Aesthetic surgical management of the lower eyelid has evolved over several decades. Given the unforgiving nature of the lower eyelid, a number of approaches have been tried but then abandoned because they resulted in complications or inadequate results. Today, there is no single ideal procedure; rather, individual surgeons select from a spectrum of techniques based on their experience and patient goals.

The surgeon gains access to the lower eyelid and cheek structures from the subciliary skin or transconjunctival approach. In addition to incisional technique, consideration is given to how the orbital fat will be handled, options to smooth the lid contour and camouflage the exposed orbital rim, treatment of skin discoloration and textural rhytides, and control of the lower lid, lateral canthal, and palpebral fissure shape. The contour of the eyelid-to-cheek transition and the structure of the midface, with descent of the malar fat pad and accentuation of malar mounds, all affect the lower eyelid appearance. Midface lifting surgery can be done in conjunction with or subsequent to blepharoplasty, but it is in its own stage of controversy and evolution and will be discussed by other authors. Although the patient and the surgeon must evaluate and discuss facial concerns, many patients are not prepared to undergo entire face lifting to achieve periorbital rejuvenation, and not all patients will require manipulation of all these structures.

Lower eyelid blepharoplasty was described in the 1980s as excision of excessive skin, herniated orbital fat, and hypertrophic orbicularis (1,2). Surgery primarily involved fat removal, replacing the lower eyelid convexity with a concavity (3). The transconjunctival approach, although described in 1924 (4), was popularized over the past 20 years (5, 6 and 7). It is used to avoid cutaneous scarring and interruption of orbicularis muscle, and to decrease the incidence of eyelid retraction. Combined skin and skin-muscle flap technique also was described to preserve pretarsal orbicularis muscle yet allow for skin trimming (8).

The suboptimal results sometimes caused by using any single approach led authors to develop more extensive surgery to prevent lower lid retraction, augment lid support, and address malar festoons, including canthopexy (9,10), tarsal strip (11), and extended lower lid blepharoplasty with orbicularis plication to the periosteum (12). Development of reconstructive techniques was necessary to correct iatrogenic lid malpositions from aesthetic blepharoplasty, such as the “Madame Butterfly” procedure (13,14), hard palate grafting (15,16), and midface lifting (17,18).

In the last decade, techniques have been introduced that tout orbital fat preservation (19, 20 and 21), release of ligamentous attachments of the lower eyelid (22, 23 and 24) to mobilize the orbicularis for tightening and redraping, and lateral canthal support (25,26). Complications such as extraocular muscle restriction (27), persistent fat protrusion and lid edema (28), and lid retraction (22) from fat redraping are reported from these aesthetic reconstructive procedures. The higher incidence of morbidity and disappointing results associated with aesthetic surgery of the lower eyelid relative to other facial procedures has stimulated innovative surgical contributions from oculofacial plastic surgeons, general plastic surgeons, facial plastic surgeons, and anatomists.