Objective To explore the importance of design of incision, formation of double tile of orbicularis muscle flap and processing of orbital fat in extra-approach lower eyelid blepharoplasty, and observe the clinical effect of double tile of orbicularis muscle flap in pouch orthopedics. Methods Eyelid margin path (extra-approach) surgery was performed on 388 patients with obvious lower eyelid bags. The incision was paralleled with lateral canthus groove, and the orbital fat was removed or resected according to clinical manifestations. The eyelid margin orbicularis muscle flap and myocutaneous flap were sutured to form the double tile of muscle flap, and the wound was fit and sutured to close. Results Primary healing of incision was achieved in all the 388 patients, with satisfactory effect. There was obvious skin relaxation in 168 patients, zygomatic surface ditch sag in 62 patients, and prominent orbital fat in 158 patients. Double tile of orbicularis muscle flap was adopted, more lower eyelid strips of orbicularis muscle crest were retained, and no ectropion occurred after operation. Two hundred and sixty patients were followed up for 1 to 2 years, the morphous of the lower eyelid was natural, and no significant surgical scar and palpebral retreat was observed. Conclusion The design of incision, formation of double tile of orbicularis muscle flap and processing of orbital fat are critical steps for extra-approach lower eyelid blepharoplasty.