Skin Excision in Advanced Lower Blepharoplasty

Introduction The periorbital region is key to facial aesthetics, and aging often leads to skin laxity, orbital fat pseudo-herniation, malar bags, and festoons. Lower eyelid blepharoplasty addresses these changes via transconjunctival (fat-focused) or transcutaneous (skin excision and canthopexy) approaches.

Extended lower blepharoplasty combines eyelid and midface rejuvenation, extending the skin–muscle flap below the orbital rim and securing it to the lateral canthal periosteum. This allows larger skin excisions while maintaining eyelid stability, effectively treating festoons and malar bags. Safe excision, up to 16 mm, requires proper flap suspension and, if needed, orbicularis or canthal support. This article shares our experience and practical guidelines for achieving optimal outcomes with extended lower blepharoplasty.

Understanding Extended Lower Blepharoplasty Extended lower blepharoplasty is a comprehensive approach that goes beyond traditional lower eyelid surgery by addressing both the eyelid and midface. This technique is particularly valuable in patients with advanced aging changes, including significant skin redundancy, malar bags, festoons, and midface descent, which often cannot be fully corrected with conventional transcutaneous or transconjunctival blepharoplasty alone. Anatomical Considerations:

• Lower eyelid–cheek complex: Aging leads to orbital fat pseudo-herniation, orbicularis oculi laxity, and inferior migration of malar fat, producing a double-convex eyelid contour and tear trough deformities.
  

• Festoons and malar bags: These result from sagging orbicularis muscle and skin–fat descent, often requiring extended dissection to achieve smooth eyelid–cheek transition.
  

• Canthal support structures: Lateral canthal tendon integrity is critical to prevent postoperative complications like ectropion or scleral show.

Figure 1. Side-by-side anatomical comparison between a Youthful face (left) and an Aging face (right), specifically highlighting how shifts in fat pads, skin elasticity, and bone structure change the facial profile over time.

Indications: Extended lower blepharoplasty is indicated in patients who present with:

1. Advanced skin laxity or redundant lower eyelid skin.

2. Significant lower eyelid fat herniation causing bulging or pseudo-herniation.

3. Midface ptosis contributing to tear trough deformities.

4. Festoons or malar bags affecting aesthetic outcome.

5. Desire for full lower eyelid–cheek rejuvenation rather than eyelid-only correction.

Surgical Principles: The procedure involves subciliary incision and careful dissection of a skin–muscle flap that extends beyond the inferior orbital rim onto the malar region.

• Proper flap suspension to the lateral canthal periosteum ensures eyelid stability even when large amounts of skin are excised.

• Fat repositioning or conservative excision is performed to restore contour and avoid a hollowed appearance.
  

• Canthopexy or canthoplasty may be incorporated for additional eyelid support, particularly in patients with preexisting laxity.
  

Figure 2. Lateral Periosteal Flap Canthoplasty: Step-by-Step A. Incision: A "subciliary" cut is made just below the lower lashes and extended outward into the natural "smile lines" (Borges’s lines) at the corner of the eye. B. Flap Mapping: The surgeon marks out a small strip of tissue (the flap) on the outer lateral orbital rim (the bony edge of the eye socket). C. Elevation: This periosteal flap is lifted from the bone and tucked about 3 mm inside the orbit to create a secure internal anchor point. D. Tensioning: The lower eyelid is pulled toward the flap to check for "laxity" (looseness) and determine how much eyelid tissue needs to be trimmed. E. Anchoring: The edge of the eyelid’s structural support (the tarsus) is stripped of skin and sutured to the periosteal flap in a "double-breasted" (overlapping) fashion for maximum strength. F. Result: The eyelid is tightened and lifted, restoring a youthful, functional position. Advantages over Traditional Techniques:

• Enables larger, safer skin excisions without tension on the lower eyelid.

• Addresses both the eyelid and midface in a single procedure, improving overall facial harmony.

• Reduces the appearance of festoons, malar bags, and tear trough deformities, producing a smoother eyelid–cheek contour.

• Minimizes the risk of postoperative complications when combined with proper canthal support and orbicularis suspension.

In essence, extended lower blepharoplasty is not merely an enlarged version of traditional eyelid surgery; it is a strategically designed approach that integrates midface rejuvenation, eyelid stability, and aesthetic refinement, providing optimal outcomes for patients with moderate-to-severe periorbital aging. Preoperative Assessment

Proper planning is critical to avoid complications. Key steps include:

1. Skin Laxity Evaluation: Determine the amount of redundant skin using pinch tests. Extended blepharoplasty permits excision beyond conventional limits.

2. Lower Eyelid Tone Assessment: Evaluate orbicularis oculi muscle tone, eyelid retraction risk, and canthal tendon integrity.

3. Midface Analysis: Examine cheek projection and malar descent to anticipate the need for midface lifting or fat repositioning.

4. Patient Counseling: Discuss realistic outcomes, emphasizing that extended skin excision may lead to longer recovery and temporary edema or bruising.

Surgical Technique and Skin Excision Guidelines Extended lower blepharoplasty requires meticulous planning and precise execution to safely excise excess skin while maintaining eyelid stability. The surgical technique combines elements of traditional lower eyelid surgery with mid-face rejuvenation, including flap mobilisation, fat management, and canthal support. Preoperative Planning

1. Skin Laxity Assessment:

   • The pinch test evaluates the maximum amount of skin that can be safely excised.

   • Age, skin elasticity, and lower eyelid tone guide the surgeon in determining excision limits.
     

2. Lower Eyelid Tone and Canthal Support:

   • Assess orbicularis oculi tone, lateral canthal tendon integrity, and scleral show risk.

   • Patients with preexisting laxity may require lateral canthopexy or canthoplasty.
     

3. Midface Analysis:

   • Examine malar descent, tear trough depth, and cheek projection.

   • Determine whether additional midface lifting or orbicularis suspension is indicated.

Incision Planning Subciliary Incision:

• Placed 1–2 mm below the lash line to minimize visible scarring.

• Lateral extension along natural crow’s feet or skin creases may be used to access the midface.

• Transconjunctival Option:

  • Considered when minimal skin excision is required and fat repositioning is the primary goal.
    

Flap Elevation and Dissection Carefully elevate a skin–muscle flap extending below the inferior orbital rim.

• Dissection continues onto the malar region to release midface soft tissues, addressing festoons and malar bags.

• Maintain a gentle, tension-free plane to preserve vascular supply and prevent flap necrosis.

Fat Management Fat Repositioning:

• Orbital fat pads can be repositioned to smooth the lid–cheek junction and reduce tear trough deformity.

• Avoid over-resection to prevent postoperative hollowness.

• Fat Removal:

  • Conservative excision may be performed for prominent fat herniation.

  • The combination of flap redraping and minimal fat removal ensures natural contour.

Skin Excision Guidelines

• The amount of skin excised depends on preoperative assessment, flap mobility, and eyelid tone.

• Conventional blepharoplasty typically limits excision to 2–4 mm, whereas extended lower blepharoplasty can safely remove up to 16 mm of skin.

• Ensure that skin excision is tension-free and that the flap can be anchored securely to the lateral canthal periosteum.

• Over-resection risks ectropion, scleral show, eyelid retraction, and unnatural appearance.

Canthal Support Lateral Canthopexy or Canthoplasty:

• Provides critical support in patients with laxity or significant skin excision.

• Anchoring the flap to the periosteum ensures eyelid stability during healing.

• Orbicularis Suspension:

  • The orbicularis oculi muscle may be anchored to the orbital rim to reinforce support and enhance the contour of the lower eyelid–cheek complex.

Closure Layered closure is recommended:

1. Muscle layer for flap support.

2. Skin layer using fine, non-absorbable sutures to minimize scarring.

3. Avoid excessive tension at the lateral canthus to prevent postoperative lid malposition.

Key Technical Points for Safety and Aesthetic Outcome Preserve vascular supply to the skin–muscle flap.

• Anchor the flap securely to the lateral canthal periosteum.

• Avoid over-resection of fat and skin.

• Integrate midface support for smooth lid–cheek transition.

• Use meticulous hemostasis to minimize postoperative edema and ecchymosis.

Evidence-Based Outcomes

Figure 3. 46 y.o. female. A. preoperative frontal view; B. postoperative frontal view at 1year; C. preoperative left view; D. postoperative left view at 1 year

Figure 4. 57 y.o. female showing important malar bags bilaterally. A. Preoperativefrontal view; B. postoperative frontal view at 1 year

Figure 5. 59 y.o. female. A. Preoperative frontal view; B. postoperative frontal view at 1 year

Conclusion Extended lower blepharoplasty represents a significant evolution in periorbital rejuvenation. By integrating midface lifting and careful skin excision, surgeons can achieve dramatic, natural results while minimizing complications. The key to success lies in preoperative planning, precise technique, and adherence to safety principles, ensuring both functional and aesthetic excellence in advanced eyelid surgery.

Reference:

Fabbri, M., Mariani, M., Botti, C., Botti, G., Murone, V., & Serra, P. L. (2025). Extended lower blepharoplasty: How much skin can we resect? Aesthetic Plastic Surgery. https://doi.org/10.1007/s00266-025-03456-x

---

Learn techniques behind Blepharoplasty

in our upcoming Step-by-Step Cadaver Hands-On masterclass

IFAAS Fresh Cadaver (Hands-On) Masterclass​

Upper & Lower Blepharoplasty – Level 1: Suture & Minimally Invasive Techniques Upper & Lower Blepharoplasty – Level 2: Incisional & Advanced Techniques

Blepharoplasty Level 1 and 2, May 5-6, 2026 - Singapore  - [Register Now] Asian Blepharoplasty (In-OR Observation), June 13-14, 2026 - Japan  - [Register Now]

---

More Upcoming Global Events

Global Event Calendar