Less skin is removed from the lower lids than the upper lids. The difference between just the right amount and too much may be only a few millimeters, A good surgeon will operate on the side of caution and remove less skin, or fat only.
An incision is made just below the lashes in the eye's natural crease. Muscle fiber are separated from fatty deposits, and the fat removed. Most of the excess fat lies in the middle of the lid, and again caution must be taken not to remove too much. After the sagging skin and muscle are trimmed, the lower-lid skin is pulled up and over to one side. Sutures follow the crease of the natural lid.
Another more recent procedure removes fat from under the eyelid with syringe inserted while the lid is pulled away from the eye. Called transconjunctival blepharoplasty, it takes about 20 minutes and leaves no scars, but is not suitable for anyone with a lot of excess skin under the eyes. People with multiple folds of the lower lid will need a two-layer operation, the first on the skin and the second on the muscle. Each layer is freed up separately and then lifted. The muscle is supported at the outside, and then the skin is redraped over it. This is more extensive than the usual blepharoplasty and leaves more bruising.