Surgeons have their own preferences when performing lower lid blepharoplasty. The older paradigm used to focus on how much fat and tissue could be removed. The more modern approach often considers how to reposition the fat to retain youthful fullness while eliminating the “bags”.
The way that I generally perform this surgery is through an incision under the lower eyelashes. As you can see below, this incision heals to invisibility rapidly. Through that incision, I separate the ligament that is responsible for the “bulge” or “bag”. This ligament connects the skin of the lower eyelid / upper cheek junction to the bone of the cheek. Separating this can allow for a smooth transition from the eyelid into the cheek without the extra bulge. I then lay the fat over the upper cheek bone, which prevents that ligament from reattaching and also maintains the fullness of the upper cheek.
Below is a recent example of how this procedure can achieve a more youthful lower lid appearance.
(Preoperative). This patient had complained of bags under her eyelids.
Three weeks later: The same patient after lower lid blepharoplasty with fat repositioning. You can still see a little discoloring in the cheek, but it is not significant. You cannot see the incision under the eyelashes at this point. There is still a thickening of the skin incision at the outer corners of the eyelids (not visible in this picture) — that takes longer to disappear but rarely is problematic.
Six weeks later: Notice the pleasant and youthful fullness of both lower lids, without any hollowing, which can make a patient look old or tired.