Lower blepharoplasty: reducing eye bags, laxity or lines under the eyes

What problems lower blepharoplasty corrects

Changes in the lower eyelid affect not only the appearance of the face but the emotional impression it conveys. The surgery is indicated to treat the following:

• Visible pads of fat under the eyes.
• Lax skin in the lower eyelid.
• Folds or fine lines forming in the area.
• Hollowing of the groove between the eyelid and the cheek.
• Loss of definition in the contour around the eye.
• Asymmetry or drooping of the lower eyelid.

Bags and lines can be due to natural ageing, genetics, chronic tiredness, stress or loss of volume in the cheekbone area. Treatment has to be adapted to the origin of the problem, since not every case calls for the same technique.

Pre-operative assessment

Before a lower blepharoplasty is carried out, a complete medical assessment is needed, centred on three areas:

• Analysis of the excess or deficit of volume in the area below the eye.
• Assessment of the state and quality of the skin of the lower eyelid.
• Review of the muscle tone of the eyelid and of its relationship with the cheek.

At this consultation any history of dry eye, eyelid laxity or previous eye surgery is also explored, since these could influence the type of operation recommended. The study includes examining the eyelid both at rest and in movement, to assess the lateral support and the possibility of retraction after surgery.

The choice of technique has to rest on the individual anatomy and not only on outward appearance. That is why, at the Instituto de Cirugía Plástica del Mediterráneo, a precise diagnosis is made before any operation.

The surgical techniques available

There are various techniques for lower blepharoplasty, selected according to the state of the skin, the amount of fat, the muscle tone and the patient’s goals. The most used are:

The transconjunctival technique

This technique is carried out through the inside of the eyelid, reaching the fat pads with no need for a visible incision. It is indicated in patients with excess fat but no significant laxity of the skin.

The advantages of this technique are:

• It leaves no external scars.
• It keeps the eyelid in its natural position.
• It reduces the risk of eyelid retraction.
• It allows a quicker recovery.

It is particularly recommended in younger people or in those with good skin quality.

The subciliary or transcutaneous technique

An incision is made just below the lash line, giving access to the fat and also allowing surplus skin to be removed if necessary. This technique is suitable for patients with lax skin, marked lines or skin with little elasticity.

In this operation:

• The pads of fat are removed or redistributed.
• The skin is tightened by moderate removal.
• Additional manoeuvres can be carried out to improve the support of the eyelid.

In some cases it is combined with a canthopexy or canthoplasty, techniques that stabilise the outer corner of the eye and prevent changes after surgery.

The laser technique

The laser can be used to make the incisions or as a complement to tighten the skin after surgery. This technology allows precise sealing of vessels, reduces bleeding and improves the quality of healing. Fractional laser can also be applied externally to treat fine lines.

What holds the eyelid up, and what is done with the fat

Two decisions account for much of the result in the lower eyelid, and both are reasonably well defined by the literature.

The first is support. The most cited review of the subciliary route brought together 264 primary lower blepharoplasties over ten years, and its conclusion was not about how much skin to remove but about the corner of the eye: reinforcing the outer canthus should be a routine part of the operation, not something reserved for difficult eyelids. The shape of the eye is preserved because the eyelid is held up.

The second is what is done with the fat. Here the discussion has moved ground: it is no longer how much is taken out but where it is put. A series of 339 lower blepharoplasties, with a mean follow-up of nearly thirteen months, compared two ways of dealing with the tear trough — repositioning the patient’s own fat or grafting it — and both resolved it, with single-digit revision rates. What they share is the underlying criterion: the aim is not to empty the eyelid, it is to fill the step that separates it from the cheek.

Hence the technique is not chosen from a catalogue. A younger eyelid, with bags and good skin, is resolved from the inside; one with surplus skin calls for the external route and, with it, support for the corner. In both cases the fat is handled with the idea of restoring contour, not of subtracting volume.

Anaesthetic and length of the operation

Lower blepharoplasty can be carried out under local anaesthetic with sedation or under general anaesthetic, according to the complexity of the case and the patient’s preference. The operation takes approximately 60 to 90 minutes and is done as a day case.

The patient goes home the same day, with the aftercare instructions already given. In every case the surgery is carried out in a safe surgical setting, with technology for monitoring during the operation and under evidence-based medical protocols.

Aftercare following lower blepharoplasty

Recovery requires certain specific measures to reduce swelling and help proper healing. The most usual advice is:

• Applying cold locally during the first 48 hours.
• Sleeping with the head raised to help drainage.
• Avoiding physical exertion and direct sun exposure.
• Not rubbing the eyes or applying make-up during the first week.
• Following the medication prescribed.

With the subciliary technique, stitches come out between the fifth and seventh day. With the transconjunctival technique no external stitches are needed. Swelling can last between 7 and 10 days and any bruising fades gradually.

The final result is apparent between the third and sixth week, although the tissues can take several months to settle fully. During that period slight temporary asymmetries or a feeling of tightness are normal and resolve with time.

Results and how long the effect lasts

Lower blepharoplasty gives lasting and natural-looking results when carried out with the right technique. The benefits include:

• Reduction or removal of the bags under the eyes.
• Smoothing of the groove between eyelid and cheek.
• Fewer lines and folds in the skin below the eye.
• An improved facial contour in the eye region.
• A more rested, youthful and harmonious appearance.

How long the effect lasts depends on the type of skin, lifestyle and the natural course of ageing. In most cases the results hold for many years with no need for touch-ups.

Uncommon complications

As with any surgery there can be risks, although the complication rate is low. The possible ones include:

• Bruising after surgery.
• Retraction of the eyelid if too much skin is removed.
• A visible scar with the subciliary technique (rare).
• Infection or eye irritation.
• Temporary dry eye.

These complications are uncommon when surgery is carried out at an accredited centre and to rigorous medical criteria. At the Instituto de Cirugía Plástica del Mediterráneo, patients are followed closely after surgery so that anything untoward is picked up and treated early.

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Lower blepharoplasty is an effective and safe operation for correcting the bags, lax skin and lines of the lower eyelid. Its effect on facial expression is notable, since it restores a fresher, brighter and more balanced look. The key to success lies in a precise anatomical assessment, the right surgical technique and careful execution that respects both the function and the appearance of the eye.

If you are considering this surgery, we recommend a consultation with a specialist in facial plastic surgery. At the Instituto de Cirugía Plástica del Mediterráneo you will receive professional care, with an individual diagnosis and a medical approach centred on a natural look, on safety and on aesthetic excellence.