conservative fat repositioning: releasing the herniated fat pads from their septal constraints and redistributing them over the orbital rim into the tear trough depression, simultaneously correcting the puffiness above and the hollowness below.

Anatomy: The Tear Trough Deformity

The youthful lower eyelid transitions smoothly into the midcheek with a continuous convex contour. With aging, two opposing processes create the characteristic under-eye complex: orbital fat herniates anteriorly through a weakening orbital septum, creating the visible "bag," while the inferior orbital rim becomes skeletonised as the overlying cheek fat descends and thins. The confluence of fat above and hollow below creates the tear trough deformity — a diagonal depression running from the medial canthus across the orbital rim.

Excising the herniated fat, as was standard practice before the 1990s, worsens the hollow component while temporarily reducing the bag — patients frequently returned years later with a hollow, aged appearance that was paradoxically more aged-looking than their original bags. Fat repositioning — arcus marginalis release and fat pad advancement over the inferior orbital rim — addresses both the excess above and the deficit below in a single manoeuvre.

Approaches

Transconjunctival (No External Scar)

The incision is placed on the conjunctival surface of the inner eyelid — no cutaneous scar is created. This approach provides direct access to the orbital fat pads for repositioning or conservative excision. It is the preferred approach in patients with good lower eyelid skin tone and no significant skin laxity, and is the only appropriate approach in patients who have undergone prior transcutaneous blepharoplasty (to avoid ectropion risk from additional anterior lamellar shortening).

Transcutaneous (Subciliary Incision)

An external incision is placed 1–2 mm beneath the lash line. This allows the skin-muscle flap to be elevated, providing direct access to the fat pads and the ability to excise excess skin. The subcutaneous scar is typically imperceptible at 12 months in appropriately selected patients. However, the transcutaneous approach carries a higher risk of ectropion — particularly in patients with underlying lower eyelid laxity — and must always be combined with a lateral canthopexy or canthoplasty in any patient demonstrating positive snap test results.

Ideal Candidate Profile

• Orbital fat herniation (under-eye bags) with or without concurrent tear trough hollowing
• Adequate lower eyelid tone — the snap test should demonstrate elastic return within 1–2 seconds
• Absence of significant lower lid laxity unless concurrent canthopexy is planned
• Optimally managed dry eye disease pre-operatively
• Good skin tone for transconjunctival approach; skin laxity requiring excision for transcutaneous approach

The Surgical Protocol

Lower blepharoplasty is performed under local anaesthesia with intravenous sedation, typically 1–2 hours for bilateral cases. General anaesthesia is used when combined with facelift surgery.

Transconjunctival Fat Repositioning

After conjunctival incision and orbital septum entry, the medial, central, and lateral fat pads are identified. The arcus marginalis — the periosteal attachment at the inferior orbital rim that creates the tear trough boundary — is released. The fat pads are advanced over the released arcus marginalis into the sub-orbicularis plane of the tear trough and secured with sutures. The effect is a continuous smooth contour from the lower eyelid into the cheek, abolishing both the herniation above and the hollow below.

Lateral Canthopexy (When Indicated)

In patients with lower eyelid laxity, a lateral canthopexy — tightening the lateral canthal tendon with permanent sutures to the internal orbital rim periosteum — is performed concurrently to provide lower lid support and prevent post-operative ectropion.

Skin Resurfacing

In patients with lower eyelid skin quality concerns (fine rhytids, crepe texture) that are not addressed by fat repositioning alone, concurrent laser skin resurfacing (fractional CO₂ or erbium) of the lower eyelid skin is frequently performed as a complement, improving skin quality without excision.

Recovery Timeline

• Days 1–5: Significant periorbital bruising and oedema. Chemosis (conjunctival swelling) may appear dramatic — it resolves and is not a complication indicator.
• Days 7–10: Bruising substantially reduced. Chemosis resolving. Sutures removed if transcutaneous approach used.
• Weeks 2–3: Most patients are presentable. Residual swelling may cause temporarily hollow appearance — this is oedema and resolves.
• Months 3–6: Oedema fully resolved; fat repositioning result stabilises. The tear trough correction continues to improve as the repositioned fat integrates with the recipient tissue.

Cost in the United States

Lower blepharoplasty ranges from $5,000–$12,000 for bilateral procedures. Concurrent canthopexy, fat grafting, or laser resurfacing adds $1,000–$3,500. Combination with upper blepharoplasty typically reduces total cost by 10–20% due to shared anaesthesia and facility overhead.

Risks and Contraindications

• Ectropion: Outward rotation of the lower lid margin, exposing the conjunctiva. The most serious complication; elevated risk in patients with pre-existing lid laxity, deep-set eyes, and prior transcutaneous surgery.
• Hollowness from over-resection: The most common cause of the "over-operated" lower eyelid appearance. Modern fat repositioning technique significantly reduces this risk.
• Chemosis: Prolonged conjunctival swelling, typically resolving within 4–8 weeks. Rarely requires intervention.
• Corneal injury: Rare; from dry eye, inadequate lubrication, or lagophthalmos.