Surgical Lower Bblepharoplasty

Strenuous exercise, weight fluctuations, hormonal changes, long working hours, stress, constant sun exposure, and genetics — all of these conditions can lead to premature aging under the eyes. Dark circles, eye bags, hollowing under the eyes, and eyelid wrinkles can make us appear older and more tired. According to board-certified dermatologist Dr. Jason Emer, a specialist in non-surgical anti-aging treatments, the gold standard for under eye improvement is a combination approach with both invasive and non-invasive procedures.


For permanent under eye bag removal, Dr. Emer’s esteemed plastic surgeons perform a lower blepharoplasty, a lower eyelid bag surgery that removes the herniated fat pockets beneath the eyes and above the cheekbones. Immediately following this surgery, Dr. Emer performs a non-surgical periocular eyelid rejuvenation procedure, an ablative skin resurfacing laser treatment around the eye that eliminates fine lines and wrinkles and smooths and tightens the skin.

How does it work?

As we age, it is normal for the skin to lose elasticity, causing the fat in the lower eyelid to droop. Highly active and athletic individuals may experience prominent lower eye bags earlier than others.

The surgery begins with a road map of the procedure: Dr. Emer’s plastic surgeon outlines the edges of the under eye bags and upper cheek bone with a marker; these markings will help determine where fat should be removed during surgery and where Dr. Emer will apply the ablative laser. If there is any temporary or permanent filler under the eye, the filler is removed prior to surgery.


Once the area has been treated with numbing medication, a small unnoticeable incision is made on the inside of the eyelid to ensure that there are no visible scars. (In an external lower blepharoplasty procedure, a subtle incision is hidden below the eyelashes in a lateral crease of the lower lid.) The patient’s eyelids are retracted (and kept open) with sutures so that the plastic surgeon can meticulously remove the unwanted fat. There is great care to remove only a minor amount of fat; if too much fat is removed, patients may appear hollowed or unnatural. Once the fat has been extracted, the incision on the inner eyelid is sutured shut. In some cases, the fat can be repositioned (“fat pad repositioning”) to fill the tear trough or cheek and give permanent volumization in those areas.

As a final step in the procedure, CO2 laser resurfacing (or an ablative laser like Erbium) is performed around the orbital rim to tighten the skin and smooth the lines and wrinkles. Prior to the laser resurfacing treatment, metal eye shields are placed over the eyes for the patient’s protection. The eye is numbed with eye drops, the eye is protected with a lubricant jelly, and the shields are carefully placed over the eyeball. The shields are essentially contact lenses that protect the eyes and do not cause any pain or discomfort. They are removed immediately after treatment.

Because the eyelid skin is incredibly thin and requires exceptional skill and caution, it is essential that lower eyelid bag surgery is performed by highly skilled, uniquely qualified, licensed, and board-certified physicians who have a depth of experience with this specific procedure.

In those instances where the lower eyelid skin is too thin or wrinkled for laser resurfacing, a lower eyelid “skin pinch” can be performed to surgically remove skin from the lower eyelid. Often performed in combination with blepharoplasty, a skin pinch is a 45-minute procedure that removes excess skin from the under-eye area. In the procedure, the sagging, excess lower eyelid skin is pinched with a forcep and then cut away. A subtle incision is meticulously placed in the lid-lash line border and then closed with thin, dissolvable sutures.


The Lower Blepharoplasty procedure can be performed while the patient is asleep or awake and involves approximately 1 to 2 weeks of downtime. It can also be complemented with upper eyelid skin removal (upper blepharoplasty) at the same time if needed.


How else does Dr. Emer rejuvenate the under-eye?

Non-surgical Eyelid Lift

To improve puffiness and sagging under the eyes, Dr. Emer uses ablative skin resurfacing lasers, such as CO2 or Erbium, or Renuvion helium plasma radiofrequency (RF) energy (as shown above) to achieve incredible results and give you a far more youthful appearance. Combining RF energy and cool helium plasma, Renuvion improves the signs of aging (including deep wrinkles, sun damage, pigmentation, pores, scars, and skin laxity) in this Non-surgical Eyelid Lift. The focused heating tightens and peels the upper layers of skin with extreme precision; this leaves the surrounding area undamaged, smooths and tightens the periorbital skin, and improves the overall skin quality around the eyes. Renuvion and CO2 ablative laser resurfacing are both aggressive treatments, and the downtime is longer than other non-surgical procedures, but the results can be dramatic in just a single treatment.​

Tear Trough Fillers

For patients seeking improvement with dark circles and tear trough hollows, Dr. Emer uses a combination of dermal fillers — such as Belotero, Juvederm Voluma / Volbella / Vollure​, and Restylane Silk — to fill the eye hollows and camouflage the deep blood vessels that give the eye a dark and sunken appearance. Dr. Emer follows the filler injections with an Aerolase microsecond YAG laser treatment, which heats the undersurface of the skin, removes pigmentation, and promotes circulation to decrease swelling and puffiness.

Cosmelan Peels and Enlighten Peels can also improve eye bags, hollows, and dark circles under the eyes when performed in combination with fillers, lasers, Renuvion (J-Plasma), and microneedling with PRP​. Safe for all skin types and especially effective for individuals with olive skin / darker skin tones, the Cosmelan Peel is a non-inflammatory depigmentation treatment that targets pigmentation by inhibiting tyrosinase, an enzyme in the melanin (skin pigmentation) formation process. At the same time, Cosmelan accelerates cellular turnover to remove dead skin cells, lift pigment, soften texture, smooth the skin, and reduce pores and fine lines.

Non-Surgical Eye Bags Improvement

For improvement with under eye bags without the benefit of surgery, ​Dr. Emer creates a patient-specific combination approach that typically includes injectable fillers; skin tightening of the eyes, brow, and forehead with external energy-based devices (such as Thermage, Forma, Venus Legacy, and BTL Exilis Ultra), which deliver RF and/or ultrasound energy to the deep layers of your skin to promote skin tightening and stimulate long-term collagen production; laser treatments (such as Fraxel or CO2​); Renuvion “shrink wrap” skin tightening; microneedling with platelet-rich plasma (PRP) and stem cells; and Cosmelan and Enlighten peels. Additionally, a revolutionary new form of internal RF heating called InMode AccuTite can be used to improve the entire upper and lower eyelids as well as the eyebrows for those with loose or crepey skin, under eye bags, and dark circles.


InMode Accutite employed as part of an Upper Blepharoplasty procedure

For those with large bags or significant puffiness under the eyes, non-surgical treatments like injectable fillers may simply camouflage the area and will only give mild improvement — or, in some cases, can cause a puffy or swollen look. For these patients, a Lower Blepharoplasty with or without a laser resurfacing treatment is needed to see substantial results.

What is the downtime?

The average downtime for a Lower Blepharoplasty procedure is 7 to 10 days, though many of Dr. Emer’s patients resume daily activities relatively quickly. To accelerate the healing process following surgery, Dr. Emer recommends various restorative treatments, including IV Hydration Therapy, hyperbaric oxygen therapy (HBOT), oxygen facials, LightStim LED Light Therapy, and a customized skin care protocol for post-treatment care.

Is it painful?

To minimize pain and discomfort during the procedure, Dr. Emer applies a topical numbing medication to the eyelid skin and/or uses injectable nerve blocks to numb the area. For patients who prefer to be asleep during the procedure, intravenous or general anesthesia can be used as well.

Am I a good candidate?

The best candidates for a Lower Blepharoplasty + Laser Skin Resurfacing procedure are those who have visible fat pockets under the eye, which are most evident when looking up or standing beneath harsh overhead lighting. Loose, crepey skin, sagging, and hollows at any age can be improved with surgery and laser resurfacing treatments to achieve significant improvement. To determine if you are an ideal candidate for this procedure, schedule a formal evaluation with board-certified dermatologist Dr. Jason Emer.

How do I schedule a consultation with Dr. Emer?

To schedule a consultation with Dr. Emer in Beverly Hills / Los Angeles / West Hollywood, California, please reach out to our concierge to schedule an appointment. Call 424-800-4140 or email us at


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