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
4.3 out of 5 stars 59 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
4.6 out of 5 stars 112 reviews

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
4.8 out of 5 stars 24 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.

lower eyelid blepharoplasty

 The primary goal for a lower blepharoplasty is to remove the excess fat bags which are creating the puffiness look This is performed through trans-conjunctival approach. If there is excess skin present on the lower lids than a pinch technique or fractionated laser resurfacing can be performed. A flat maxilla is best treated with small cheek implants placed through intra-oral approach to give more volume in the mid face area. Both procedures can be performed together or separately.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.7 out of 5 stars 125 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
4.2 out of 5 stars 5 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
4.8 out of 5 stars 26 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
4.9 out of 5 stars 133 reviews

Lower blepharoplast with fat grafting

The number of different opinions given here shows you that a lower lid blepharoplasty is one of the more challenging situations that cosmetic surgeons deal with, because the complications associated with it [lid retraction, ectropion, hollowing, etc].

There are many ways to approach your anatomy, which is a challenging one:  low cheek volume, prominent eye with already subtle retraction [right greater than left] with prolapsed orbital fat. From the photos, its not possible to see the amount of skin wrinkling or excess.

In my practice, I perform transconjuntival blepharoplasty with and without fat transposition, skin/muscle blepharoplasty, SOOF-lift [cheek-lift], ectropion repair [tarsal strip], and fat grafting. Having all these techniques at my disposal, allows me to address each patient individually with whichever of these techniques that I feel will give the patient the BEST result while MINIMIZING risk.

Looking at your anatomy, I feel your best option with the least amount of risk would be a lower lid transconjuntival blepharoplasty with fat excision/transposition WITH adjunct fat grafting the the malar region. The fat grafting will not only give you improved volume to the lid/cheek junction and prevent hollowing, but it will also support the lower eyelid position. In a recent presentation at a national meeting [publication in print] we have shown that fat grafting to the cheek region can improve the lower eyelid position by 0.5-1 mm.

As I mentioned, its hard to assess your skin quality from the photos, but if on examination,  I felt you could use skin improvement, AND had good lid tone, I would offer a very conservative skin pinch excision.

As you already have mild lower lid retraction, I would NOT perform a skin muscle flap or skin laser resurfacing, UNLESS a lower lid retraction repair with a graft is also done at the same time.

I have provided a link to pre and post op results on a transconj bleph with small skin pinch along with fat grafting. On my photos, you can see many examples of lid retraction repairs, and example of laser skin resurfacing done WITH lid retraction repair.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 30 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
4.7 out of 5 stars 110 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.