The development of bags under one’s eyes is a common aging problem. While some younger people have it naturally, most acquire them as a result of time and with increasing age. They are a cosmetic concern for many and certainly helps create a tired and aging facial appearance. Lower eyelid bags are a frequent reason that brings one into a plastic surgeon’s office.
What is the cause of lower eyelid bags? To understand them, one has to realize that the eyeball inside the bony walls of the orbit is encased in a bed of fat. This permits the eyeball to be moved around by pressure on it without causing it to rupture or burst. This cushioning fat is held back inside the bony rims of the orbit by thin ligaments that run from the lower eyelid to the bone. As we age, this ‘ligament’ weakens and fat comes slowly spilling out. Essentially think of the lower eyelid bag as a hernia of fat. You can prove this by gently closing one eye and pressing on the eyeball. Notice that the lower eyelid bag pushes out as you push in.
Understanding this eye anatomy gives you insight into how to fix it. There are several very different surgical approaches . You can remove part of the fat which is sticking out through standard lower eyelid surgery. (blepharoplasty) This is a tried and true method that has been done for decades. More recent approaches include a ligament repair and fat transposition. In the ligament suture method, like a hernia repair, the fat is stuffed back in and the ligament is tightened and sutured to keep it from coming out again. In the fat transposition technique, the exact opposite is done. The protruding fat is teased out and brought over the bone, filling out the area underneath the bag. All three methods hope to achieve a smooth lower eyelid. All methods involve a lower eyelid incision (right below the lashes) with removal of excess skin as well.
In a younger patient without excess skin, the fat bags are generally removed through inside the lower eyelid but the hernia repair and fat transposition methods cannot be done due to the limited space.
Which one of these lower eyelid bag surgeries should one have? The choice depends on the shape of one’s eye, the underlying bone, and how much excess fat and skin one has. In an eye that has bags but with a deep tear trough underneath, the fat transposition method may be better. It helps fill out the tear trough and avoids a sunken eye appearance years later by preserving tissue. The hernia repair method can be used on any protruding lower eyelid bag and debate remains as to whether it is better to put it back or remove it. In the patient with a thin face and deep-set eyes, it is better to keep all of the fat and put it back in.
Dr. Barry Eppley
Indianapolis, Indiana