While the predominant problem of the upper eyelids is excess skin with only occasionally a small excess of fat, the lower eyelids are just the opposite. Here there is only occasionally excess skin, but the problem usually is just excess fat in the lower lid that causes bulging.
Since the problem is just fat bulging from the inside, it is usually treated with what is called a transconjunctival blepharoplasty, which involves removal of fat from a hidden scar inside of the eyelid. This does not need stitches, has no external scar, and heals inconspicuously.
When there is excess eyelid skin, then a pinch of skin can be removed with a tiny incision just below the lower lashes.
In the past, surgeons frequently took too much fat from the lower eyelids, creating a bit of a skeletonized look with the roundness of the lower eye too visible. Dr. Teitelbaum seeks to make the area flat, but still full. Humans lose fat around the eye with age, and it is very important not to remove any more fat than absolutely necessary to restore a beautiful and youthful shape to the lower eyelids.