Lower blepharoplasty

What it treats

• Aging of the lower lid includes excess skin, orbital fat herniation, tear trough hollowing and midface descent; weakening of the lid's supporting structures lets the fat pads prolapse (review of 54 anatomic studies) (PMID 39585706).
• The lower lid has a less favorable complication profile than the upper lid (PMID 39585706).
• The aging contour is both fat prolapse and cheek descent, which exposes the orbital rim and deepens the tear trough (PMID 10697189).
• Removing lower lid fat can leave a concave contour, the "operated" look (PMID 7624408).
• Members of the American Society of Ophthalmic Plastic and Reconstructive Surgery reported an average of 46 lower lid and 53 four-lid blepharoplasties a year each (161 respondents) (PMID 28151825).

How it is done

Approach

• Transconjunctival: the incision is inside the lid; in 122 consecutive cases there was no lid retraction or ectropion, and the main problem was fat left behind in 7.4% (PMID 2771349).
• Transcutaneous (subciliary): the incision is below the lashes and a skin-muscle flap is raised; in a 10-patient left-right study both approaches graded the same at 6 months (PMID 7568479).
• Skin pinch: loose skin is excised without undermining; 71 patients, temporary scleral show in 3; in 25 measured patients a mean 8 mm of skin was removed (range 4-12 mm) (PMID 18434828).
• Lid height moved 0.05 mm after transconjunctival surgery with or without a skin pinch, 45 patients (PMID 18209632).
• Surgeon survey: transconjunctival approach used by 96%, transcutaneous by 82%; fat excision 99%, fat repositioning 80%, lateral canthal suspension 96% (PMID 28151825).

Fat excision or fat repositioning

• Arcus marginalis release: Hamra released the septum at the orbital rim and advanced the lower lid fat over the rim, 152 cases over 3 years (PMID 7624408).
• Transconjunctival fat repositioning: medial and central fat pedicles moved into a subperiosteal pocket on the maxilla, 24 patients followed 6-30 months; some variable resorption (PMID 10697189).
• Septal reset: the orbital septum itself is reset over the rim, which gives the lid a firmer undersurface than fat transposition alone (PMID 15253208).
• Five-step technique, 100 lids in 50 patients: deep malar fat augmented, orbicularis preserved, minimal or no fat removed, orbicularis retaining ligament released, lateral canthus supported, minimal skin removed; no lower lid malposition (PMID 21278622).
• Fat removal followed by grafting the removed fat, 229 patients: 97.8% satisfied (PMID 30418468).
• Minced free fat graft (69) against pedicle fat flap (73): no significant difference in complications or satisfaction; reoperation 5.8% against 12.3% (p=0.2) (PMID 37463504).
• Deep fat excision with septum-fat flap transposition, transcutaneous, 107 patients: 91.6% complete correction of bags and tear trough, 8.4% undercorrection (PMID 41051496).
• Transcutaneous technique with a capsulopalpebral fascia incision and selective omission of canthoplasty, 340 patients: no ectropion or other major complication (PMID 40952103).

Instruments and anatomy

• CO2 laser against monopolar cautery, randomized, 78 patients: less chemosis with the laser; conjunctival granuloma in 3 (7.89%) of the cautery group (PMID 36723988).
• Pretarsal nerve safe zone, 46 cadaver hemifaces: the zone for the muscle incision lies 6.0-6.5 mm below the lid margin, 9.4 mm from the medial canthus line and 3 mm from the lateral canthal crease; incising there preserves the nerve supply and prevents pretarsal atrophy (PMID 37384881).

Results and evidence

• Literature review 1997-2017, 49 studies, 10,698 patients: pooled reoperation 0.77%, scleral show 0.37%, lid malposition 0.25%, ectropion 0.24%; mean follow-up 14.8 months (PMID 30084870).
• In that review, photographs beyond 24 months existed for 10 patients (0.094%) (PMID 30084870).
• Randomized trial, 50 patients, traditional lower blepharoplasty against fat transposition, both with canthopexy: 96% improvement on photographs; self-esteem scores improved at 6 months (PMID 22124642).
• Extended transconjunctival blepharoplasty with ligament release and free fat grafts, 200 consecutive patients, mean follow-up 22 months: no scleral show; fat necrosis 3.5%; revision 1.0% (PMID 41150997).
• Transcutaneous blepharoplasty with orbicularis suspension, 78 patients, at least 12 months: malposition (29.5%) and scleral show (28.2%) unchanged from before surgery; no ectropion; revision 1.3%; 98.7% satisfied (PMID 41677016).
• Negative preoperative canthal tilt was associated with scleral show in the same series (PMID 41677016).
• Deep fat excision series: FACE-Q lower eyelid score improved from 66.7 to 21.9; patients perceived a 3.3-year age reduction (PMID 41051496).
• Review of 24 cohort studies (2000-2025): fat excision or transposition is safe through either incision; transposition is probably easier through the skin; the literature lacks rigorous outcome reporting (PMID 41415593).
• Systematic review, 36 articles: no major complications with visual disturbance reported; most complications resolved with conservative care or revision (PMID 40995580).

Risks and complications

• Conventional lower blepharoplasty with fat removal through the septum carries a reported potential lower lid malposition rate of 15%-20% (PMID 18434828).
• Repair of lower lid retraction after blepharoplasty, 30 patients: success depended on time since surgery, globe prominence and septal or skin involvement (PMID 1390423).
• Subtle retraction and eversion after skin pinch or laser resurfacing were detected by MRD2 at the lateral limbus and by tarsal margin show, not by standard MRD2, and were prevented by lateral canthal resuspension (PMID 31444052).
• Fat grafting and repositioning for tear trough or lid-cheek junction, 33 studies, 4,671 patients: total complications 11.2%, contour irregularity or undercorrection 6.2%, hematoma, swelling or bruising 6.2%, reoperation 2.4% (PMID 39158343).
• Strabismus, IRIS Registry, 368,623 patients: 3-year incidence of strabismus diagnosis 2.0% after lower against 1.5% after upper blepharoplasty; strabismus surgery 0.15% against 0.06% (PMID 38346431).
• Chemosis, 1,047 patients: persistent type 3 chemosis was more frequent after transcutaneous surgery with lateral canthoplasty than after transconjunctival surgery, and more frequent with radiofrequency (PMID 38610858).
• Orbital hemorrhage after cosmetic eyelid surgery: 0.055%; permanent visual loss 0.0045% (PMID 15599241).
• Scarring review, 3,650 patients: hypertrophic scar in 36; no keloid reported after cosmetic eyelid surgery (PMID 36797842).
• Ectropion prevention review, 16 studies: Frost sutures, periosteal anchoring, barbed sutures and splinting were used; evidence quality low; one study found no benefit from Frost sutures (PMID 40907566).

Recovery

• Subcutaneous tranexamic acid in eyelid surgery including lower blepharoplasty, 130 patients randomized by side: less bruising on day 0 and at 1 week; 69% of patients reporting saw less bruising on the treated side; no change in bleeding during surgery (PMID 38624153).
• Botulinum toxin into the lateral orbicularis at closure, 40 Asian patients randomized: narrower subciliary scars; scar scale scores the same (PMID 34128526).
• Repositioned fat: the fixation suture comes out after 3-5 days; texture and contour settle over 1-2 months (PMID 10697189).
• Edema occurred in 5 and pronounced chemosis in 2 of the patients who had orbicularis suspension, canthopexy or canthoplasty with a pinch blepharoplasty (PMID 18434828).
• Orbital hemorrhage is most likely in the first 3 hours after surgery (PMID 15599241).

Combined procedures

• Hamra performed arcus marginalis release with fat preservation in all composite rhytidectomies, and in isolated blepharoplasty for patients without advanced facial aging (PMID 7624408).
• The septal reset was added to composite rhytidectomy after orbicularis repositioning and fat transposition (PMID 15253208).
• TOPS database, 13,346 facelifts: blepharoplasty was the most common added procedure; combined procedures raised the odds of adverse events (PMID 32459769).
• Midface lift through a skin-muscle flap, 130 patients: tear trough volume increased whether fat was left alone, repositioned or removed; mean follow-up 12 months (PMID 36719989).
• Transconjunctival deep-plane midface lift, 124 patients, median follow-up 56 months: no significant complications; patients with heavy excess skin or festoons were advised traditional techniques (PMID 22859542).
• Facelift approach can be chosen by midface ptosis grade, with transconjunctival blepharoplasty plus skin pinch or fat transposition as the lower lid options (PMID 33657627).
• Blending the lid-cheek junction: 22 studies of fat conservation, fat augmentation, fat repositioning, ligament release, septal reset and deep cheek filler (PMID 29787515).

Current questions

• Approach for fat preservation: both incisions are safe; a 2025 review found outcome and complication reporting too weak to name a best approach (PMID 41415593).
• Pedicle transposition or free fat graft: equal outcomes in a 142-patient comparison (PMID 37463504); free grafts from removed fat in 200 patients gave 3.5% fat necrosis (PMID 41150997).
• Routine or selective canthal support: a 340-patient series omitted canthoplasty selectively without ectropion (PMID 40952103); canthal surgery was linked to persistent chemosis (PMID 38610858); routine canthopexy maintained canthal position in 104 patients (PMID 31985628).
• Durability: long-term photographic follow-up is rare (PMID 30084870).
• Strabismus after lower blepharoplasty is more frequent than after upper blepharoplasty in registry data (PMID 38346431).

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).
• Orbicularis retaining ligament: the ligament that tethers the lid-cheek junction; released in some techniques (PMID 21278622).
• 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