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 70 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 114 reviews

Negative vector

The first surgeon is correct in that doing your lids via an open approach even with canthal tightening will lead to an increased risk of scleral show and even frank ectropion. However, doing a transconjunctival approach with a SOOF lift is quite safe for patients with a negative (neutral and positive) vector mainly because the midface SOOF lift actually helps support the lower lid rather than the converse. As the originator of the SOOF lift blepharoplasty (which is performed with a transconjunctival incision) I can tell you that in my opinion this is the best procedure for improving the hollow look under the eyes that accompanies the aging process as well as the associated fat herniation. I use this approach in over 90% of my patients.  Seek a facial specialist and get two to three opinions, look at the doctor’s photos and you'll do alright in most cases.

M. Sean Freeman, MD
Charlotte Facial Plastic Surgeon
4.7 out of 5 stars 48 reviews

Lower lids and negative vector

 A negative vector suggests an increased risk of lower lid retraction if skin is removed. However, if the lower lid is weak and skin is removed, then a canthopexy may be recommended. If just fat removal this can be done transconjunctival.  Best to be seen in person.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 28 reviews

Lower eyelid surgery and the risk of lower eyelid retraction

this is a very good question to ask and the first surgeon is not wrong though it sounds as though they may be inexperienced.

You do have a mild to moderate negative vector which potentially would necessitatea lid tightening procedure at the same time as your lower eyelid blepharoplasty called a tarsal strip. Not every surgeon is capable of doing this and that maybe why they recommended filler. The other the other more casual recommendations of skin removal etc.may be overlooking your negative vector.

Here's what you need and there's really not much exception here. At a minimum you would need a "skin muscle flap" to suspend the muscle and potentially the tarsal strip that I mentioned. The skin removal for your lower eyelids should be minimal or even potentially not at all. If you are to have a midface lift through the same lower blepharoplasty incision performed properly that would help support your lower eyelids even further. In experienced hands this can be done safely under local anesthesia and you should do well. That being said multiple consultations in person with a surgeon is recommended.

I hope that was helpful

Chase Lay, MD

Chase Lay, MD
Bay Area Facial Plastic Surgeon
4.9 out of 5 stars 75 reviews

Lower blepharoplasty with negative vector

You clearly have a negative vector eye and this puts you at significantly greater risk for lower eyelid malposition with any type of skin removal.  The correct approach for your eye is to do a transconjunctival removal of the fat with an autologous fat transfer to the midface.  There is no risk of lid malposition with this procedure.  The second best approach is fillers. 

A lower transconjunctival blepharoplasty without the addition of volume will leave you with hollow looking eyes.

Mark Glasgold, MD
Highland Park Facial Plastic Surgeon
4.4 out of 5 stars 41 reviews


I understand your confusion - there are many ways to address your concerns.  Based solely on your pictures, I wouldn't say that you should avoid a lower lid blepharoplasty completely.  You do have either a neutral or very slightly negative vector (would prefer to examine you to determine this for sure).  This would put you at a slightly higher risk for an ectropion.  

That simply means that the surgeon should be more conservative in the surgery than they would normally be.  In your case, I would combine a transconjunctival approach to remove/move the fat around in your lower lid with a pinch blepharoplasty (remove just a small amount of skin).  This all depends of course on findings during a consultation with an actual examination of your eyelids.  Another reasonable approach would be to just do a standard blepharoplasty but be very conservative in the amount of tissue removed.  There are other maneuvers and post-op techniques that can also be performed to reduce the chance of an ectropion. 

I hope this helps.  I know it's confusing, but the best thing you can do is find a surgeon that is experienced in this area that you trust.


Asif Pirani, MD, FRCS(C)
Toronto Plastic Surgeon
5.0 out of 5 stars 35 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
4.5 out of 5 stars 25 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 73 reviews

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
4.8 out of 5 stars 143 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.