Lower Blepharoplasty (Lower Eyelid Surgery) in Thessaloniki and Athens, Greece

Lower blepharoplasty is not a single operation but a set of techniques, combined differently for each eye. Together they deal with the bag of fat, the hollow along the tear trough, loose skin and the support of the lower lid. Which techniques each eye needs is decided by a careful examination before surgery.

In the lower lids, correct assessment and the choice of technique are the key point [1]. When there is only a bag, removing or repositioning it from inside the lid is often enough. When the skin, the muscle or the tendon at the outer corner of the eye is also lax, further steps are needed.

I do not remove a large amount of fat. I move it into the hollow directly below, to smooth the transition from the lid to the cheek [4, 5]. This can also improve dark circles caused by the shadow of that hollow.

The operation can be extended lower, to treat a deep tear trough or a low bag where the lid meets the cheekbone (malar bag, festoon), and in selected cases it is combined with a midface lift. Injectable materials and laser cannot remove or reposition fat.

My approach: less skin, more support

Removing too much skin is a common cause of a pulled-down lower lid. That is why I am conservative with skin:

• I remove skin extensively only when an extensive facelift or midface lift leaves genuine excess tissue.
• When the indication is borderline, I either leave the skin alone, remove a minimal strip (skin pinch), or lift the lower lid indirectly from the temple with Pascali’s temporal MORE technique: I fully release the orbicularis oculi muscle from the ligaments of the lower lid and reposition it, so that the skin and muscle of the lower lid are lifted without a major fixation of the canthus.
• Always with strong support of the midface and of the structures at the outer corner of the eye [3, 6].

Lower blepharoplasty suits healthy adults with bags, a hollow or loose skin under the eyes that give them a tired look. The degree of laxity and the anatomy of your eyelids matter more than your age, and lower lid surgery can be done at a younger age than upper lid surgery.

At the consultation I examine each eye separately and we decide together which techniques it needs and whether to combine the operation with other facial surgery. You receive a written plan and cost. The tests you need beforehand depend on the type of anaesthesia and on whether you are prone to dry eye.

What happens at the consultation?

I examine each eye on its own: the fat bags, the hollow along the tear trough, the skin, the position and tone of the lower lid, the tone of the canthus and the support of the midface. I ask about dry eye and check the conjunctiva for signs of irritation. I also assess the rest of your face, because a tired look comes not only from the eyelids but also from the brows, the forehead and the midface. We then decide together which techniques each eye needs and whether the operation should be combined with other facial procedures. You receive a written plan and cost.

What tests and instructions apply before surgery?

Under local anaesthesia no special tests are usually needed; with sedation or general anaesthesia you need pre-operative blood tests. If you are prone to dry eye, we assess it beforehand and plan your aftercare in advance. Stop smoking 4 weeks before and 4 weeks after the operation. If you take anticoagulants or antiplatelet medicines (blood thinners), tell me; they are stopped only in agreement with the doctor who prescribes them. The date of surgery is set once these checks are complete.

Lower blepharoplasty is usually done under local anaesthesia, with sedation when needed or general anaesthesia if you prefer, and takes 20 minutes to 1 hour. The bag is removed or repositioned either from inside the lid or through an incision just below the lashes. I often combine two or three techniques in the same eye.

Local anaesthesia alone is enough for the lower lids; some patients choose sedation or general anaesthesia to feel more comfortable. When upper and lower blepharoplasty are done together, local anaesthesia with sedation is the better option. In every case the operation is painless and needs no hospital stay. How long it takes depends on what each eye needs.

Transconjunctival blepharoplasty: when there is only a bag

When there is only a bag, I remove or reposition it through a small incision on the inner surface of the lid, through the conjunctiva. This technique leaves no external scar, gives very good results and allows a faster recovery. Because the muscle and skin are not cut, the lower lid keeps its support.

Open blepharoplasty and skin pinch: when the skin is loose

When the skin is lax, a simple removal of skin (skin pinch) can be done, as in upper blepharoplasty, together with removal of the bag through the conjunctiva; or an open operation through an incision below the lashes, when skin, muscle and fat all need work. Skin removal is always measured and conservative.

Fat repositioning and the tear trough

Instead of being removed, the fat of the bag can be moved into the hollow directly below it, along the tear trough [4, 5]. This corrects the bag and the hollow at the same time and improves dark circles. As a complement, I use fat transfer to the eyelids and around the eyes, often with nanofat.

Did you know? In many facial operations I add nanofat: fat from your own body, processed into a very fine graft, which improves the quality and texture of the skin [7]. I use it to complement surgery and rarely on its own, because the share of fat that survives is not predictable.

Canthopexy and canthoplasty

When the whole eyelid structure is more markedly lax, the outer canthus is fixed again with a canthopexy or canthoplasty, together with the lid’s orbicularis muscle sling [2, 3]. A canthopexy supports the lower lid so that it is not pulled down during healing, and it can give the eye a more almond shape. I perform it only when it is indicated.

Incisions and stitches

With the transconjunctival technique the incision is inside the lid. With the open technique it lies just below the lashes and blends into the natural crease. I close it with a continuous intradermal stitch, so that no cross-marks from external stitches are left, and the stitches come out on day 5.

Combining it with other procedures

Lower blepharoplasty is often combined with upper blepharoplasty, a brow lift or a temporal lift for the so-called foxy eye or cat eye look, where the eye becomes more almond-shaped or more slanted. In patients having an extensive facelift or midface lift, it is done in the same operation, and then skin removal is justified [6]; see the deep plane facelift page. For very mild laxity, laser resurfacing or radiofrequency also gives some improvement.

Hospital stay

No hospital stay is needed. You go home the same day and can go out straight away wearing sunglasses. After sedation or general anaesthesia you need someone to accompany you, and you must not drive.

Swelling and bruising are strongest in the first 5 days, when the stitches also come out. You can return to work after about 1 week, wear make-up after 2 weeks and exercise after about 1 month. Swelling in the lower lids takes 2 to 6 weeks to settle completely.

For the first few days I recommend sleeping on 2 pillows, and for the first 24 hours applying cold compresses to the eyes. Your eyes work normally straight after the operation, because your vision is not affected. When you go back to work depends on two things: being able to function, and avoiding comments from people around you. Some patients choose to take 2 weeks or more off, so that the operation goes unnoticed.

Lower blepharoplasty needs no hospital stay: you go home the same day. The stitches come out on day 5, and swelling and bruising are strongest during those first 5 days, so plan your stay around the stitch-removal visit: 5 to 10 days in Greece in total.

After sedation or general anaesthesia, someone must accompany you on the day and you must not drive. You can go out straight away wearing sunglasses; after day 5 you no longer need them, and a little concealer covers any bruising.

Flying home: from day 5, after the stitches are out, with no limit on flight length.

Follow-up from home: by video call at 10 days, 1 month, 6 months and 1 year.

What to arrange at home: someone to help on the first day, 2 pillows to sleep on and cold compresses for the first 24 hours, lubricating eye drops, and, if you are prone to dry eye, taping and steroid drops as we plan before surgery. Allow about 1 week off office work, or 10 to 15 days for physically demanding work; some patients take 2 weeks or more so that the operation goes unnoticed. All follow-up checks are done by me; nursing care at home can be arranged if you would like it.

After lower blepharoplasty the bags and puffiness under the eyes settle and dark circles improve noticeably. Because the fat is redistributed rather than removed in large amounts, the eye does not look hollow. The result is long-lasting; in my experience, more than 15 years.

The lower lids heal very well and the scars are inconspicuous: they take 1 to 2 months to reach the point where they show little or not at all, and after about a year they are almost invisible. Fat that has been removed very rarely comes back. The skin and the midface keep ageing, and today’s aesthetic accepts slight laxity after some years as more natural. When a canthopexy is done, the eye can become more almond-shaped, depending on what you want.

Lower blepharoplasty is a well-studied operation, but the more complex or traumatic the surgery, the more often complications such as ectropion, scleral show, scarring or poor healing can occur. My experience has shown that the lower lids call for very conservative choices, always guided by the right indications.

Smoking: stop at least 4 weeks before and 4 weeks after the operation. Smoking increases healing complications and reduces the success of fat transfer.

We do not publish prices. The cost of lower blepharoplasty differs from person to person, depending on the technique, any additional work on the outer corner of the eye or on the fat, and whether it is combined with another operation. You receive a quote after the consultation, once I have examined you and we have agreed the plan together.

What affects the cost:

• The technique: transconjunctival, skin pinch or open.
• A canthopexy or canthoplasty, when needed.
• Fat repositioning, or fat transfer and nanofat.
• The anaesthesia: local, sedation or general.
• Combining it with upper blepharoplasty, a brow lift, a temporal lift or a facelift.