Lower eyelid surgery

This article covers how bagginess of the lower lid, laxity of the skin and the transition between the lid and the cheek are assessed, how the operation is planned, the recovery process and the risks. The lid itself and the repositioning of cheek tissue are described as separate aims.

What is lower eyelid surgery?

Lower eyelid surgery is an operation that addresses bagginess of the lower lid, excess skin and irregularity of the contour beneath the lid.¹ Its medical name is lower lid blepharoplasty.²

Bagginess does not mean that the amount of fat in the area has simply increased; laxity of the structures that hold the fat of the eye socket in place, allowing the fat to become prominent forwards, can also contribute to that appearance.² The hollow beneath the bag can relate to a lack of volume and to the structure of the transition between the lid and the cheek.³ Fullness and hollowing occurring in the same person explains why removing all of the fat may not be appropriate.⁴

The subject of this article is the lid itself. Repositioning cheek tissue, procedures aimed at changing the shape of the corner of the eye, and correcting the skin of the upper lid are separate aims.² That they can be done in the same session does not mean that all of them are obligatory parts of lower eyelid surgery.⁵

Who is it suitable for?

Surgery can be assessed in people with marked bagginess of the lower lid, laxity of the skin, or a marked hollow in the transition between the bag and the cheek.¹ General health, eye health, and whether expectations can be met by the procedure planned, are part of that decision.⁶ A method is not chosen by looking at outward appearance alone; which tissue the complaint arises from is investigated.⁵

Not all of the darkness around the eye arises from a fat bag, and a dark appearance persisting after surgery is among the reported outcomes.² A change in colour and the shadow formed beneath a bulge are not assessed as the same target.⁷ Swollen folds sitting on the cheek also need examining separately from the fat bags of the lower lid.³

Symptoms of dry eye present before surgery relate directly to problems afterwards, and are therefore asked about beforehand.² Discomfort with contact lenses or previous eye surgery should also be reported. Having a risk factor for dry eye is not by itself an absolute bar to surgery, but it does call for more careful assessment.⁸

What does the examination assess?

Skin, fat and contour: The distribution of the excess skin, the position of the fat bags, irregularities on the surface of the lid and the differences between the two sides are examined.² Asymmetry present at the outset is recorded; not every difference noticed later is assumed to have been created by the surgery.⁹

Lid laxity and the position of the margin: The contact of the lower lid with the globe, how far it moves away when pulled, and how it returns when released are assessed.² This examination helps plan the amount of skin to be removed together with the need for support.³

Bony support and vector: Whether the globe sits forward relative to the bony rim beneath it and to the support of the cheek is assessed; this situation is called a negative vector.³ In such an anatomy, lid support and the amount of tissue to be removed are handled more carefully.³

The ocular surface: Dryness, stinging, watering, sensitivity to light, eye medicines in use and previous eye procedures are recorded.⁸ Examinations relating to the ocular surface are extended according to the complaints and the findings.²

Health and procedure history: Previous lid, brow and facial surgery; eye disease, high blood pressure, thyroid disease, a tendency to bleed, allergies, medicines and supplements are reported.⁹ The examination explains which complaint will be addressed by this operation and which needs assessing separately.⁵

How is the operation planned?

The plan is not limited to the name of the incision; which tissue will be preserved, which will be reduced and how the lid will be supported are determined together.¹⁰ An operation on the lower lid alone and one to which upper lid or cheek procedures are added are not counted as the same scope.⁵

Is bagginess, skin laxity or the hollow of the transition the main issue?

A lid with a marked fat bag and little excess skin and a lid where lax skin is the main issue may not need the same procedure.³ Where there is a hollow at the transition, how reducing the fat will affect that hollow is also considered.⁴ At the examination, the deficiency just beneath the bag is assessed as much as the most prominent part of the bag itself.⁴

The degree of muscle and skin laxity is a decision separate from any procedure on the fat alone.³ Because removing too much skin can contribute to the lower lid margin being pulled down, the amount removed is planned with the position of the lid preserved.⁹ Removing more tissue does not mean a better result will be obtained.

Is the incision made through the conjunctiva or below the lashes?

Both approaches are used in this operation; which is chosen is determined by the findings at the examination. In the transconjunctival approach the incision is made on the inner surface of the lower lid, and fat can be removed or repositioned through that route.⁷ That incision does not by itself remove excess skin on the outer surface; where excess skin is to be addressed as well, it is planned separately.³

In the approach through the skin below the lashes, the incision is made just beneath the lashes and gives direct access to the excess skin.⁷ Techniques for preserving and repositioning fat can be applied from either approach.¹⁰ For that reason an operation from the inner surface is not synonymous with removing fat only, nor is an operation below the lashes synonymous with removing skin only.

The patient selection and the added procedures of the studies comparing these routes differ from one another. A review examining 24 cohort studies states that fat can be safely removed or repositioned by either approach, and that studies making a direct comparison are few.¹⁰ It does not follow from this that one of the routes is safer for everyone, or that their risks are entirely the same.

Is fat removed or repositioned?

Removing fat aims to reduce the bagginess, while repositioning it aims to soften the hollow beneath the lid using the fat already there.² Fat can be moved to another position with its attachment preserved, and limited reduction can also be carried out in selected areas.⁴ That decision is made according to the findings at the examination and depends on whether a lack of volume accompanies the bagginess.

Injecting fat taken from another part of the body is not the same procedure as repositioning the fat of the lid.⁴ Any need to add volume is assessed separately; fat injection does not need to be added to every lower eyelid operation. Choosing a technique that preserves volume does not guarantee symmetry or smoothness either.¹¹

Is a support stitch needed at the lower lid margin?

Canthopexy is covered in this article for the purpose of supporting the position of the lower lid margin.³ Laxity of the lid, the position of the margin at the outset and the bony support are decisive here; the need for support is not the same in everyone and is determined by the examination.³

Applying support does not mean the risk is reduced to zero. The results of operations carried out together with a canthopexy or a more extensive repair of the corner are not transferred directly to operations where no support is added.¹² Whether a procedure at the corner of the eye is being considered for lid support or for changing the shape of the eye is separated clearly at the consultation.

How does it differ from a midface lift and from procedures at the corner of the eye?

A midface lift is a separate procedure directed at the position of cheek tissue, whereas lower eyelid surgery concerns the skin, the fat and the supporting structures of the lid.² That the route below the lashes or through the conjunctiva can be shared does not mean these two operations are the same. Alongside the choice of incision, which tissue will be moved must also be discussed.⁵

Changing the shape of the corner of the eye is the subject of almond eye surgery; the account of support here is not a recommendation for that aim. Where there is excess skin on the upper lid, upper eyelid surgery is assessed separately.⁶ Upper eyelid ptosis and drooping of the brow are also outside the scope of this article.

How is the anaesthetic planned?

The operation is performed under general anaesthetic and takes 45-60 minutes. The form of anaesthetic is not chosen by looking at the site of the incision alone; the procedures added and the health history also enter the assessment.⁵

Where a procedure such as upper eyelid surgery or a midface lift is added, the operation time, the hospital stay and the recovery timetable are reassessed together.

How do you prepare for surgery?

Smoking and nicotine: Smoking is a risk factor for wound healing problems after surgery. Direct surgical data on nicotine products other than cigarettes are scarcer. The practice reference of the American Society of Plastic Surgeons notes a lack of clinical data on e-cigarette use and surgical risk, but states that because nicotine is known to reduce blood flow, e-cigarettes and other nicotine products are regarded as a potential risk factor.¹³ Stopping smoking, vaping and other nicotine-containing products at least 1 month before the operation, and not using them after surgery until healing is complete, is therefore advised. The studies below concern smoking cessation; their results do not establish the same reduction in risk for every nicotine product. A review pooling 6 randomised and 15 observational studies showed that every week of abstinence added benefit, and that studies with at least 4 weeks of abstinence produced markedly better results than shorter ones.¹⁴ A study appraising systematic reviews together reported that cessation interventions beginning at least 4 weeks before surgery and combining multiple behavioural support sessions with pharmacotherapy reduced complications. The same study notes that interventions with only one component, even when started more than 4 weeks before surgery, raise quit rates without reducing complications.¹⁵ Shorter intervals are not useless either: in a meta-analysis of 55 studies covering adults undergoing a range of operations, the risk of pulmonary complications was 27 per cent lower in relative terms among those who stopped at least 2 weeks before surgery, and 29 per cent lower among those who stopped at least 4 weeks before, compared with those who continued smoking.¹⁶ The benefit therefore grows as the interval lengthens; being late does not make stopping pointless. The interval applied and the nicotine policy can vary from surgeon to surgeon.

Coexisting illness: Diabetes and blood pressure are expected to be under control before surgery. Where there is an active infection in the body, surgery is postponed.

Medication: Blood thinners and some herbal products can increase bleeding. Every medicine and supplement you take needs to be declared. Prescribed medication should not be stopped on your own decision.

Tests and anaesthetic assessment: The tests required are determined by general health and by the anaesthetic assessment.¹⁷ Any previous problem with anaesthesia or drug allergy should be declared. The instructions given about fasting and about how to take medication on the day of surgery are followed.

Home and transport: Someone is arranged to accompany you home on discharge.¹⁷ The timing of check-ups, the help you may need in the first days and the plan for time off work are organised beforehand. Follow the surgical team's guidance on preparing the operation area; do not shave or prepare the incision area at home on your own initiative.

Preparation relating to the eyes: Eye drops in use, problems experienced with contact lenses and previous eye surgery are reported.⁵ Where there is dryness, stinging or sensitivity to light, these need assessing before surgery.⁸

What is recovery like?

The timetable below is the framework of clinical practice for an operation directed at the lower eyelid alone. The physical demands of your work and the course of healing can change these times. If another procedure is added, this timetable is assessed again.

The hospital stay is planned as 1 night. The first check-up is within the first week. The stitches are removed after 1 week; a conjunctival incision can be closed with stitches or left to heal on its own. 1 week is allowed for returning to desk work. A return to driving can be assessed within 1-3 days. 2 weeks is expected for returning to sport, and 2-4 weeks for a full return to daily life.

Bruising is expected to settle over 7-10 days and marked swelling over 1 week. These intervals do not mean everyone reaches the same appearance on the same day. Vision can be blurred in the first few days, and the ointments used can also affect vision temporarily.¹⁸

The shape becomes possible to assess over 1-2 months, while residual mild swelling can last up to 2-3 months. Assessing the shape therefore does not mean that all swelling has finished by that day. The direction of healing is monitored at check-ups; swelling that increases, is painful or is markedly one-sided is not explained by recovery time alone.

As the swelling reduces, the position of the lid margin, the closing of the eye and the state of the ocular surface are also monitored.⁹ Where the lid moves away from the globe, is pulled down, or the eye does not close fully, the next check-up is not waited for.⁹

What to pay attention to after surgery

The following is a general framework. Where the instructions you were given differ, your surgeon's instructions apply.

The incision and strips: Where an outer incision has been made, wound closure strips are applied to the incision line. When the strips are removed is decided at the check-up. Covering the eye for the first 2-3 nights may be advised; your surgeon says whether that is needed.

Sleeping: Rest with the head elevated. Your surgeon decides how long that position and the avoidance of physical strain are continued. A sleeping position that puts no pressure on the incision is preferred. Returning to sleeping on the side or front is assessed according to the state of the incision and the swelling.

Cold application: Cold is applied to the operated area without pressing on it. The form and duration of the application are determined by your surgeon's instructions.

Showering, wound and dressings: When you may shower depends on the dressing used. If there is a skin incision, once allowed you can shower without rubbing the wound and pat the area dry gently. Baths, swimming pools and the sea wait until the wound has closed completely.

Washing your face: A return to washing the face is decided according to healing and is assessed within 3-7 days on average. The incision line is not rubbed, and directing water into the eye is avoided.

Eye care: Eye drops or ointment are given routinely after surgery. Hands are washed before applying them.¹⁸ The eyes are not rubbed and the incision line is not pulled at.¹⁹

Movement: Strain such as bending the head down, straining and heavy lifting is limited in the early period. Movements that stretch or rub the incision area are avoided. Even if you feel well, do not return to strenuous activity suddenly. Activity and rest through the day are organised according to the plan given on discharge.

Pain: There may be mild pain and tenderness in the lid.¹⁸ The painkillers provided are used as instructed. Pain that keeps increasing, becomes severe eye pain, or comes with a reduction in vision should not be watched and waited out.⁹ The surgical team is told if a new painkiller or additional medicine is to be used.

Returning to work and sport: 1 week is allowed for returning to desk work; for physically demanding work, healing is assessed separately. 2 weeks is expected for returning to sport and 2-4 weeks for a full return to daily life. Because long periods at a computer can increase complaints of dryness, the demands your work places on the eyes should also be stated.⁸

Driving: A return to driving can be assessed within 1-3 days. Do not drive while your vision is blurred.¹⁸ Do not take the wheel before the effect of the anaesthetic on attention and reflexes has passed and you have seen that the painkiller does not make you drowsy.

Make-up and contact lenses: Make-up around the eyes and contact lens wear are not planned before 2 weeks; after that time, a return is decided according to assessment at a check-up with your surgeon.

Sexual activity: A return can be assessed once everyday movements no longer cause marked pain and you feel comfortable. Pressure on the head and around the eyes, movements that stretch the incision line, and marked straining are avoided. Rather than a fixed day, the course of healing and the surgeon's advice are taken as the guide.

Smoking: Smoking impairs wound healing after surgery as well; cigarettes and nicotine products should be avoided until healing is complete.

Findings that are normal: Swelling, bruising and tenderness in the lower lid, and numbness or altered feeling around the incision, can occur.²⁰ Irritation, watering and a feeling of dryness in the eye can also occur.²¹ What matters is less the presence of a mild finding than how it changes. Swelling that increases rather than settling, pain that progresses, or vision becoming impaired should not be judged as ordinary healing.¹⁸

How do the scars change?

An incision made below the lashes is placed close to the lash line so that the scar is less noticeable.⁷ That does not mean there will be no scar; a conspicuous scar is among the reported risks of eyelid surgery.²⁰ With a procedure carried out through the conjunctiva there is no incision in the outer skin.⁷

Maturing of the scar is expected to take between 4 and 6 months. An incision line that looks red, firm or more prominent early on is assessed over that period. The final appearance of the scar is not settled on how it looks at the first check-up.

Where an incision below the lashes has been made, silicone gel and massage are advised for the care of the scar. When they are begun and how they are applied are determined by the surgeon according to how the incision is healing. With a procedure carried out through the conjunctiva there is no outer incision, so this care is not applied. The plan given by the surgeon is followed for care of the incision.

Small lumps around the incision are not always the same problem; thickening of the scar and a small cyst developing under the skin are told apart, because the two are managed differently.⁹ Care is taken to protect the area from the sun, and darkly tinted sunglasses are advised.²¹ Where there is wound separation, discharge or increasing tenderness, it is not treated as merely part of the scar maturing; assessment is requested.

Risks and complications

The risks are assessed together with existing eye health and the scope of the operation planned.⁵ The headings below are not an order of frequency. Because the routes of incision and the procedures added differ, it is not appropriate to describe every technique with a single percentage of success or complications.¹⁰

A review examining 36 studies states that lower eyelid surgery is generally safe with a low complication profile, that no major complication affecting the eye or vision was reported, and that most problems relating to appearance and function can be resolved with conservative management or revisionary surgery.²² The same review also states that comparing the methods with one another is difficult, because the studies differ in design and in technique.²²

Problems of shape, symmetry and the scar

Asymmetry, a conspicuous scar and failure to achieve the expected change can occur.¹⁹ Part of the bagginess remaining and hollowing caused by removing too much fat are different needs for correction.⁴ Contour irregularity can also develop after fat has been repositioned.²

The same review states that the rates in the 21 articles reporting reoperation ranged from 0 per cent to 9 per cent, and that most of the articles remained below 3 per cent.²² These are separate rates for different operations and different follow-up times; because the studies differ, no pooled result was calculated, and this range is not an estimate of individual risk.²²

Problems with the position of the lower lid margin

The lid being pulled down is called retraction and the margin rolling outwards is called ectropion. More of the white of the eye becoming visible can relate to these conditions, but they are not all the same finding.⁹ Removing too much skin, scar tissue developing between the layers, and existing laxity not being adequately addressed can all contribute to these problems.⁹

In a series of 265 people operated on below the lashes, 3 people had increased visibility of the white of the eye, 2 of whom had a corrective procedure; 6 people developed marked swelling and 2 developed a mild collection of blood, and 5 people who developed scar tissue within the lid early on were given an injection to reduce it.²³ No conspicuous scar and no ectropion were reported.²³ In the same series upper lid surgery was added for 177 people and brow surgery for 17, and the median follow-up was given as 4 months.²³ These results belong to one surgeon's selected practice; they are not a general long-term risk rate, nor evidence that one route of incision is superior to another.

The lid being pulled down can also be temporary; where a lasting problem of position develops, further treatment may be needed.²⁰ The closing of the eye and the protection of the surface are assessed separately from appearance alone.⁹

Dry eye, chemosis and the ocular surface

Surgery can increase existing dry eye or create new complaints.⁸ In a retrospective series of 892 people reported in a review, dry eye was reported in 21.4 per cent of those who had lower lid surgery alone and in 31.3 per cent of the group in which the upper and lower lids were operated on together.⁸ That is a single series; it is not a rate that holds for all lower eyelid operations. Another study reported in the same review found that measurements of the ocular surface returned to their starting level at follow-up; not every complaint of dryness is permanent.⁸

Chemosis is swelling of the transparent membrane covering the surface of the eye.¹² A retrospective study covering 1,047 people states that prolonged chemosis was reported more often with the route below the lashes combined with a procedure at the outer corner of the eye than with the conjunctival route.¹² Because the route of access and the support procedure changed together in that study, the difference cannot be attributed to the incision alone; the group sizes are also given differently in the article's abstract and in its tables, so the subgroup figures are not carried here.

Chemosis can settle on its own; where it lasts or affects the closing of the lid, protection of the ocular surface and the position of the lid are reassessed.⁸ A complaint that can be temporary is not a reason to wait out increasing pain or a reduction in vision at home.¹⁸

Bleeding, the wound and infection

Bleeding at the incision line, a collection of blood under the skin, infection and problems of wound healing can develop.²⁰ Superficial bruising and bleeding that creates pressure within the eye socket are not the same thing.⁹

Where redness spreads, or there is discharge, worsening pain or separation of the wound edges, assessment is needed.¹⁸ Prevention of infection and treatment where needed are decided according to the person's situation; there is no single medication plan for everyone. Having been given drops or ointment does not make it unnecessary to report a new complaint.

Rare situations that threaten sight

Bleeding within the eye socket is rare, but it can impair the blood supply to the optic nerve and threaten sight.⁹ Injury to the eye from surgical instruments and problems caused by the ocular surface being left exposed are also among the risks to be assessed.³ The chance of losing vision is low, but it cannot be disregarded.²⁰

Sudden reduction in vision, rapidly increasing tight swelling, or severe eye pain unlike anything usual, calls for urgent assessment.⁹ The day of the scheduled check-up is not waited for.¹⁸

Anaesthetic and general surgical risks

Unwanted effects related to the anaesthetic and allergic reactions are assessed together with the form of anaesthetic used and the health history.²⁰ General surgical risks apply to every operation and are covered in the preoperative assessment.

Blood clots: A clot forming in the leg veins and travelling to the lungs is serious. One-sided leg pain and swelling, sudden shortness of breath or chest pain need urgent assessment.

The approach to preventing clots is decided according to the person's risk and the operation planned. The measures to be used are explained in the discharge and care plan. No blood thinner is started without being prescribed, and existing treatment is not altered on the person's own decision.

Does the result change over time?

Natural ageing continues after surgery; it cannot be said that the result will be maintained for the same length of time in everyone.¹¹ Where bagginess or laxity becomes noticeable again later, the skin, the fat and the support of the lid are assessed separately.³

The follow-up time in the research does not mean that everyone maintained the same result over that period.²² Telling early swelling apart from a lasting problem of shape matters for any decision to operate again.⁹ By contrast, a problem with lid position that affects the ocular surface is not deferred simply to wait for the final shape to settle.⁹

What can be expected from the result?

Reducing the bagginess, addressing the excess skin and, in a suitable person, softening the hollow of the transition can be aimed at.¹ What can be expected is built on which complaint will be addressed by which procedure.⁵ Preserving the natural position of the lid and its ability to close is an important part of the plan.³

The operation is not expected to remove every line around the eye, the change in colour, or sagging of the cheek.² A lack of volume, the surface of the skin and the position of cheek tissue can call for different decisions.⁴ Where an added procedure on the upper lid, the cheek or the corner of the eye is being considered, its aim and its risks are discussed separately.⁵ No promise of complete symmetry is made and no particular appearance is guaranteed.¹¹

When should you contact a doctor?

Do not wait for the scheduled check-up in the following situations:

• Sudden reduction in vision, loss of vision or newly developed double vision
• Severe eye pain, rapidly growing tight swelling or the eye protruding forwards
• The eye not closing, a new change in the position of the lower lid margin, or marked stinging
• Fever, spreading redness or discharge from the incision line
• Separation of the wound or bleeding that does not stop
• Pain that increases rather than settling, or becomes marked despite the pain treatment given

Bleeding within the eye socket can threaten sight.⁹ Where there is a sudden visual problem or severe eye pain, urgent assessment should not be delayed while trying to reach the surgeon.¹⁸

One-sided leg pain and swelling, sudden shortness of breath or chest pain are also emergencies. Where there is a sudden breathing problem in particular, urgent assessment is not delayed.

About the numbers in this article

The intervals given for the operation, the hospital stay, stitch removal and returning to activity, and for bruising, swelling, the shape settling and the scar maturing, are a framework of clinical practice. The summary box covers an operation directed at the lower eyelid alone; where a procedure such as upper eyelid surgery or a midface lift is added, the times and the timetable are set again.

The numbers in the research are not the personal complication rates of this practice. The route of incision, any support procedure added, upper lid or brow surgery carried out in the same session, and the follow-up time are all weighed alongside each figure.²²²³ The percentages given for dry eye belong to a single series reported in a review.⁸

The range of 0 per cent to 9 per cent given for reoperation is not a combined result; because the studies differed, no meta-analysis was carried out in the review.²² Because the smoking studies cover different operations, the relative reductions in the shared paragraph should not be read as a risk percentage specific to lower eyelid surgery.¹⁴¹⁵¹⁶

References

1. American Society of Plastic Surgeons. Eyelid Surgery. Accessed 6 September 2026. Institutional text ↩ ↩² ↩³

2. Naik MN, Honavar SG, Das S, Desai S, Dhepe N. Blepharoplasty: an overview. J Cutan Aesthet Surg. 2009;2(1):6-11. doi:10.4103/0974-2077.53092 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹ ↩¹²

3. Bhattacharjee K, Ghosh S, Ugradar S, Azhdam AM. Lower eyelid blepharoplasty: An overview. Indian J Ophthalmol. 2020;68(10):2075-2083. doi:10.4103/ijo.IJO_2265_19 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹ ↩¹² ↩¹³

4. Miotto GC, Shauly O, Menon A. Lower Eyelid Blepharoplasty With Volume Preservation Using the Skin Flap. Aesthet Surg J Open Forum. 2023;5:ojad074. doi:10.1093/asjof/ojad074 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

5. American Society of Plastic Surgeons. Eyelid Surgery Consultation. Accessed 6 September 2026. Institutional text ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰

6. American Society of Plastic Surgeons. Eyelid Surgery Candidates. Accessed 6 September 2026. Institutional text ↩ ↩²

7. American Society of Plastic Surgeons. Eyelid Surgery Procedure Steps. Accessed 6 September 2026. Institutional text ↩ ↩² ↩³ ↩⁴ ↩⁵

8. Zhang SY, Yan Y, Fu Y. Cosmetic blepharoplasty and dry eye disease: a review of the incidence, clinical manifestations, mechanisms and prevention. Int J Ophthalmol. 2020;13(3):488-492. doi:10.18240/ijo.2020.03.18 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹

9. Oestreicher J, Mehta S. Complications of blepharoplasty: prevention and management. Plast Surg Int. 2012;2012:252368. doi:10.1155/2012/252368 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹ ↩¹⁰ ↩¹¹ ↩¹² ↩¹³ ↩¹⁴ ↩¹⁵ ↩¹⁶

10. Atiyeh B, Chrabieh E, Makkawi K, Beaineh P, Issa O, Emsieh S. Transconjunctival or Transcutaneous Approach for Fat-preserving Lower Lid Blepharoplasty? Plast Reconstr Surg Glob Open. 2025;13(12):e7345. doi:10.1097/GOX.0000000000007345 ↩ ↩² ↩³ ↩⁴

11. American Society of Plastic Surgeons. Eyelid Surgery Results. Accessed 6 September 2026. Institutional text ↩ ↩² ↩³

12. Di Maria A, Barone G, Gaeta A, et al. Persistent Conjunctival Chemosis after Lower Lid Blepharoplasty: A Comparison of Different Surgical Techniques. J Clin Med. 2024;13(7):2093. doi:10.3390/jcm13072093 ↩ ↩² ↩³

13. American Society of Plastic Surgeons. Managing the risks of smoking in plastic surgery patients. Practice reference, 9 October 2024. Accessed 5 September 2026. plasticsurgery.org ↩

14. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124(2):144-154.e8. doi:10.1016/j.amjmed.2010.09.013 ↩ ↩²

15. Fiddes RA, McCaffrey N. Preoperative smoking-cessation interventions to prevent postoperative complications: a quality assessment and overview of systematic review evidence. Anesth Analg. 2025;140(6):1377-1387. doi:10.1213/ANE.0000000000007187 ↩ ↩²

16. Tang E, Rodriguez RM, Srivastava A, et al. Impact of short duration smoking cessation on post-operative complications: a systematic review and meta-analysis. J Clin Anesth. 2025;106:111967. doi:10.1016/j.jclinane.2025.111967 ↩ ↩²

17. American Society of Plastic Surgeons. Eyelid Surgery Preparation. Accessed 6 September 2026. Institutional text ↩ ↩²

18. Guy's and St Thomas' NHS Foundation Trust. Blepharoplasty: During and after your surgery. Accessed 6 September 2026. Institutional text ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷ ↩⁸ ↩⁹

19. National Health Service. Eyelid surgery. Accessed 6 September 2026. Institutional text ↩ ↩²

20. American Society of Plastic Surgeons. Eyelid Surgery Risks and Safety. Accessed 6 September 2026. Institutional text ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶

21. American Society of Plastic Surgeons. Eyelid Surgery Recovery. Accessed 6 September 2026. Institutional text ↩ ↩²

22. Gimenez AR, Rohrich R, Borab Z, Fisher S, Fagien S, Rohrich RJ. Safety and Complications in Lower Eyelid Blepharoplasty: A Systematic Review. Plast Reconstr Surg Glob Open. 2025;13(9):e7102. doi:10.1097/GOX.0000000000007102 ↩ ↩² ↩³ ↩⁴ ↩⁵ ↩⁶ ↩⁷

23. Alhumaemydi R, Diab MM, AlSuhaibani AH. Refining transcutaneous lower blepharoplasty: Key steps for minimizing complications. Saudi J Ophthalmol. 2025;39(2):143-147. doi:10.4103/sjopt.sjopt_89_25 ↩ ↩² ↩³ ↩⁴