Objective To explore the effect of septum orbitale replacement and lateral canthopexy on tear trough deformity improvement and aesthetics in patients undergoing eyebag plastic surgery. Methods A total of 56 patients who underwent eyebag plastic surgery in the Department of Plastic Surgery, People's Hospital of Zhengzhou from March 2023 to June 2024 were selected as the research subjects. According to the random number table method, they were divided into the control group and the observation group, with 28 patients in each group. The control group was treated with traditional lower eyelid skin approach surgery, and the observation group was treated with septum orbitale replacement and lateral canthopexy. The tear trough deformity improvement, aesthetics, satisfaction, wound healing and complications were compared between the two groups. Results The proportion of grade 0 in the Barton classification of tear trough deformity after surgery in the observation group (89.29%) was higher than that in the control group (64.29%) (P <0.05), and the proportion of grade 1 (10.71%) was lower than that in the control group (35.71%) (P <0.05). After 3 months of surgery, the lower eyelid wrinkle score in the observation group was lower than that in the control group, and the skin aesthetics score in the observation group was higher than that in the control group (P <0.05). The satisfaction rate in the observation group was 98.21%, which was higher than 75.00% in the control group (P<0.05). All patients achieved primary healing of the lower eyelid incisions, without any complications. Conclusion The application of septum orbitale replacement and lateral canthopexy in eyebag plastic surgery can effectively improve the tear trough deformity and lower eyelid wrinkles, and enhance the aesthetics of the local skin, with good prognosis after surgery and fewer complications. It is worthy of clinical application.