Doctor's Column

Lower blepharoplasty cannot be solved simply by removing fat or injecting fillers. In order to fundamentally improve under-eye wrinkles, bulging, and sunken tear troughs, long-term satisfaction can only be achieved by comprehensively performing fat repositioning, orbital septum reinforcement, and midface (front cheek) lifting. Plastic surgery specialist Dr. Sung-hoon Kim explains through actual cases and anatomical structures why simple fillers or fat grafting are ineffective, and what the true essence of surgical treatment is.

SH Plastic Surgery Facial Designer, Director Sung-hoon Kim

Hello, I am Sung-hoon Kim, a plastic surgery specialist and facial designer.

It seems I am greeting you a bit late. The intense heat of summer has faded before we knew it, and deep autumn seems to have arrived along with a cool breeze.

Autumn is often called the "season of the mirror." This is because the subtle changes on our faces that we couldn't quite notice under the strong summer sunlight

are revealed more clearly under the soft yet honest autumn light.

In particular, the eye area, which accounts for the largest part of our impression, is where these changes are felt the fastest and most significantly.

Have you ever looked in the mirror and thought that the area under your eyes looks more sunken than before, that your dark circles have deepened, or that it bulges downward, making you look tired and aged? I, too, often feel the signs of aging appearing under my eyes day by day.

Recently, a patient who visited shared concerns about their under-eye area, so today, through that person's story, I would like to talk about lower blepharoplasty.

“Doctor, my under-eye area looked sunken, so I got fillers several times. At first, it seemed a bit better, but as time passed, the wrinkles became deeper, and people tell me I look even more tired.”

This is one of the stories I frequently hear in the consultation room.

One of the very first changes that appear as we age is right under the eyes.

Many people feel stressed because every morning when they look in the mirror, they look hollow; even with makeup, the dark circles aren't concealed; and whenever they take photos, the reason they look older is concentrated under the eyes. That is why many people first choose relatively simple procedures like fillers or fat grafting.

It may look fine at first. The sunken under-eye area is filled out, and the dark circles seem to have improved to some degree.

However, the problem reveals itself over time. The tear trough looks deeper,

and as the filler clumps or becomes uneven, it results in an impression that actually looks more tired and aged.

This is because the under-eye area is not simply a matter of "filling a sunken space," but rather the anatomical structure itself is the cause.

The tear trough is a structural crease created by a tough ligament (tear trough ligament) pulling from the bone to the skin.

Because this ligament does not stretch easily, no matter how much you fill it with fillers or fat grafting, it cannot be a fundamental solution.

On the contrary, if it is overfilled, the surrounding area becomes prominent, creating the adverse effect of making the hollow appear even deeper.

For this reason, many people repeat fillers or fat grafting, only to eventually visit saying, "Surgery is the only answer after all."

To properly resolve the problem of bulging and sunken under-eyes, a comprehensive approach is required: releasing the ligament, repositioning the fat,

and, if necessary, reinforcing the septum and lifting the anterior cheek.

Methods that simply remove fat or fill with filler can actually become aggravating factors.

Today, I would like to delve deeply into this very topic: the true essence and principles of lower blepharoplasty.

Definition and Explanation of the Lower Eyelid

1. Definition of the Lower Eyelid

The lower eyelid refers to the bottom eyelid of the eye and its surrounding structures.

Clinically, it is described by including the skin, orbicularis oculi, subcutaneous fat, orbital fat, retaining ligaments, and the bone structures connected to them.

The lower eyelid is a complex space where multiple anatomical layers interact with each other, rather than just being simple skin.

2. Anatomy of the Tear Trough and Lower Eyelid

The core of lower eyelid concerns is the "tear trough."

The tear trough is formed by the tear trough ligament, a firm ligamentous structure extending from the bone to the skin.

An anatomical paper by Wong et al. (PRS, 2012) confirmed through cadaveric studies that this ligament actually exists and is the cause of under-eye wrinkles and hollowing.

Furthermore, Haddock et al. (2009) explained that the tear trough and the lid-cheek junction are not simply skin issues or a lack of fat,

but are due to an anatomical structure where muscles and ligaments interlock.

In the superficial layer, the boundary between the palpebral and orbital portions of the orbicularis oculi coincides with the tear trough.

In the deep layer, ligaments directly connecting the bone to the skin pull downward, creating a depression.

For this reason, even if the sunken area is simply filled with fillers or fat grafting, the pulling force of the ligament remains intact, which can make wrinkles look deeper or result in unevenness in the case of overcorrection.

3. Aging and Lower Eyelid Changes

The changes that occur with aging are as follows:

Loss of skin elasticity and thinning of the skin

Protrusion of orbital fat forward, bulging out like eye bags

Weakening of the septum, which pushes the fat out and deepens wrinkles

Accentuation of under-eye hollowing due to loss of anterior cheek volume

These changes work in combination to simultaneously cause dark circles, wrinkles, hollowing, and bulging.

4. The Necessity of a Surgical Approach

Ultimately, improving the lower eyelid requires a comprehensive surgical approach that releases the ligament, repositions the fat, reinforces the septum, and, if necessary, lifts the anterior cheek.

Simple fat removal carries a 100% risk of recurrence and complications, and fillers or fat grafting alone cannot resolve the tension of the ligament.

Recent surgical trends are also shifting toward a "volume-preserving strategy," which preserves and repositions tissue rather than unnecessarily removing it.

Lower blepharoplasty combined with fat repositioning, septal reinforcement, and lifting provides long-term satisfaction and natural results.

The term "lower eyelid" is generally used as a broad term referring to the lower eyelid area,

that is, the palpebral and periorbital structures including the lower eyelid down to the upper cheek area.

Clinically, it often includes the following elements:

Eyelid skin and subcutaneous tissue

Orbicularis oculi muscle (orbicularis oculi)

Subcutaneous fat or pre-orbital fat (preseptal fat, orbital fat)

Boundary structures (e.g., ligaments, retaining structures)

Aging changes such as soft tissue sagging, hollowing, wrinkles, and fat protrusion

In plastic surgery and blepharoplasty, the term "lower eyelid blepharoplasty / infraorbital rejuvenation" is commonly used

to refer to cosmetic and functional corrective surgeries on the lower eyelid and immediately adjacent areas.

For example, this may include excision of sagging skin, excision or repositioning of fat, release or reinforcement of ligaments, and adjustment of the junction with the cheek.

According to the StatPearls literature on "Lower Eyelid Blepharoplasty," blepharoplasty is a surgical procedure aimed at improving lower eyelid deformities or aesthetic factors, and includes skin and fat excision, muscle reinforcement, and tissue repositioning.

Literature from EyeWiki also explains that while lower blepharoplasty was centered on simple tissue removal in the past, tissue preservation and repositioning methods are emphasized today.

A paper analyzing the anatomical structure of the tear trough and the lid/cheek junction through anatomical dissection.

It explains that the junction between the palpebral and orbital parts of the orbicularis oculi muscle is superficially related to the tear trough.

The Anatomical Truth of Lower Blepharoplasty

1. Why does the tear trough form?

Many people think that tear troughs form because "the under-eye area is sunken," but in fact, it is not simply due to sunken skin.

In the tear trough, there is a structure called the **Tear Trough Ligament (TTL)**.

It firmly connects from the bone to the skin, tethering the skin down, which is the main cause of the under-eye area appearing sunken.

This ligament does not stretch easily.

Therefore, simply filling it with filler or fat will not fundamentally improve the issue.

Rather, injecting too much can make the surrounding area stand out and cause the sunken area to appear even deeper—literally creating the opposite effect.

2. Why is merely removing fat dangerous?

In the past, if the under-eye area was bulging, surgeries that simply removed fat were common. On the surface, it looks simple and easy.

But the problem comes afterward. If you unconditionally eliminate the fat, it will eventually recur, or the under-eye area may become hollowed out and look even more aged.

Thus, this method yields low long-term satisfaction and often leads to the need for revision surgery.

3. The most effective method is a 'comprehensive approach'

That is why I always emphasize a comprehensive approach when discussing lower eyelid improvement.

It cannot be solved by simply addressing just one factor.

Releasing the ligament, repositioning the fat, reinforcing the septum, and lifting the anterior cheek as needed is the most definitive method.

In some cases, a small amount of fat removal may also be necessary.

When done this way, what kind of changes happen?

The tear trough is naturally smoothed out,

the aegyo-sal (subciliary roll) becomes plump and revitalized,

the bulging, stubborn fat is neatly organized,

and because the anterior cheek is also lifted, the face transforms into a much more youthful and vibrant appearance.

4. What are the actual changes after surgery?

Patients are often amazed just about a month after surgery.

The under-eye roll (aegyo-sal) is beautifully revived, and the bulging under the eyes is gone.

The hollow-looking tear troughs and anterior cheekbones are smoothly connected, brightening the entire face and giving it a more youthful appearance.

That is why I always say that the under-eye area should never be approached simply by filling it because it is hollow, or removing it because it is bulging.

Fundamental improvement is possible only when the cause is addressed structurally.

Reflections of Face Designer Kim Sung-hoon

If lower blepharoplasty is approached simply as a matter of filling in hollow areas or removing bulging fat, a satisfying result can never be achieved.

The under-eye area is both a structure that protects the sensory organ of the eye and a delicate tuning ground that determines the overall impression of the face.

The skin, fat, muscles, ligaments, and bones are all closely interconnected, so touching just one part alone will not create overall harmony.

What I talk about most with patients in the consultation room is that "one must look at the whole, not just the parts."

Under-eye hollowing is not simply caused by a lack of fat, nor is bulging caused solely by having too much fat.

The overall balance collapses as ligaments pull, the orbital septum weakens, and the front cheekbones lose volume.

Therefore, a surgical approach must take all of these factors into consideration simultaneously.

Whether to reposition fat, reinforce the septum, lift the front cheekbones, or remove a small amount of fat depends on the individual anatomical conditions of each patient.

Calling lower blepharoplasty simply "under-eye surgery" does not do it justice.

This is because it is virtually a surgery that addresses the harmony of the entire midface.

When the under-eye area is smoothly contoured, it goes beyond merely improving a tired appearance; it changes the impression when smiling, the naturalness of facial expressions, and further, the balance of the entire face.

After surgery, many patients give feedback such as, "People no longer tell me I look tired," and "My face looks much brighter."

This is the result of not just treating a single layer of skin, but taking into account the anatomical structure and the function of facial expressions together.

I do not consider the title "Face Designer" to be merely a marketing phrase.

I believe that design is not about creating something brand new, but a process of bringing out the beauty that was originally there.

Lower blepharoplasty is no different.

It is not about forcefully making someone look young, but about correcting the structural imbalances under the eyes to restore the original naturalness and vitality of the face.

Plastic surgery must be free of exaggeration.

This is especially true for under-eye surgery. If it is even slightly overdone, the facial expression becomes unnatural, and forced results quickly become obvious.

Therefore, the surgeon must possess an anatomical understanding alongside a restrained aesthetic sensibility.

Where one defines the "boundary between when to remove and when to fill" determines the outcome.

I always think of each patient's face as a blank canvas.

And rather than drawing lines on that canvas, I consider my work to be bringing out the lines that were hidden beneath all along.

Lower blepharoplasty is not simply a surgery to look younger, but one that restores vitality to your life.

Moving forward, I want to remain a face designer who revives the natural vitality held within my patients' eyes.

Truth without exaggeration, anatomical truth, and natural beauty. That is the philosophy I always pursue.

Speaking from the heart, today's reflection ended up being a bit long.

Thank you for reading until the end.

If you have any questions, please book a consultation and let's have a more detailed and in-depth conversation together.

I will assist you with a customized design tailored just for you.

Sincerely, Face Designer Dr. Kim Sung-hoon

FAQ

Q1. Is it absolutely impossible to improve with fillers?

A1. Temporary improvement is possible for younger individuals with mild cases. However, long-term satisfaction is low because it cannot resolve the structural cause where the ligaments pull down.

Q2. Can the fat just be completely removed?

A2. Simple removal carries a high risk of recurrence and complications. It is desirable to utilize the fat through repositioning and septal reinforcement.

Q3. Are the surgical scars very visible?

A3. The lower eyelid incision line is located right beneath the eyelashes, making it barely noticeable over time.

Q4. How long is the recovery period?

A4. Usually, stitches can be removed in about a week, and swelling and bruising naturally fade over 2 to 3 weeks.

Q5. Is there a possibility of recurrence?

A5. Compared to simple fat removal, the combination of fat repositioning + septal reinforcement + lifting offers superior long-term maintenance.

Q6. Can this surgery be performed regardless of age?

A6. It is possible for anyone from their 30s to their 60s. However, the technique varies depending on skin elasticity and wrinkle conditions.

Q7. Why is an anterior cheek lift necessary?

A7. If the anterior cheek area is sunken, the under-eye area looks even more hollow. Combining it with a lift revives the overall harmony of the face.

Q8. Can a failed filler procedure also be corrected?

A8. Yes, it is possible. If the area has become uneven or bumpy due to fillers, it can be corrected through fat repositioning and septal reinforcement.

Q9. Is there a specific method for scar management?

A9. We manage scars so they are barely visible by combining ointments, lasers, and scar injections.

Q10. Will the under-eye love bands (aegyo-sal) disappear after surgery?

A10. On the contrary, the love bands are plumply revived.

This is because the core of the surgery is not removing unnecessary fat, but repositioning it correctly.

In the next post, I will explain the secret to achieving long-term satisfaction with lower blepharoplasty ^^

If you are curious, please refer to the video above ^^

※ This post reveals actual before and after photos of the surgery to provide accurate information.

Please note that these photos were posted with the patient's consent, and bruising and swelling may vary and differ from person to person.