Lower blepharoplasty

Lower blepharoplasty, also known as lower eyelid surgery, is a cosmetic eyelid procedure that removes or repositions excess fat and addresses loose skin and muscle beneath the eyes.  By correcting these age-related changes, lower blepharoplasty can reduce under-eye bags and create a smoother, more refreshed appearance.

Under-eye bags, dark circles, and tear troughs are different concerns, although they can occur together. 

Each has different causes and may require a different treatment.

Under-eye bags are commonly caused by protrusion of the natural fat beneath the eyes. Aging-related tissue changes, skin laxity, and genetics can make them more prominent.

Dark circles may result from shadows created by under-eye bags or tear troughs, but can also be caused by pigmentation, thin skin, or visible blood vessels. Lower blepharoplasty may not correct dark circles caused primarily by these factors.

A tear trough is a hollow along the transition between the lower eyelid and cheek, where the skin is adherent to the bone.  Aging-related changes in soft tissue and the midface can make it more prominent, creating shadows that make the eyes appear tired or sunken. 

Because these concerns have different causes, lower blepharoplasty should be individualized rather than simply removing fat.

Lower blepharoplasty may be appropriate for patients with prominent under-eye bags, lower eyelid fat protrusion, excess lower eyelid skin, or puffiness that creates a tired or aged appearance.

The procedure may also benefit patients with tear troughs or lower eyelid–cheek contour changes when these are related to the underlying eyelid anatomy. In selected patients, lower eyelid fat can be repositioned rather than simply removed to create a smoother transition between the eyes and cheeks.

Not everyone with dark circles or under-eye concerns needs lower blepharoplasty. During consultation, I assess the lower eyelid, skin quality, fat distribution, tear trough, eyelid support, and midface to determine whether lower blepharoplasty alone—or another or combined treatment—is most appropriate.

My approach to lower blepharoplasty begins with identifying the cause of the under-eye concern rather than simply removing fat.

Under-eye bags can result from lower eyelid fat protrusion, prominent orbicularis muscle, skin laxity, tear troughs, or a combination of these factors. Dark circles and under-eye hollowness may have different causes and may not be fully corrected by lower blepharoplasty alone.

During consultation, I assess the lower eyelids in relation to the cheeks and midface to determine whether lower blepharoplasty alone is appropriate or whether another or combined procedure would provide a more balanced result.

Under-eye puffiness or a tear trough may occur together with cheek descent, deep nasolabial folds, and jowling. When the cheeks and midface have descended, simply removing the eyebags may make the surrounding facial sagging appear more noticeable.  In these situations, treating the lower eyelids alone may not provide the rejuvenating result the patient is looking for. A more comprehensive facial approach, such as a Deep Plane Facelift combined with Lower Blepharoplasty, may provide better overall facial balance.

Not everyone with dark circles or tired-looking eyes needs Lower Blepharoplasty.

I recommend the procedure when physical examination shows a specific problem that Lower Blepharoplasty can address, such as excess lower eyelid fat or prominent orbicularis muscle.

If these findings are accompanied by significant cheek or facial sagging, I may recommend addressing both concerns rather than treating the eyelid alone. The goal is to avoid creating a situation where removing under-eye fullness makes the surrounding cheek laxity appear more prominent.

There are two main approaches to Lower Blepharoplasty: Transconjunctival Blepharoplasty and Subciliary Blepharoplasty. The choice is not simply based on whether a patient wants a scarless procedure. It depends on the patient's anatomy, skin quality, concerns, and the surgical goals.

Transconjunctival Lower Blepharoplasty is performed through the inside of the lower eyelid, leaving no external scar. It can be particularly useful for younger patients with isolated excess lower eyelid fat and for patients with thinner, less elastic skin who may have a higher risk of lower eyelid retraction.

Subciliary Lower Blepharoplasty uses an incision just below the eyelashes. I may prefer this approach when the main concerns include prominent lower eyelid muscle, tear trough deformity, or specific anatomical changes that require greater surgical exposure. It allows me to directly visualize and address the underlying structures more precisely.

I generally avoid removing lower eyelid skin during the initial Lower Blepharoplasty because excessive skin removal, particularly while postoperative swelling is present, can increase the risk of lower eyelid retraction or ectropion. In many patients, the remaining skin gradually contracts and improves over the following months. If additional skin removal is still appropriate after healing, it can be considered later.

One of the most important decisions during Lower Blepharoplasty is determining how much lower eyelid fat should be treated.

I believe the amount should be individualized rather than following a fixed rule of removing either "as little as possible" or a predetermined amount. The goal is to adequately address the fat contributing to the eyelid bags while maintaining a natural transition between the lower eyelid and cheek.

The lower eyelid contains three main fat compartments, and all need to be carefully evaluated during surgery. Inadequate treatment can leave residual fullness, while excessive removal can create an overly hollow appearance.

In selected patients, lower eyelid fat can be repositioned to soften a tear trough or improve the transition between the eyelid and cheek.

However, lower eyelid fat is limited in volume and cannot adequately replace the volume or correct the descent of an entire sagging cheek. When the underlying problem involves significant midface or facial descent, facial repositioning with a Deep Plane Facelift may provide a more comprehensive solution than relying on fat repositioning or fat grafting alone.

A successful Lower Blepharoplasty is not simply the removal of "eyebags." It is a carefully planned procedure that addresses the specific anatomy responsible for the patient's concern while protecting the delicate structures of the lower eyelid.

It is also important to have realistic expectations. Lower Blepharoplasty primarily addresses lower eyelid bags and certain forms of puffiness. It does not automatically eliminate dark circles, fine wrinkles, or significant under-eye hollowness. These concerns may require different or additional treatments.

Lower eyelid surgery continues to change as swelling decreases, the skin contracts, and the tissues remodel. Although the initial recovery occurs within weeks, final contour refinement can take many months and may continue for up to a year.

My goal is not simply to make the eyebags disappear. I want the eyes to look refreshed, natural, and harmonious with the rest of the face.

For some patients, the best result may involve combining Lower Blepharoplasty with Upper Blepharoplasty, Deep Plane Facelift, or another complementary procedure. A holistic assessment allows me to determine which combination, if any, is appropriate.

Ultimately, Lower Blepharoplasty should be individualized to the patient's anatomy and goals. By assessing the eyes together with the midface and lower face, I can determine whether Lower Blepharoplasty alone is sufficient or whether a more comprehensive facial rejuvenation approach would provide a more balanced and natural result.

By Dr. Aicee Bernal (officially licensed as Ma. Concepcion M. Bernal MD

Board-Certified Plastic and Reconstructive Surgeon

Manila, Philippines

Before surgery: 

Your medications and supplements will be reviewed during consultation. If you take anticoagulants, antiplatelet medications, or other medicines that may increase bleeding, you will be given individualized instructions regarding whether and when they should be adjusted.

Anesthesia: 

Lower blepharoplasty may be performed under local anesthesia or, when appropriate, with IV sedation in a hospital setting. The choice depends on the surgical plan, patient's preference, and overall medical considerations.

Procedure:

Lower blepharoplasty is performed through either a subciliary incision beneath the lower eyelashes or a transconjunctival incision inside the lower eyelid. The appropriate approach depends on the patient's eyelid anatomy, skin quality, amount of fat protrusion, and surgical goals.

During surgery, the lower eyelid fat may be carefully removed, reduced, or repositioned depending on the patient's anatomy. When appropriate, fat repositioning can soften the tear trough and create a smoother transition between the lower eyelid and cheek. Skin and muscle are addressed selectively when necessary, while preserving the natural shape and function of the lower eyelid.

There are two main approaches to lower blepharoplasty: transconjunctival lower blepharoplasty and subciliary lower blepharoplasty. The choice depends on the patient's eyelid anatomy, skin quality, fat distribution, and surgical goals.

Subciliary Lower Blepharoplasty 

A subciliary lower blepharoplasty uses an incision just below the lower eyelashes. This approach provides access to the lower eyelid skin, muscle, and fat and may be appropriate when there is excess skin or other anatomical changes that require an external approach.

The incision is placed along the natural lower eyelid contour, where the scar typically becomes less noticeable as it heals.

 Transconjunctival Lower Blepharoplasty (Scarless Lower Blepharoplasty)

Transconjunctival lower blepharoplasty uses an incision inside the lower eyelid, leaving no visible external scar. It is particularly useful for patients with prominent lower eyelid fat and limited excess skin.

Because the approach avoids an external skin incision, it may be preferred in selected patients when lower eyelid fat is the primary concern.

There is no single technique that is best for every patient.  During consultation, I assess the lower eyelid skin, fat compartments, muscle, tear trough, eyelid support, and surrounding midface before deciding which approach is most appropriate.

• Post-op Medications: Medications after surgery, including pain relievers, antibiotics, and eye medications when indicated, are prescribed based on the individual patient and surgical technique.

• Suture Removal: Sutures are usually removed after about 6–7 days for subciliary lower blepharoplasty. Transconjunctival lower blepharoplasty generally does not require external skin sutures.

• Downtime: Swelling, bruising, and mild discomfort are expected during the early recovery period. Cold compresses and keeping the head elevated can help reduce swelling. Most patients can return to work within about 7–14 days, depending on the amount of swelling and bruising and the nature of their work.

• Scarring: Subciliary lower blepharoplasty leaves a fine scar along the lower lash line that typically becomes less noticeable as it matures. Transconjunctival lower blepharoplasty has no external skin incision or visible external scar.

• Results: The initial improvement becomes noticeable as swelling decreases, but the lower eyelids may continue to change as the tissues heal and the skin gradually contracts. The final contour may take several months to refine, with scar and tissue maturation continuing for up to a year. Recovery varies depending on the surgical technique, amount of tissue treated, individual healing, and whether another procedure is performed at the same time.

The cost of lower blepharoplasty in the Philippines varies depending on the surgical technique, anesthesia, surgical setting, complexity of the procedure, and what is included in the surgical and hospital fees. For patients considering lower eyelid surgery in Manila, the total cost depends on whether the procedure is performed under local anesthesia in the clinic or in a hospital with anesthesia services.

Cost of Lower Blepharoplasty for uncomplicated cases

Lower Blepharoplasty Under Local Anesthesia: ₱55,000–₱70,000*

Subciliary Lower Blepharoplasty: ₱55,000
Transconjunctival Lower Blepharoplasty: ₱70,000
When performed in the clinic under local anesthesia. Postoperative medications are not included.

Lower Blepharoplasty Under Sedation in a Hospital: ₱130,000–₱170,000*

Hospital-based surgery with a board-certified anesthesiologist. This estimate excludes preoperative laboratory tests, medical clearance, and postoperative medications.

The difference in cost primarily reflects the surgical technique, surgical setting, anesthesia, hospital and operating-room fees, and anesthesia services. These prices are provided as a general guide and may change depending on the patient's individual surgical plan and the facilities or services required. A final quotation is provided after consultation and treatment planning.

Lower blepharoplasty is generally a safe procedure when carefully planned and performed, but like any surgery, it carries potential risks and complications. During consultation, I discuss the expected benefits, alternatives, and possible complications, as well as measures taken to minimize these risks.

• Bleeding or hematoma
• Infection
• Dry eyes or eye irritation
• Lower eyelid retraction or Ectropion
• Asymmetry or Contour irregularity
• Difficulty closing the eyes
• Visual Changes
• Scarring

Lower blepharoplasty requires careful assessment of the lower eyelid, fat compartments, eyelid support, tear trough, and relationship between the eyelid and midface. My training in Plastic and Reconstructive Surgery informs an individualized approach to preserving lower eyelid function while addressing the specific anatomy responsible for each patient's concern.