The presence of a hollow between the lower eyelid and cheek creates an appearance of sadness and fatigue. Besides, the elevation that occurs in the lower eyelid results in elder look. The reason is not only prolapse of orbital fat but also skin loosening, orbicularis muscle or ligments weekness, and bone resorption The goal of lower blepharoplasty is the reestablishment of the smooth contour of the lower eyelid area and lid-cheek junction. Traditional lower blepharoplasty focused on excision of skin, muscle, and fat. Although aesthetically effective in many cases, potential problems include lower lid malposition, scleral show, and hollow lower lid area. Modern lower blepharoplasty highlights less aggressive fat resection, fat reposition, minimal skin resection and lower lid support.
　　Previously, I performed fat reposition for the management of lid bags. Only few cases accepted additional filler injection due to prominent hollowness with mild orbital fat prolapse preoperatively. Most of these cases were satisfied after these procedures. However, one patient complained that the elevation over lower eyelid recurred about one year after fat reposition with transconjunctival approach. Advanced hollowness was noted below the inferior orbital rim. Therefore, I created a subciliary wound and dissected to the orbital ring. Advanced lysis of the orbicularis retaining ligment was done and midface lift was also performed. After the procedure, the lid-cheek junction was smoothed and the patient felt better.
　　In my experience, for the cases presented hollowness below the inferior orbital rim and minimal orbital fat prolapse, combined fat reposition and cheek lifting achieve better contour of lid-cheek junction. Canthopexy or canthoplasty was not regularly performed expect initial presentation with involutional ectropion. Therefore, pre-operatively evaluation and explanation were very important. In my opinion, mid face lifting gives enough support of the lower eyelid. Combined minimal skin resection, proper fat reposition and effective mid face lifting will prevent ectropion after lower blepharoplasty and provide better outcome and happier patient.