Ask a doctor

Lower Blepharoplasty with Negative Vector Orbit? (photo)

I met with 3 different board certified plastic surgeon in Canada regarding lower bleph. I received 3 different answers. 1- This surgeon said it would be big mistake to have surgery because of negative vector. The solution: fillers. 2-a traditional lower bleph with a bit of skin removal. 3- lower transconjunctival bleph with facial laser resurfacing. This is all so confusing. From my pictures, does it appear I should avoid surgery due to negative vector? Could cause lid retraction? Sunken eye?

Doctor Answers (15)

Treating negative vector in related to the lower eyelids requires an experienced cosmetic surgeon to balance eyes and cheek


A negative vector is when the cheek bone is relatively back to the projection of the eyeball or the front of the cornea. This means that the eye is forward while the cheekbone is back.

Being a specialist in oculofacial plastic surgery who does a lot of revisional surgery, I have learned that it is important to balance everything. This is because the position of the lower eyelid is very dependent on multiple factors like the lateral canthal tendon, the position of the lower lid retractor, the tone of the skin and the orbicularis muscle. So if you want to push through with the surgery, you have to find a surgeon who can provide you the level of care you need.

As a board certified facial cosmetic surgeon, I not only look at the eyes but I think of the face as a whole. I try to balance everything to help with facial aging. A common strategy for negative vectors is not only addressing the eyes but addressing the mid-face and cheek area. I would add volume using a filler or something more long-term such as a cheek or submalar implant.  I hope that was helpful, and thank you for your question.

New York Oculoplastic Surgeon
4.5 out of 5 stars 21 reviews

You might also like...

Fat transposition


For eyelids like yours I usually recommend a transconjuncitval blepharoplasty with a fat transposition.  The fat of the lower lid is moved into the tear troughs to decrease the negative vector.  Below is a link with some photos.

Stuart H. Bentkover, MD
Boston Facial Plastic Surgeon
5.0 out of 5 stars 17 reviews

Lower Blepharoplasty with Negative Vector Orbit? (photo)


Thanks for sharing your concerns.

A negative vector orbit refers to the part of the bony eye socket under the eyes that is smaller than normal due to loss of bone volume. This can be fixed by either a cheek and orbital rim implant, fat transfer or fillers. In doing so, you do not affect the lower lid structurally but visually it looks better. A lower lid blepharoplasty in your case would deal with the excess skin , bulging fat and tightening the eyelid margin by a canthopexy. Combining lower blepharoplasty with volumizing the orbital rim and the under eye area will be the best option.

Naveen Somia, MBBS, PhD, FRACS
Sydney Plastic Surgeon
5.0 out of 5 stars 24 reviews

Treating the negative vector lower eyelid


Judging from your photos, I agree that you have a negative vector anatomy which simply means the mid face bones and lower eyelid/cheek volumes are deficient. This results in the front of the eye (cornea) to extend beyond the upper cheek plane (when you look from the side) so if you draw a line from the surface of the eye to the cheek it moves in a negative vector (towards the body).  

The key in these cases, is to change the negative vector to a positive or neutral vector.  This represents the youthful rejuvenated contour. To do this, augmentation of the midface and lower eyelid region is needed. My preferred approach is to do this with fat transfer to the lower orbital rim and into the cheeks. Next, it is combined with either a transconjunctival lower eyelid blepharoplasty or skin pinch to address the eyelid contribution.  In my opinion, the key in this case, is the volume augmentation.  Alternative ways to add volume is through fillers.

I hope this helps.

Dr. Karam 

Amir M. Karam, MD
San Diego Facial Plastic Surgeon
4.5 out of 5 stars 76 reviews



A negative vector does NOT preclude surgical eyelid rejuvenation. Your appearance would definitely be improved with a lower blepharoplasty.  There are two choices: transconjunctival blepharoplasty with some type of skin surface treatment i.e. laser, TCA peel or skin pinch. If a transcutaneous approach (under the lashes) is used, then it must be combined with some form of canthopexy to support the lower lid so ectropion (sagging) does not occur. A negative vector is merely a sign that the surgeon looks for to devise the correct operation. Fillers only will not give you the improvement that you want.

Lorne M. Tarshis, MD
Toronto Facial Plastic Surgeon
5.0 out of 5 stars 3 reviews

How to treat the lower eyelid


It seems from your picture that you are relatively young. I am guessing that the lower eyelid puffiness started earlier in life for you than most people.  I have had great success with the transconjunctival approach to fat removal in these situations.  This needs to be done conservatively so as to avoid the hollow look. Without an in-person exam, I can't tell if you need tightening or resurfacing, but these can be done at the same time.  By going transconj, one should be able to avoid retraction. (I have never seen it happen when going this route).

Paul W. Loewenstein, MD
Milwaukee Plastic Surgeon
4.5 out of 5 stars 14 reviews

Lower blepharoplasty with prominent globe, negative vector


We have had the best results with transconjunctival remodeling of the fat and a cheeklift performed at a superficial level.

This raises the fatty tissue of the cheekpad.

The cheeklift should be done in s subtle fashion and not attempt to do heavy lifting through the lower eyelid.

We are very cautious with grafting below the lower eyelids because of the potential for visibility of the grafts.  I have seen many, many cases of unhappy fat injection patients where the visibility of the grafts is very difficult or impossible to treat completely.  

Remember the fat pockets that look like they are right underneath the skin are actually below three layers of tissue!


Brent Moelleken, MD
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 90 reviews

I offer tear trough implants for negative vector patients


As you see from the responses to your question, there is no single answer. I offer my patient skin incision, fat removal and tear trough implants place subperiosteal to augment the check and change the vector. The concern with the transconjunctival fat removal is long term recurrence.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
5.0 out of 5 stars 52 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.