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Lower Eyelid Bulging/Bags

Patients with puffiness, bulging, or bags in their lower eyelids are often told they look tired.  Lower eyelid blepharoplasty flattens these unsightly bulges, helping to restore a more energetic and youthful appearance.

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Bulging fat pads

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After lower blepharoplasty

Aging and gravity are responsible for a number of changes in the lower eyelids.  Bulges or bags occur when pockets of fat push forward through the lower eyelid (see picture).  While everyone normally has fat behind their lower eyelids, aging eyelids loosen and allow the fat to bulge forward.  Eyelid skin slackens and wrinkles with age because it loses elasticity, in the same way that an old rubber band loses its ability to snap back to its original size.  Lower eyelid blepharoplasty improves the appearance of lower eyelids in two ways:  it flattens bulging pockets of fat and removes excess skin, if present.

As lower blepharoplasty does not improve vision in any way, it is always considered cosmetic and is never covered by insurance.


Dr. Lee uses a two incision approach for lower eyelid blepharoplasty.  Fat is removed by a hidden incision on the inside of the eyelid (trans-conjunctival incision).  Excess skin is then removed using an incision just below the eyelashes.  Neither of these incisions causes any visible scar.

For more photos, visit the Gallery

Aging and gravity may also cause formation of a "tear trough" indentation at the junction of the lower eyelid and cheek partly because of a shadow effect from bags, and partly because the cheeks deflate and descend, leaving a hollow previously occupied by cheek tissue.

In patients with tear trough indentations, fat repositioning during blepharoplasty can help fill in the sunken areas. 

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Tear trough indentation due to cheek descent and loss of tissue

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After lower blepharoplasty with fat repositioning

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Festoons cannot be corrected by

standard lower blepharoplasty

Not every patient is a good candidate for lower blepharoplasty.  If the skin over the cheek has become stretched out over time, cheek pouches called festoons may result (see picture);  these cannot be flattened with traditional lower eyelid surgery alone.

If a patient's major complaint is skin wrinkling occurring with smiling, this, also, cannot be corrected by blepharoplasty, because they are the result of muscle action and not excess skin (see picture).  Botulinum (Botox) injections may be a better option in this situation.  If the cheek bone is set too deep with respect to the eyeball, full removal of bags may cause a sunken or hollow appearance.

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Wrinkles due to smiling muscle action and not excess skin

are better treated with botulinum toxin (Botox) injections

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Lower lid retraction

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After repair with tissue graft to lower eyelid

Historically, lower eyelid blepharoplasty was performed using a single incision just below the eyelashes, but this was found to cause the lower eyelid to sink to a lower position in a certain percentage of patients ("lower eyelid retraction").  The two incision approach used by Dr. Lee has been shown in studies to minimize the chances of lower eyelid retraction (Ophthal Plast Reconstr Surg. 2008 Jan-Feb;24(1):7-9;  Ophthalmology. 1989 Jul;96(7):1027-32)

Lower eyelid blepharoplasty can yield wonderful results, but it is important to have realistic expectations.  Here is what lower eyelid blepharoplasty cannot do:

    1)  make your eyes look the way they did when you were twenty

    2)  eliminate all skin wrinkles

    3)  duplicate the effect of stretching your eyelid with your finger

    4)  pull up the cheeks to fill in the tear trough indentation, as this would be part of a face lift (although lower blepharoplasty with fat repositioning can help this greatly)


The risks of lower eyelid surgery are the same as for upper eyelid blepharoplasty.  Blindness has been reported to occur in a very small percentage of patients (about 0.005%, or 1 out of 20,000 patients).  To put this in perspective, you are three times more likely to die in a car accident in Georgia over one year than go blind in one eye from blepharoplasty (Georgia vehicle crash death rate was 0.015% in 2016).  Infection is possible with any surgery, but the chance of it occurring is incredibly low with eyelid surgeries due to the excellent blood flow in the eyelids.

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Before surgery

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After upper and lower blepharoplasty

For more photos, visit the Gallery

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