Objective To investigate the effect of transconjunctival lower eyelid blepharoplasty combined with orbital septal fat release on lower eyelid smoothness in middle-aged and elderly patients with lower eyelid skin laxity and tear trough deformity. Methods A total of 100 middle-aged and elderly patients with lower eyelid skin laxity and tear trough deformity admitted to the Department of Aesthetic Surgery, Xi'an Huamei Aesthetic&Plastic Hospital from January to December 2024 were selected as the research subjects. According to the random number table method, they were divided into the control group and the experimental group, with 50 patients in each group. The control group received transconjunctival lower eyelid blepharoplasty, and the experimental group received transconjunctival lower eyelid blepharoplasty combined with orbital septal fat release. The lower eyelid smoothness, tear trough improvement effect, satisfaction and complication rate were compared between the two groups. Results The lower eyelid smoothness scores of the experimental group at 3 and 6 months after surgery were lower than those of the control group (P<0.05). The tear trough improvement effect scores of the experimental group at 3 and 6 months after surgery were higher than those of the control group (P<0.05). The satisfaction of the experimental group was better than that of the control group (P<0.05). The incidence of complications in the experimental group (6.00%) was lower than that in the control group (22.00%) (P<0.05). Conclusion Transconjunctival lower eyelid blepharoplasty combined with orbital septal fat release can effectively improve lower eyelid skin laxity and tear trough deformity in middle-aged and elderly patients, enhance lower eyelid smoothness, reduce the risk of postoperative complications, and achieve high patient satisfaction.