Custom Cosmetic Blepharoplasty of the Lower Lids

By Joseph Walrath, MD | Jun 17, 2017 | Blepharoplasty, Cosmetic

Are you a cookie cutter lower lid cosmetic patient?

The old adage, “When all you’ve got is a hammer, everything is an anvil” is also quite true in lower blepharoplasty.  There are countless ways to perform lower blepharoplasty, some ways hard, some ways easy.  Unfortunately, the easy ways really only work for a specific subset of patients, patients with minimal tissue redundancy or laxity, who have never undergone prior surgery.  For everyone else, it’s the hard way… or a beeline to a bad outcome. Consequently, most enlightened plastic surgeons tend to avoid the patients that require more advanced techniques.  Put another way, when speaking to surgical scrub technicians during surgery last week, I asked if anyone else did the technique I was doing, and the answer was, “No, the plastic surgeons we work with don’t operate on patients like this.”


Lower lid anatomy relevant to the cosmetic surgeon

Figure 1. Cosmetic lower lid anatomy.


A thorough appreciation of eyelid anatomy is critical for successful lower blepharoplasty outcomes.  Lid tone (the ability of the lid to snap back into position after being pulled away from the eye) is related to muscle and tendon laxity.  Any significant laxity of these structures needs to be addressed surgically.  Significant laxity necessitates an “open” approach to lower blepharoplasty, as opposed to an “inside-the-eyelid”, or transconjunctival, approach.  The presence of malar (cheek) edema below the bony eye socket rim is critically important to note.  A lower lid surgery that does not also tighten the midface will likely lead to persistance of that edema, and an unhappy patient!   The degree of tear trough hollowing is important to note, as this may make fat transfer more important than simple fat removal.  Minimal hollowing without excessive fat, in a young person, may be treated with filler alone. The activity of the orbicularis is important, as adjunctive Botox may be required for optimal results.

When planning surgery, the decision tree that I utilize is depicted below (Figure 2):


Figure 2. Decision tree for lower blepharoplasty


Transconjunctival lower blepharoplasty

Don’t get me wrong, sometimes simply plucking out a little fat from the lower lid and calling it a day is the right approach.  This type of procedure, called “transconjunctival”,  often has the shortest “down time” of the range of lower lid cosmetic surgical techniques.  This technique works quite well for young-ish patients with good lid tone, minimal skin and muscle excess, and a net excess of fatty eyelid tissue.  However, there are some serious drawbacks with this technique:

1. It does not address potential lid laxity through tightening.  Caveat:  the lid can be tightened with advanced techniques performed at the same time as upper blepharoplasty.    However, this is often neglected, or so it seems, based on the sheer number of late-term eyelid mechanical complications that I see in patients with a history of cosmetic transconjunctival lower blepharoplasty.

2. It does not address the muscular sling of the lower lid in any meaningful way.  In some patients, this muscular sling is lax and the cosmetic complaints are directly due to that abnormality.

3. It cannot address very loose skin or excess lower lid muscular bulk.

4.  It can combine fat transfer from the eye socket into the tear trough, but in general this technique is not as robust as transferring fat pedicles with an open incision.  Most importantly, fat transfer from either approach expands the healing time associated with the procedure by several weeks (in the form of low grade nonspecific swelling of the lower lid and cheek), and consequently, this nullifies the chief advantage that I see with transconjunctival lower blepharoplasty: shorter downtime.


Open lower blepharoplasty

The more advanced lower blepharoplasty technique is “open”, or “transcutaneous”.  This involves a skin incision at the outset, via which all the eye socket tissue is accessed.  The open technique provides the best access to tighten the lateral canthal tendon of the lower lid, in patients with loose lids.  In certain, more advanced cases, open lower blepharoplasty allows better access to other internal structures of the lower lid that are important, the so-called lowed lid retractors, which occasionally require modification.   For patients with significantly loose skin and/or muscle, the open technique is, in my experience, the best.  To wit:  I have on one or two occasions been unhappy with a “transconjunctival” outcome because of the excess skin and muscle laxity that was not addressed, and I subsequently performed a followup “open” lower blepharoplasty in the office treatment room setting (at no charge to the patient!) to correct this.


Triad Tightening of the Lower Lids

I refer to the open lower blepharoplasty approach that I utilize as the “Triad” lower blepharoplasty, because it is the only technique that can adequately address the three structures that become loose with age: the lid tendon, the surrounding muscle, and the lower lid skin.  This technique is particularly important in patients who tend to swell and retain fluid in the lower lids at baseline.  (In my schema, I think of the lower lids as sponges that can retain water, in which normal eyelid movements “wring” out the sponge.  By tightening each layer of the eyelid, the sponge becomes more efficient at wringing out the water.”)

In patients with midface edema (“festoons”) below the lower lids, this Triad tightening must include the suspensory muscular system of the cheek, a.k.a. a midface lift  (This is NOT the same as a facelift!).  The muscular system that encircles the eyelids, the orbicularis oculi muscle, is also tightened independently of the cheek.  The ligamentous structures of the eyelid itself are then also tightened, with a procedure known as a lateral canthoplasty.  Finally, the skin itself is tightened, often by removing vertical excess prior to closure. All of these steps can be seen in a surgical photo montage on this site.

Fat transfer from the eye socket into the cheek is often performed at the same time.  The source of the fat is important, because it remains attached to its blood supply within the eye socket.  This means that this fat survives, as opposed to fat that is harvested in a syringe and injected into the midface.



Lower blepharoplasty is a highly individualized surgery.  Some techniques that would work on one patient would fail, or lead to complications, on another.  It is important to tailor the surgical approach to each individual patient’s anatomy.