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Navigating Lower Eyelid Blepharoplasty: A Detailed Guide of the Different Complaints, Approaches, Risks, and Recovery

Lower eyelid blepharoplasty, a cosmetic surgical procedure designed to address signs of aging around the eyes, has become increasingly popular for those seeking a refreshed and appearance. In this article, we will delve into the details of lower eyelid blepharoplasty, exploring the different incisions/approaches, recovery time, and potential risks associated with this transformative surgery.


Lower eyelid blepharoplasty, or lower lid eye lift, is performed to improve the appearance of the lower eyelids. It aims to address issues such as under-eye bags, puffiness, and sagging skin, providing a rejuvenated and more youthful look.

There are a variety of concerns that patients can have with their lower eyelid. Each concern is addressed uniquely with different surgical techniques. Most commonly, a combination to address more than one concern is required.

  1. The "Puffy" Eyelid

Image Courtesy of Reviva Labs

The person with the "puffy" eyelid often has a fullness in the undereye, which can frequently cause a "tired" appearance. What causes this?

Image Courtesy of Dr. Niamatu

In fact, it is most often caused by something called "pseudoherniation of the orbital fat". What does this mean? Well, there are fat pads around the eye (both in the upper and lower eyelids. As we age, or sometimes genetically, the tissue covering the orbital fat (known as the orbital septum) can weaken, and cause a bulging of the fat pad.

It is important to delineate this issue from other complaints of the lower eyelid, as addressing this surgically includes tightening of the orbital septum as well as removal of some of the orbital fat, a technique which shouldn't necessarily be performed in all patients.

2. The "Sagging" Eyelid

Image Courtesy of Dr. Guy Massry

The person with a "sagging" eyelid can complain of an almost droopy appearance. This is known as "ectropion". This can contribute significantly to an aged face. There are several reasons this can happen, including underlying medical problems, but is often caused by increased elasticity and loss of support.

Commonly, a "snap-back" test is performed to assess for this, and involves lightly pulling on the lower eyelid skin. In patients without this issue, the skin should "snap back" relatively quickly. In patients with this ailment, there is a delayed return to normal.

Correction for this procedure involves tightening the skin and underlying tissue by suturing them in a different position.

3. The "Prominent" Eyelid

Image Courtesy of Eyebag Doctor

At first glance, a person with a prominent undereyelid can be misconstrued as having a "puffy" appearance caused by pseudoherniation of fat previously discussed. However, these patients actually have a prominence of the main muscle of the eye, known as the orbicularis oculi.

Treatment for this condition typically entails removal and tightening of this muscle. In certain cases, botox to the muscle can also improve appearance for a non-surgical treatment option.

4. The "Wrinkled" Eyelid

Image Courtesy of Alma Lasers

As we age, we almost invariably will develop fine lines and wrinkles around the eyes. While there is a plethora of treatment options that are non-surgical (read more about that here), surgery can provide a more permanent solution.

Surgery for this complaint entails tightening of the skin and underlying tissues, often which extend to the lateral eyelid.

5. The "Dark" Eyelid

Image Courtesy of All About Vision

A person with a dark undereye can give the appearance of looking "tired". This caused by a multitude of issues, including genetics, allergies, trauma, or other underlying conditions.

In general, it is often caused by a genetic predisposition to hyperpigmentation. It can also be caused by prominent vessels directly underneath the thinnest skin of the human body (the lower eyelid), contributing a change in hue.

Typically, there are no great surgical options to treat this condition. However, there are several non-invasive or minimally-invasive options. Treatments are aimed at the underlying contributing factor.

For example, if hyperpigmentation is thought to be the cause, a trial of lightening creams such as hydroquinone can be used. Lasers can also be used to mitigate the changes in color, although caution must be exerted in that lasers themselves can cause hyperpigmentation in select individuals.

Alternatively, if the thinness of the skin is thought to be the primary cause, adding volume in the form of fillers or fat grafting can be used. Other types of lasers can also be used to minimize the appearance of the underlying blood vessels.

Surgical Information for Lower Eyelid Blepharoplasty

Incisions and Approaches:

Image Courtesy of Ento Key

1. Transconjunctival Incision:

   - In this technique, an incision is made inside the lower eyelid, along the conjunctiva. This approach is suitable for patients with minimal excess skin and is particularly effective for addressing under-eye fat pads without external scarring.

2. Subciliary Incision:

   - A common approach involves an incision just below the eyelashes, known as the subciliary incision. This method allows for the removal or repositioning of excess skin, fat, or muscle, resulting in a smoother and more youthful lower eyelid appearance.

3. Trancutaneous Incision:

 - This incision goes directly into the skin at a naturally occurring crease. This is less commonly used in cosmetic blepharoplasty but is still a potential approach for surgery of the undereye.

Recovery Time:

1. Initial Healing:

   - The initial recovery period involves swelling, bruising, and discomfort. Patients are advised to rest and avoid strenuous activities to promote healing.

2. Sutures Removal:

   - Sutures are typically removed within a week after surgery. Dissolvable sutures may also be used, eliminating the need for removal.

3. Resuming Normal Activities:

   - While individual recovery experiences vary, most patients can return to normal activities within 1 to 2 weeks. However, it may take several weeks for residual swelling to subside and final results to become apparent.

Potential Risks:

1. Bleeding and Hematoma:

   - Bleeding is a potential risk during and after surgery. Hematoma, the collection of blood under the skin, may require drainage. If not treated, this could potentially lead to blindness.

2. Infection:

   - Infections are rare but can occur. Proper pre and post-operative care, including antibiotics, helps minimize this risk.

3. Ectropion or Entropion:

   - Changes in eyelid position, such as ectropion (outward turning) or entropion (inward turning), are potential complications that may require additional interventions.

4. Scarring:

   - Scarring is an inherent risk with any surgical procedure. Surgeons aim to minimize visible scarring through meticulous incision placement.

5. Dry Eyes:

   - Temporary dry eyes may occur after surgery. Patients are advised to use lubricating eye drops as needed.

6. Corneal Abrasion:

  • Any operation of the eye can scratch the cornea which requires additional treatment. Measures are taken during surgery to minimize this risk.


There is no "one size fits all" when it comes to treating the under eye. Several patients with the complaints of looking "tired" or "aged" in this region can have a variety of underlying causes. Most often, patients have a combination of issues that should be addressed, as is beautifully illustrated in the image below.

Image Courtesy of Dr. Rachel Ho

Therefore, a thorough consultation with a qualified plastic surgeon or aesthetician is crucial before undergoing lower eyelid blepharoplasty.

Lower eyelid blepharoplasty is a transformative procedure that can significantly enhance the appearance of the lower eye area. Choosing a skilled plastic surgeon is paramount to achieving natural-looking and satisfying results. Potential risks are generally minimal, and with proper preoperative preparation and postoperative care, individuals can enjoy a more rejuvenated gaze. As with any cosmetic surgery, open communication with the surgeon and realistic expectations play a crucial role in the success of the procedure.

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