Eyelid Surgery (Blepharoplasty)

Lower Blepharoplasty

Overview:

Lower blepharoplasty is a surgical procedure designed to rejuvenate the under-eye area by reducing puffiness, removing ‘bags’, and smoothing loose or wrinkled skin.

As we age, the skin of the lower eyelids becomes thinner and loses elasticity, while the fat that supports the eye can start to protrude forward. This creates the appearance of tiredness, swelling, or dark shadows under the eyes.

Lower eyelid surgery restores a smoother contour between the lower eyelid and the cheek, giving a more rested and youthful appearance. Depending on your anatomy and skin type, there are several ways this can be achieved.

An upper and lower blepharoplasty may also be combined with other facial aesthetic procedures such as a facelift and rhinoplasty.

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Types of Lower Blepharoplasty:

1. Transconjunctival Lower Blepharoplasty

In this approach, the incision is made inside the lower eyelid, leaving no visible external scar. Through this internal incision, excess fat (lower eyelid bags) can be removed or repositioned to smooth out the puffiness.

This technique is ideal for younger patients or those with good skin tone, where the main concern is bulging fat rather than loose skin. It can be combined with fat grafting to further refine the skin surface and improve skin texture.

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2. Subciliary Lower Blepharoplasty

The incision is placed just below the lower lash line, allowing the surgeon to gently lift the skin and underlying muscle. Through this approach, excess skin can be trimmed, and fat can be removed or repositioned to smooth the lid contour and remove wrinkles.

In many cases, rather than removing bulging fat entirely, that fat is used to fill the hollow or groove known as the tear trough. By redistributing volume, it smooths the transition between the eyelid and cheek and avoids a hollow look. Note that fat redistribution is often combined with a midface lift or fat grafting to achieve seamless blending of the under-eye and cheek areas.

For patients with lax lower eyelids, a canthopexy or canthoplasty (tightening of the outer eyelid corner) may be added to ensure proper eyelid support and a natural eye shape.

Indications:

Lower eyelid surgery can help if you have one or more of the following concerns:

• ‍Under-eye bags or puffiness:
  Caused by fat pads pushing forward, creating a tired or swollen appearance even when well rested.
• ‍Skin laxity or fine wrinkles:
  Loose or wrinkled skin below the eyes that makeup cannot conceal.‍
• Tear trough deformity (hollow or shadow under the eye):
  A deep groove or dark circle where the eyelid meets the cheek, often from loss of volume or fat displacement.‍
• Lower eyelid laxity or malposition:

When the eyelid has lost its natural tone and may sag slightly away from the eye, causing irritation.

The goal of surgery is to restore smoothness, reduce heaviness or shadowing, and achieve a natural, rested look.

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Ancillary Procedures:

Lower blepharoplasty can be customised and often combined with other treatments to address the cheek at the same time:

• ‍Midface lift:
  A midface (cheek) lift elevates the soft tissues of the cheek that may have descended with age.
  When performed with lower blepharoplasty, it creates a smoother and more youthful lid-cheek junction.‍
• Fat grafting:
  Small amounts of your own fat can be carefully placed into the under-eye area or upper cheeks to restore lost volume and improve the overall contour between the lower eyelid and the cheek.‍
• Malar implants:
  While some patients are good candidates for fat graft, others may benefit from malar implants, which are small, custom-shaped implants placed over the cheekbone to enhance cheek projection and support the lower eyelid region. By improving cheek structure and volume, malar implants can reduce the appearance of under-eye hollowing and a flat midface, creating a more harmonious and youthful look. These implants can be made from various materials [see link to blog] and can be designed to match the unique bony anatomy of a patient determined from a CT scan. They can be placed through the lower eyelid incision or through a small incision inside the mouth.

Recovery After Eyelid Surgery

Recovery after eyelid surgery varies from person to person, but most patients follow a predictable pattern. The eyelid skin is delicate and bruises easily, so the early stages often look more dramatic than they feel. This settles steadily with time.

What to Expect

First Few Days

During the first two to three days, it is normal to experience swelling, bruising, mild oozing and a feeling of tightness around the eyes. Your eyes may feel dry, gritty or watery, and your vision may be slightly blurry. Using the prescribed ointment and cold compresses will help reduce irritation and swelling. Keeping your head elevated, especially when sleeping, also makes a noticeable difference.

The First Week ‍

After the first few days, swelling and bruising usually begins to settle. The eyelids may still feel firm or tender. Non-dissolving stitches, when used, are usually removed at around five to seven days. Many patients feel comfortable doing light tasks or desk work by the end of the first week, although you may still be self-conscious about bruising. Avoid contact lenses for at least a week and avoid makeup for the first two weeks. Once the skin has healed, protect the area from sun exposure with sunglasses and sunscreen.

Weeks Two to Four‍

Most of the bruising has resolved by this stage, and any remaining swelling is usually mild. You can generally return to routine daily activities. Light exercise can resume, but heavier lifting and strenuous activity should still be avoided.

After Four Weeks‍

The eyelids continue to soften and settle over the next month. Incision lines gradually fade from pink to a fine pale line. Final results are usually apparent between three and six months once all swelling has resolved and the scars have matured.

Possible Risks

Most side effects are mild and temporary, such as swelling, bruising, dryness, tearing, or early asymmetry between the two sides. These usually improve on their own. Less commonly, there may be infection, bleeding, delayed healing, changes in eyelid position or over- or under-correction of skin or fat. Temporary blurred or double vision can also occur. Very rarely, significant bleeding behind the eye can threaten vision. Although this is extremely uncommon, sudden severe swelling, loss of vision or intense pain requires urgent medical attention.

Medicare coverage‍

In Australia, Medicare will only contribute to the cost of an upper eyelid blepharoplasty when the procedure is performed for medical or functional reasons, rather than for cosmetic improvement. To be eligible, there must be clear evidence that excess upper eyelid skin is affecting vision or causing functional problems. Medicare does not cover lower eyelid blepharoplasty or any blepharoplasty performed solely for cosmetic reasons. Even when a Medicare item number applies, there may still be out-of-pocket costs related to surgery, anaesthesia or hospital fees, depending on your insurance cover.