This is also called external incision lower eye bag surgery. It is mainly aimed at correcting the eye bag bulge combined with lower eyelid laxity or an exceedingly deep tear-trough groove or any problems unable to be corrected by trans-conjunctival incision eye bag removal (non-scar eye bag removal), which achieve bulged fat removal, eyelid suspension, and tear trough-groove correction; it is the most radical lower eye bag surgery. An incision is made from the medial canthus to the lateral canthus along the lower eyelash margin to first extract the excess and bulged fat pads in the eye pouch and repair the adipose fascia to prevent future relapse. Then, the partial fats are transferred and grafted to the depression of the tear-trough groove; the excess loose lower eyelid skin due to fat removal is resected properly, then the eyelid is suspended and fixated to the lateral canthus. This technique not only effectively alleviates eye pouch and tear-trough depression but also lifts and suspends the lower eyelid skin to prevent fine lines or skin looseness after surgery; it can even be combined with regional midface lift to improve the nasolabial folds or mouth corner drooping. Therefore, its applications would be customized to individuals.

In addition, some patients with congenital inferior eye socket depression (depressed eye pouch) or severe tear-trough depression due to a previous eye bag removal undergo concurrent tear-trough groove filling with autologous fats (free fat grafts) via this technique to level the eye pouch and tighten the eyelids. The fats are harvested from the periphery of the umbilicus or the medial thighs, which sustain long-term and harmonic results.