Lower blepharoplasty I — Assessment and decision algorithm
Applied anatomy, examination of the four components and the complete algorithm that decides approach and associated manoeuvres.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- Four components are examined separately: skin, muscle, fat and malar support. The technique follows from their combination.
- The reference procedure is conservative: transconjunctival resection + transposition + subciliary pinch.
- Avoid the subciliary approach (cicatricial ectropion) and orbicularis resection (denervation ectropion).
- With a tear trough marked by malar deficit, fat transposition is preferable to resection — always.
Applied anatomy: what to keep in mind while examining
The lower eyelid is organised in three lamellae. The anterior is skin and orbicularis; the middle is the orbital septum; the posterior comprises the retractors — capsulopalpebral fascia and inferior tarsal muscle — and conjunctiva. Behind the septum lie three fat compartments: medial, central and lateral. The anatomical fact that most conditions dissection is that the inferior oblique muscle runs between the medial and central compartments: it is the landmark that prevents injuring it and the one that orients the opening. At the orbital rim, the junction of septum with periosteum and the orbital retaining ligaments define the tear trough medially and the tear valley (palpebromalar groove) laterally; releasing those ligaments is what allows the groove to be blurred when transposing fat. The pretarsal portion of the orbicularis provides the tone that keeps the lid apposed to the globe: denervating it is the neurogenic route to ectropion.
Examination of the four components
| Component | How to examine | Finding → action |
|---|---|---|
| Skin | Pinch the excess skin with the patient looking upward | Minimal pinch → transconjunctival. Perceptible pinch or malar bag → add subciliary pinch |
| Muscle | Forced lid closure and exaggerated smile activating the zygomatics | No hypertrophy → transconjunctival ± pinch. Hypertrophy → subciliary with skin and muscle resection |
| Fat | Bag in profile + pressure on the globe to confirm true herniation | Does not pass the cheek (pseudo-prolapse) → filler. Passes it (prolapse) → compartment surgery |
| Malar support | Cheekbone projection and tear trough depth | Malar deficit with marked groove → fat transposition, not resection |
Complete decision algorithm
- Minimal skin laxity, no muscle hypertrophy, true herniationIsolated retroseptal transconjunctival
- Moderate skin laxity, malar bags, no muscle hypertrophyTransconjunctival + subciliary skin pinch
- Orbicularis hypertrophy demonstrated dynamicallySubciliary with skin and muscle resection + canthopexy
- Associated ectropion or pre-existing lid laxityLateral canthopexy + transconjunctival (lower ectropion risk)
- Marked tear trough with pseudo-prolapse from malar deficitPreseptal fat transposition. Add fat grafting if the case is difficult
- Skeletonised eye (volume deficit, not excess)Autologous fat grafting in tear trough and tear valley. Do not resect
- Infraorbital skin rhytidosis without major skin excess35% trichloroacetic acid peel instead of extending the resection
The principle governing the whole indication
In lower blepharoplasty one must be conservative. The reference procedure is transconjunctival compartment resection + transposition + subciliary pinch, deliberately avoiding two manoeuvres: the wide subciliary approach, which produces cicatricial ectropion, and orbicularis resection, which produces it through pretarsal denervation. Resecting fat in pseudo-prolapse deepens the groove and creates the skeletonised eye, whose later correction requires fat grafting with a considerably less predictable result. Under-resecting is always recoverable; over-resecting almost never is.
Characterising the dark circle: not all are surgical
| Predominant | Diagnosis | Treatment |
|---|---|---|
| Colour | Idiopathic orbital rim hyperchromia | Carboxytherapy. Not surgical |
| Oedema or fine wrinkles | Periorbital rhytidosis; rule out medical cause | CO₂ laser or peel |
| Groove | Malar projection deficit with pseudo-prolapse | Fat transposition or filler. Do not resect |
| Volume | True fat herniation | Compartment surgery |
References
- 1.Chou E, Liu J, Seaworth C, et al. Comparison of Lower Eyelid Laxity Measurements. Ophthalmic Plast Reconstr Surg. 2022;38(4):353-357.
- 2.Nassif PS. Lower blepharoplasty: transconjunctival fat repositioning. Facial Plast Surg Clin North Am. 2005;13(4):553-559.
- 3.Gurtner GC, Neligan PC, editors. Plastic Surgery. Volume 2: Aesthetic Surgery. 4th ed. Edinburgh: Elsevier; 2018.
Related specialty: Blepharoplasty