When Do I Do a Lower-Eyelid Blepharoplasty and How?

Like the upper eyelid, I find myself performing many more fat transfers to correct the aging process than traditional eyelid surgery.  Further, if I perform a traditional lower-eyelid procedure I will almost always use some fat transferred to improve the result.  In fact, I look at traditional eyelid surgery as a complement to fat grafting, rather than the other way around.

There are two principal ways to manage the lower eyelid traditionally, either a skin-muscle procedure in which there is an external incision or through what is known as a transconjunctival approach that has no skin incision.  I prefer the latter approach not to limit the risk of scarring, which is pretty minimal, but to avoid changing the shape and contour of the lower eyelid.  When surgeons use a skin-muscle flap, they must tack the suture to the lining of the bone.  When that occurs, there can be slight inaccuracy or change during the healing process such that the canthus (where the upper eyelid meets the lower eyelid) can be altered so the person does not look the same or worse yet does not look natural.  For this reason, I almost never make an incision in the lower eyelid skin if I can avoid it.

I use the analogy of the typical eyebags as “rocks” that appear only when the tide (fat level) is low and so the way to manage the eyebag is to refill the tide (fat) to a higher level to cover it up.  This works in about 90% of individuals.  At times however the eyebag is so prominent that you simply cannot cover it up with fat.  In these cases, which are less than 10% of the time, I have to remove some fat at the same time that I add it below the existing fat.  This combination of reducing the rocks and increasing the tide can help effect the most favorable desired change for a smoother result in the lower eyelids.

I have been asked though what about the wrinkles?  That is a matter for neurotoxin (Botox) and laser skin resurfacing to help manage the aging of the skin.  I believe cutting away wrinkles surgically simply does not work and can contribute to the problem mentioned above of changing the eyelid shape, which is a terrible thing.


Sam M. Lam, MD, FACS is a board certified plastic surgeon in Dallas, Texas. To schedule a consultation please call 972.312.8188. To Learn more about Dr Lams’ surgery procedures or to ask Dr Lam a question please visit his surgery forum.