How do I get rid of eye bags?

If you have lower eyelid fat bags that bulge significantly out and create a tired look, surgery might be your best bet depending on a careful analysis of your eyelid anatomy and laxity. Either the fat can be conservatively removed, or it can be shrunk with a cautery device, or it can be transposed down to fill in a tear trough deformity below the bulge.

However, lower eyelid surgery in my practice has become relatively rare because so much can be done by adding Restylane into the tear trough to fill in the hollow that creates such a tired appearance. In fact, in the properly selected patient, the results you can get with Restylane are actually not able to be achieved with surgery. Plus, the lower lids are very sensitive and somewhat prone to complications with surgery and these are largely avoided with fillers.

There are many causes for eye bags.  Several things are often occurring at once. 

Over time, the orbital septum weakens, and fat bulges against this septum.  This is seen as a bulge below the eyes.  It is usually treated by fat repositioning, and sometimes by slight reduction of the fat, often from inside the eyelid (transconjunctival).

Hollowness develops around the fat bulge above, due to hollowing of the facial fat.  We often replace the missing fat.  In our practice, we use nontraumatized fascial fat grafts (LiveFill), usually placed at the eye cheek junction and the tear trough rather than fat injection, although that is a nice option as well in the right hands.

The cheeks fall.  In our practice, for the appropriate patient, we perform a cheeklift, often using a minimal incision, although there are many types of cheeklifts, depending on the patient's anatomy and problem.

Loose skin can also cause a problem.  When the loose skin occurs below the lower eyelid, we strongly believe in not just removing the skin, as this usually changes the eye shape to a rounded or pulled down shape, even if minor amounts of skin are removed.  Rather, we typically perform a minimal incision cheeklift to "give" skin to the lower lid, which can then more safely be removed. 

Weakening of the lower eyelid, or canthus occurs with age.  It is often beneficial to tighten this canthus to counteract this issue.

Skin damage caused by the sun over the years destroys elastic fibers and causes sun spots, all contributing to aging around the eyes.  Laser resurfacing with a myriad of new lasers often helps this problem as well.

For a complete discussion on these topics, you may wish to read our chapter in the textbook Mathes Plastic Surgery, in its entirety on the drbrent.com website under Articles.

Fillers such as Juvederm and Restylane are also wonderful for filling in hollows, and are actually becoming much more popular over the last several years as they have become longer lasting.

Lower Eyelid Fat Pads or "Bags"

A very common aging change in the lower eyelids is the development of 'bags', which are in most cases due to an outward bulging of the fat pads behind the lower lids. These 'bags' of fat can be improved by conservative removal through an invisible incision on the inside of the lower lid (trans-conjunctival approach) in patients that do not require skin excision, or through the under-eyelash (sub-ciliary approach) in patients that are having some excess lower lid skin removed.

As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.

In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.

Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.

Structural Fat Grafting of the Lower Lid

As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.

In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.

In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.

Eye bags are caused by fat accumulation in three little compartments in the lower lids and two in the upper lids. This is diet-resistant fat, which means it is not related to weight gain or loss.

Fat pads in the lower lids are removed through an incision on the inside of the lower lids and through an incision along the crease of the upper lids. Fat is not removed with liposuction but by teasing it out and cauterizing it to make sure it does not bleed.

This is a complicated problem with many solutions, none of which are perfect in isolation.

Three main problems that cause eye bags:

1. Fullness caused by "pseudoherniation" (bulging) of normal orbital fat that surrounds and protects the eyeball or just below this area, a relative hollow that develops and is aggravated by gravitational descent of cheek fat
2. Loose skin and muscle surrounding from age, heredity and environmental factors (smoking)
3. Pigmentary issues related to dark discoloration with thin skin and prominent blood vessels compounded by a shadowing effect due to the contour issues (1. and 2.) listed above.

Surgical treatments include:

• Carefully remove or reposition orbital fat
• Reposition/lift cheek fat and tissues
• Reposition/tighten eyelid skin and muscle
• Fill orbital contour hollows with fat injections

Non-surgical treatments include:

• Skin care with peels
• Anti-pigment treatments
• Intense pulse light and non-ablative laser treatments for vascular pigment and skin tightening
• Soft tissue filler enhancement for hollows

Although this is most often treated with surgery (called a blepharoplasty), no two cases are identical and for some a nonsurgical option may be worthwhile.

The bags are bulging fat, normally held back in the eye socket. The shadow created along the "tear trough" is what contributes to the problem.

Most surgeons remove the bags by taking out the fat, but as we get older we lose fat around the eyes and so it may actually accelerate the aging process in the end. Better to reposition the fat into the tear trough rather than remove it in many cases.

For milder cases, a filler into the tear trough such as Restylane, Perlane, or Juvederm often works very well.