Dr Scott J Turner | Specialist Plastic Surgeon (FRACS) | Sydney
How long does eye bag surgery actually last? It is a reasonable question, and for years the honest answer was that the long-term data was thin. A 2026 paper in Plastic and Reconstructive Surgery helps fill that gap. Titled Long-Term Results with the Extended Transconjunctival Lower Eyelid Blepharoplasty, it followed 200 patients, some for as long as eight years. You can read it here. Here I discuss what the authors found, and how evidence like this shapes the way I approach lower eyelid surgery.
For years, lower eyelid surgery meant taking the fat out. We now know that removing too much can leave the area looking hollow and tired, sometimes within a few years. The thinking this study examines, over a far longer follow-up than most, is to reposition the fat rather than discard it, and to treat the tear trough and the lid-cheek junction together. If you are weighing up lower blepharoplasty, that shift is worth understanding.
The study also carries weight because of who produced it. Its senior author, Bryan Mendelson, is an Australian surgeon whose anatomical research, including the original description of the tear trough ligament, underpins much of how facial surgeons understand this region. I am Dr Scott J Turner, a Specialist Plastic Surgeon and Fellow of the Royal Australasian College of Surgeons (FRACS), and I consult at my Sydney clinics in Bondi Junction and Manly. Surgery on the lower eyelid carries real risks, and no result is guaranteed.
What actually causes under-eye bags
The lower eyelid sits over three small pockets of fat that cushion the eye. A thin layer called the orbital septum holds that fat in place. With age, the septum weakens and stretches, and the fat begins to push forward. That forward bulge is what most people recognise as an eye bag.
But the bag is only half the picture. Just below it runs a groove called the tear trough. It marks the boundary where the eyelid meets the cheek, and it deepens for several reasons at once. The fat above it pushes out. The cheek fat below it descends. The skin thins. A structure called the tear trough ligament tethers the skin firmly to the bone along this line, and as the surrounding tissues change, that tether becomes more obvious. The result is a shadowed hollow that no amount of sleep or concealer fully hides.
This is why removing fat alone often disappoints. Take the fat out, and you flatten the bulge. The groove beneath it is still tethered to the bone, so the hollow remains.
Why surgeons moved away from simply removing fat
The older operation was straightforward. Make an incision, remove the protruding fat, close up. For a younger patient with isolated, modest bulging, it could work well. The trouble showed up over time. And in patients who had more going on.
Remove too much fat, and the eye socket loses volume it was never meant to lose. The area takes on a hollow, sunken look. With the volume loss that continues with age, an over-resected lower eyelid can end up looking more tired than before surgery. Once the fat is gone, it is difficult to put back. Correcting a hollowed lower eyelid is one of the harder revision problems in facial surgery.
So the question changed. Instead of asking how much fat to remove, surgeons began asking where the fat should go.
Repositioning the fat, not discarding it
Rather than throwing away the fat that causes the bag, it can be used to fill the hollow that sits just below. The tissue that creates the problem becomes the material that solves it.
There are two ways to do this. The fat can be repositioned as a flap, slid over the bony rim while keeping its blood supply. Or removed, trimmed into small pieces, and grafted back along the rim. The 2026 study used the second approach, placing the trimmed fat along the bony rim to soften the tear trough and the lid-cheek junction. The intent is to even out the transition between eyelid and cheek, so there is no longer a sharp line between a bulge and a hollow.
This is technically demanding work, and not the only valid approach. Which method suits a patient depends on their anatomy.
The tear trough ligament, and why releasing it matters
Filling the hollow is only part of the job. If the ligament tethering the skin to the bone is left intact, it keeps pulling the tissue down, and over time the groove can reassert itself. The more recent techniques release that ligament surgically, freeing the tethered skin so the repositioned fat can sit smoothly across the junction.
This is the part that has been debated among surgeons, and the concern was a reasonable one. The lower eyelid depends on a network of supporting structures to hold its position against the eye. If you release one of them, does the lid sag? Does the white of the eye start to show below the iris, a problem called scleral show?
The 2026 study set out to answer that, with follow-up running for years. Across the 200 patients, the authors reported no cases of scleral show or lower eyelid drooping over the long term. They attributed this to the main canthal ligaments that hold the eyelid in place. Those sit above the tear trough ligament and were left untouched. The structure released was not the one holding the lid up.
I include these figures because they come from published, peer-reviewed research rather than marketing claims. They are not a promise about your result. They are evidence that, with careful patient selection, releasing the tear trough ligament did not destabilise the lower eyelid in this group.
The transconjunctival approach: surgery without an external scar
Where the incision is placed matters to most patients. There are two main routes into the lower eyelid.
The external approach places a fine incision just below the lash line. It allows excess skin to be trimmed directly, but it leaves a scar, and it carries a higher risk of pulling the eyelid downward as it heals.
The transconjunctival approach goes through the inside of the lower eyelid. There is no external scar at all. It reaches the fat directly and avoids disturbing the muscle and skin on the front of the lid, which is part of why it tends to interfere less with eyelid position. Recent research, and much of current practice, favours this route. Significant excess skin can often be managed with laser resurfacing rather than cutting.
An unexpected finding: the effect on the smile
One of the more interesting findings had nothing to do with the eye at rest. It was about the smile.
When we smile, the muscle around the eye contracts. In some people, the tethering at the tear trough creates a deep crease and a slightly squinted look, with fine crinkling of the lower lid. By releasing the muscle origins there, the surgeons found the crease softened and the smile relaxed, and this held over the follow-up. It is an early finding from one surgical group rather than settled fact. Still, it points to something worth appreciating. The lower eyelid is not a still photograph. How it moves matters as much as how it looks at rest.
The risks you should weigh
No eyelid operation is without risk, and the area is unforgiving of complications. These are the risks I discuss with every patient considering lower eyelid surgery.
Fat grafting can occasionally form a small firm lump under the skin if a piece of grafted fat does not survive, a problem called fat necrosis. In the study it occurred in around one in thirty patients and was managed without further surgery, but it is a recognised risk of any fat grafting.
Swelling of the clear membrane over the eye, called chemosis, can occur, particularly when lower eyelid surgery is combined with upper eyelid surgery or a facelift. It usually settles over a few weeks. Scarring inside the lid is possible, more so in patients prone to thickened scars.
The more serious risks, though uncommon, are the ones that affect eyelid position. The lid pulling away from the eye, downward malposition, or scleral show. A very rare but serious risk of any eyelid surgery is bleeding behind the eye, which can threaten vision and requires emergency treatment. Dry eye can occur or worsen after surgery, which is why your eye health is assessed carefully beforehand.
As with any surgery, results vary. Some asymmetry is normal. Revision is occasionally needed. I would rather you understand these risks fully than be reassured falsely. This is surgery. It deserves the same consideration as any operation.
Who tends to be a suitable candidate
There is no single profile, but some patterns are clear.
Younger patients with genuine fat bulging, a defined tear trough, and otherwise good skin tend to do well with this kind of surgery. The study noted this group as among the most suitable. In older patients, the under-eye change is often part of a broader pattern of facial ageing. The eyelid procedure may then be combined with cheek volume restoration or a facelift to address the midface descent that contributes to the appearance.
Some apparent eye bags are not really about the lower eyelid at all. When the cheek fat pad has dropped, it exposes the lid-cheek junction and creates a hollow that looks like a bag but comes from the midface. In those cases, lower eyelid surgery alone may not fully address the concern. I assess this carefully at consultation. Operating on the wrong structure leads to disappointment.
Stable eye health matters too. Dry eye, previous eye surgery, and other ocular conditions need to be reviewed before proceeding, and being a non-smoker, or willing to stop well before surgery, supports healing.
Recovery, in realistic terms
Lower eyelid surgery brings bruising and swelling around the eyes. This is most noticeable in the first week to two weeks, and most patients take time away from work and social commitments during it. The transconjunctival approach involves no external stitches in most cases, and the internal incision is not visible.
Swelling settles over several weeks, and the final result refines over some months as the tissues soften and any repositioned fat stabilises. Vision can be a little blurred early on from ointment and swelling, and your eyes may feel dry or gritty for a time. None of this is unusual, and your aftercare instructions are built around protecting the healing eyelid.
I avoid giving a single date by which everything is back to normal, because it genuinely varies. The visible early recovery is measured in weeks. The final contour settles over months.
How this shapes my approach
Reading a study like this is not about adopting a technique wholesale. It is about weighing the evidence against what I already do. The long follow-up matters more to me than the satisfaction scores, because the real test of eyelid surgery is how a result looks in five years, not five weeks. The emphasis on repositioning rather than removing fat fits how I assess these cases, where the aim is contour, not just flattening a bulge. And the finding that some apparent eye bags are really a midface problem is one I apply at every consultation. Evidence informs judgement. It does not replace the assessment of the person in front of me.
Before you decide
Lower eyelid surgery has changed for good reason, and the long-term evidence is more solid than it once was. But the right operation depends entirely on your anatomy, and no paper can tell you what suits your face. If under-eye bags or the tear trough are something you are considering, start with an honest assessment of what is contributing and what surgery can realistically achieve. You can read more on the lower blepharoplasty procedure page, or contact the practice to arrange a consultation. A GP referral is required before your first appointment.
Frequently Asked Questions
Will my eye bags come back after surgery?
The orbital fat that is removed or repositioned does not regrow, so the specific bulge that is treated is unlikely to return in the same form. Ageing continues, however. The skin keeps thinning and the midface keeps descending, so the under-eye area will keep changing over the years. Techniques that release the tear trough ligament and reposition fat appear, in long-term research, to hold their correction well, with one 2026 study showing stable results over several years. That research reflects a specific surgical group and is not a guarantee of any individual outcome.
Is there a visible scar after lower eyelid surgery?
When the transconjunctival approach is used, the incision is made inside the lower eyelid, so there is no external scar. This is the approach often chosen when the main concern is fat and the tear trough. If there is significant excess lower eyelid skin, an external incision below the lash line may be needed, which leaves a fine scar that typically fades over about a year. Skin excess can sometimes be managed with laser resurfacing instead, avoiding an external incision. Which approach suits a patient depends on their anatomy.
What is the difference between removing fat and repositioning it under the eyes?
Older lower eyelid surgery focused on removing the fat that causes the bulge. Repositioning, or grafting, instead uses that fat to fill the hollow of the tear trough that sits just beneath the bag. The aim is to smooth the transition between the eyelid and cheek rather than simply flatten the bulge, which can otherwise leave a hollow. Repositioning is more technically demanding and is not appropriate for every patient, but it has become the preferred approach for many surgeons addressing combined bags and tear trough hollowing.
How long does recovery take after lower eyelid surgery?
Bruising and swelling are most noticeable in the first one to two weeks, and most patients plan time away from work and social events during this period. Swelling continues to settle over several weeks, and the final contour refines over some months. Eyes may feel dry, gritty, or temporarily blurred in the early days. Recovery varies between individuals, so your surgeon’s specific aftercare guidance, rather than a fixed timeline, is the best guide.
Can lower eyelid surgery be combined with other procedures?
Yes. Lower eyelid surgery is commonly performed alongside upper blepharoplasty, and in older patients it may be combined with a facelift or cheek volume restoration where midface descent is contributing to the under-eye appearance. Combining procedures can be appropriate where several areas contribute to the concern, but it also affects swelling and recovery. Whether a combined approach suits you is a decision made at consultation based on your anatomy and goals.
Reference
Wong CH, Hsieh MKH, Mendelson B. Long-Term Results with the Extended Transconjunctival Lower Eyelid Blepharoplasty: A Prospective Study of 200 Consecutive Cases. Plastic and Reconstructive Surgery. 2026;157(6):975. doi:10.1097/PRS.0000000000012545. View on PubMed
