Mechanism
Lower eyelid aging progresses in two main ways: herniated orbital fat creating under-eye bags, and laxity of the skin and orbicularis oculi muscle causing wrinkles and sagging skin. Lower blepharoplasty (skin excision) addresses the latter. Through a subciliary incision placed just beneath the lower lash line, the surgeon elevates a skin (or skin-muscle) flap, addresses fat pads if necessary, drapes the flap superolaterally to measure the true excess skin, trims the precise amount, and closes the incision. Located within the natural subciliary crease, the resulting scar fades exceptionally well.
When is skin excision needed instead of transconjunctival fat removal alone?
A simple assessment test: look up at the ceiling and open your mouth—if the fat bags protrude prominently while the skin remains taut and smooth, the primary issue is orbital fat, making a transconjunctival approach (no external skin incisions) the ideal choice. If the skin appears wrinkled, creased, and sagging when looking straight ahead, excess skin is the primary concern, requiring skin excision; many patients over 50 present with both.
Why is ectropion a risk that must be addressed beforehand?
The lower eyelid is supported by the canthal tendons and orbicularis oculi muscle tone; both weaken with age. If more skin is removed than the eyelid can tolerate, the lid margin can be pulled downward (ectropion, lower scleral show), leading to tearing, dry eyes, and an aesthetic outcome worse than before. Surgeons minimize this risk by measuring excess skin while the patient looks up with their mouth open (the position of maximum lower lid tension), adopting a conservative excision approach, and performing lateral canthal reinforcement (canthopexy/canthoplasty) when lid laxity is present.
Risks to consider
Ectropion or lower scleral show, pinkish subciliary scars for the first few months, prolonged swelling and bruising, temporary dry eye symptoms, asymmetry, hematoma, infection (rare), and temporary numbness of the eyelid skin. Over-resecting orbital fat can lead to a hollowed appearance and deeper tear troughs.
At BonBoz
Our plastic surgeons conduct in-person consultations: performing the snap-back test to evaluate eyelid tone, the look up–open mouth maneuver to measure true excess skin, and thoroughly assessing fat herniation alongside tear trough deformities. The surgical plan may involve skin excision alone, skin excision with fat management, or a combination with fat repositioning when a tear trough is present; canthal reinforcement is integrated when eyelid laxity is detected. The consulting surgeon directly performs your procedure, strictly prioritizing conservative skin removal to prevent ectropion.
