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Puffiness Under the Eyes – and the Risks of Surgery

Bags – or puffiness – under the eyes often give the impression of fatigue. It might not look good in the mirror, but you’ll doubtless hear comments from friends and family like “did you sleep badly?” or “why do you look so tired?” If you don’t like what you see in the mirror, what can you do about it?

Puffiness under the eyes: how do they arise? Moisture in the eyelids
In children, fluid accumulates in the eyelids (especially the lower eyelids) when they are tired or ill, but this disappears overnight when people sleep. This is also the case in adults, but this situation can be made worse by aging and smoking. Chronic inflammation attracts fluid to the eyelids and this stretches the skin of the lower eyelids. Further, as people age, their connective tissue changes, causing skin to become less elastic and sag and wrinkle, and the upper and lower eyelids to become weaker.

Fat in the eyelids
As connective tissue weakens, the fat around the eye socket can come forward and appear in the lower eyelids. This is called a fat prolapse. Unlike fluid, which can be pushed away, fat prolapses – literally bumps of fat – cannot, and can only be removed with surgery.

Before lower eyelid correction with the Hamra technique, performed by Dr. Paridaens (published with the patient’s permission).

After Hamra’s eyelid correction by Dr. Paridaens. There is a nice filling of the transition from the lower eyelid to the cheek, which means that the bags are practically gone! (Published with the patient’s permission).

Face bags: when to perform surgery?
If there is a clear sagging of lower eyelids as well as excess skin and proliferating fat (as opposed to subcutaneous lumps) then eyelid surgery can also bring cosmetic improvements to that region. These procedures are often performed under local anesthesia, but if more extensive surgery is required, this can also be performed under general anesthesia.

If there is a hollow tear gutter that contributes to a tired appearance, it can be filled with a natural filler: excess fat from the lower eyelids. Through surgery through a skin cut, this fat can be released and moved over the lower eye socket – this is known as the Hamra technique (Dr. Paridaens).

The excess fat in the lower eyelids is used to fill the hollow groove. Here you can see how the fat apron is fixed to the peritoneum (blue) under the lower eye socket edge. This means that filler injection is no longer required!

Puffiness under the eyes: which surgery?
If there is horizontal sagging of the lower eyelids with an excess of skin and fat, I usually opt for a lower eyelid correction, whereby access to the connective tissue bulkhead is obtained via a cut in the skin, a few millimetres below the eyelash edge. After this, the connective tissue shot can be ‘fed’, whereby the fat is brought back into the eye socket, where it functions as a ‘shock absorber’ for the eye. The fat can also be redistributed over the rim of the eye if there was a filling defect there (Loeb-Hamra technique). Rarely does fat really have to be removed. What is critical for the success of this technique is that the eyelid on the side is fixed to the bone, otherwise a poor-functioning and cosmetically disturbing droop will arise. This so-called canthopexy is an operation that many surgeons find difficult to perform. That is why such an operation is best performed by a surgeon who is experienced with lower eyelid surgery and often performs canthopexy.

A canthopexy provides fixation of the lower eyelid to the peritoneum so that the contour remains good: an important step in the lower eyelid correction

Young woman with tired appearance due to bags under the eyes on the basis of small fat loss and visible lower eye socket margin (reproduced with patient’s permission)

Lower eyelids after the Hamra technique: better filling of the eye socket edge resulting in fewer bags under the eyes (reproduced with patient’s permission)

Puffiness under the eyes: complications and how do you prevent them?
Complications are rare if the surgeon is trained in this technique and if the patient is healthy and has a healthy lifestyle. Complications consist of thread breakage, bleeding and infection. To prevent these complications, we provide instructions for aftercare: be careful with bending over, lifting and pressing for two weeks, and do not exercise during this period – although walking and cycling gently is fine. Cooling (15 min for each hour) of the eyelids with special bags – or even bags of frozen peas – for two days can help against swelling. If blood thinners are used, temporary cessation might be advised, depending on the circumstances, as there is an increased risk of bruising if patients have high blood pressure or if they take blood thinning drugs.

ELZA - Dr Dion Paridaens

Dr. Dr. Paridaens is a consultant orbital surgeon at ELZA Institute in Dietikon, Zurich, and has 25 years of experience with cosmetic eyelid surgery and has developed and published various eyelid surgery techniques. He operates at home and abroad. In view of his expertise, many clients, who are unfortunately dissatisfied with their eyelid surgery performed elsewhere, ask him for advice, often asking if he “can do something about it”. He also specializes in these reoperations, although he never operates on a patient if he thinks there is nothing he can do to improve their situation.


The ELZA Institute

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