Lower blepharoplasty
All cosmetic surgery involves risks and individual results vary. Cosmetic surgery is a serious decision. Decisions about whether to proceed should be made after careful consideration and following at least two consultations with a qualified medical practitioner.
Lower blepharoplasty — lower eyelid surgery — is a surgical procedure that addresses puffiness, bags under the eyes, excess skin, and fine wrinkles in the lower eyelid region. With age, the orbital fat that cushions the eye can prolapse forward through a weakening orbital septum, creating the characteristic bulging appearance under the eyes. Lower blepharoplasty addresses this by removing or redistributing the prolapsed fat, with or without removal of excess skin, depending on the technique used and the patient’s anatomy.
Lower blepharoplasty is technically more demanding than upper blepharoplasty and carries a different risk profile — in particular, the risk of ectropion (outward turning of the lower lid). Technique selection and conservative tissue handling are important in minimising this risk. Dr Roth will discuss the most appropriate approach for your anatomy at consultation.
All surgery carries risks — read the full blepharoplasty risks page → | Full blepharoplasty overview →
Am I a Candidate?
You may wish to discuss lower blepharoplasty with Dr Roth if you have concerns about any of the following:
Under-Eye Bags
Puffiness or fullness caused by prolapsed orbital fat pushing forward through a weakened orbital septum
Excess Skin
Loose or crepey lower eyelid skin creating fine wrinkles and a tired appearance
Tear Trough Hollowing
The shadowed groove between the lower eyelid bag and the cheek — fat repositioning can improve the transition
Tired Appearance
A fatigued look around the eyes that is present even when well-rested and does not reflect how you feel
Not all under-eye concerns require surgery. Tear trough filler, for example, may be appropriate for some patients. Dr Roth will discuss all relevant options at consultation.
The Consultation
- A detailed discussion of your goals and expectations
- A review of your medical history, medications, allergies, and any previous eye surgeries
- A physical examination of the lower eyelids — assessing skin laxity, fat prolapse, lid tone, and the position of the lower lid margin
- Assessment of lower lid laxity — important in determining whether a canthopexy or canthoplasty is needed to support the lid and reduce the risk of ectropion
- An evaluation of tear production and dry eye symptoms — these can be worsened by lower eyelid surgery
- Pre-operative photographs for planning purposes
- A full discussion of risks, recovery, and realistic outcomes
A minimum of two consultations is required before any cosmetic surgical procedure proceeds.
The Procedure — Two Main Approaches
The technique used depends on your anatomy — specifically whether the primary concern is fat prolapse alone, or fat prolapse combined with excess skin or muscle laxity.
Canthopexy and Canthoplasty
In patients with lower lid laxity or a tendency to snap-back slowly, a canthopexy (tightening of the outer canthal tendon without cutting it) or canthoplasty (reconstruction of the outer canthal tendon) may be performed at the time of surgery to support the lower lid margin and reduce ectropion risk. This will be discussed and planned at consultation if applicable.
Recovery
Important Post-Operative Instructions
- Apply cold compresses gently over closed eyelids — do not apply direct pressure to the eyes
- Keep head elevated on two to three pillows for the first week, including while sleeping
- Use lubricating eye drops as prescribed
- Do not rub, touch, or apply pressure to the lower eyelids
- Do not wear eye make-up until cleared by Dr Roth (typically two weeks)
- Do not wear contact lenses until comfortable and cleared at follow-up
- Protect the area from sun exposure — use SPF50+ and sunglasses
- Take paracetamol for pain — avoid ibuprofen and anti-inflammatory medications
- Attend all follow-up appointments — lower lid healing requires careful monitoring
Risks and Complications
Lower blepharoplasty carries real risks that must be understood before proceeding. Common side effects include temporary swelling, bruising, dry eyes, itching, and sensitivity to light. More serious complications include infection, bleeding, scarring, asymmetry, changes in sensation, ectropion (outward turning of the lower eyelid — the most significant risk specific to lower blepharoplasty), lagophthalmos (difficulty fully closing the eye), and — very rarely — changes in vision. Some complications may require further surgical intervention.
Read the full blepharoplasty risks page →
Frequently Asked Questions
Common questions about lower blepharoplasty answered by Dr Jason Roth, Specialist Otolaryngologist and Head and Neck Surgeon, Sydney.
Upper blepharoplasty addresses excess skin and fat in the upper eyelid, typically restoring the eyelid crease and opening the eye. Lower blepharoplasty addresses the lower eyelid — specifically the fat prolapse, excess skin, and tear trough hollowing that creates the under-eye bag appearance. The two procedures have different anatomical goals, different techniques, and a different risk profile. They are frequently combined in the same anaesthetic where both the upper and lower eyelids are of concern.
This depends on your anatomy and is determined at consultation. The transconjunctival approach (no external scar) is preferred when the primary concern is fat prolapse and the lower eyelid skin quality is good — with adequate elasticity to contract after fat removal. The transcutaneous approach (external subciliary incision) is used when there is also excess skin or significant muscle laxity that needs to be addressed. Dr Roth will assess your anatomy carefully and recommend the most appropriate technique.
Ectropion is the outward turning of the lower eyelid margin away from the eye — the most significant complication specific to lower blepharoplasty. It can cause the lower lid to droop, exposing the inner surface of the lid, and can lead to significant dry eye symptoms, tearing, and cosmetic disturbance. It is caused by excessive skin removal, vertical tension on the lower lid, or pre-existing lower lid laxity.
Prevention involves: conservative skin excision, careful technique, avoiding over-resection of skin, and performing a canthopexy in patients with pre-existing lower lid laxity. Dr Roth assesses lower lid tone (the “snap-back” test) at consultation to identify patients at higher risk. Mild ectropion often resolves with massage and time; more significant ectropion may require revision surgery.
Lower blepharoplasty is not associated with a Medicare rebate in the way upper blepharoplasty can be for functional visual field impairment. Lower eyelid surgery is almost always considered cosmetic for Medicare purposes. A detailed quote covering all fees — surgeon, anaesthetist, and hospital — will be provided at consultation.
- Days 1–3: Swelling and bruising peak. Rest at home, cold compresses, head elevation.
- Days 5–7: Suture removal (transcutaneous cases). Bruising fading.
- 10–14 days: Most patients comfortable in social settings.
- Weeks 2–4: Return to work and most normal activities.
- Months 3–6: Final result apparent. Scars fading.
It can — depending on the technique used and your anatomy. When the fat is repositioned (rather than simply excised) during transconjunctival lower blepharoplasty, it can be placed into the tear trough depression to improve the transition between the lower eyelid and the cheek. This fat repositioning approach specifically addresses both the bulge and the hollow simultaneously. The degree of tear trough improvement achievable varies between individuals and is discussed at consultation.
For patients with significant tear trough hollowing but minimal fat prolapse, tear trough filler may be a more appropriate non-surgical option and will be discussed at consultation.
The removal of prolapsed fat is durable — the fat does not regrow. For transcutaneous cases where skin has been excised, the result is also long-lasting, though the remaining lower eyelid skin continues to age over time. Most patients find their result remains satisfying for ten years or longer before any further change becomes noticeable. Individual variation in ageing rate, genetics, and sun exposure all influence how the result evolves.
Blepharoplasty Overview → | Upper Blepharoplasty → | Brow Lift → | Blepharoplasty Risks → | Pre-Operative Information →
Dr Roth’s Clinical Perspective
Lower blepharoplasty requires a more conservative approach than upper blepharoplasty, and the most common complication I see from lower blepharoplasty performed elsewhere is over-resection — too much skin removed, producing lower lid retraction and scleral show. The lower eyelid is under constant gravitational and muscular tension, and any scarring or shortage of skin will tend to pull the lid down over time. My approach to the lower lid is conservative on skin excision and to rely on the fat repositioning or transconjunctival approach to address the under-eye fullness without compromising lid support.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS), IBCFPRS
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
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