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Bags under the eyes

Fat is the main culprit of the appearance of 'bags' under the eyes. This fat has nothing to do with being over weight. It is normal fat which has changed its position.

In youth the fat is underneath the eyeball, inside the skull. As we age our eyeballs sink downwards and backwards a little. This squeezes the fat out forwards, causing swelling under the skin. Only a few patients have a true excess of fat, and their bags are noticeable when they are young adults.

The rest of us with bags have fat which has been squeezed into the ~ more noticeable position. Bags can also have a skin component with wrinkles or loose skin overlying the fat.

The results of cosmetic surgery to improve appearance under the eyes are generally not as dramatic or reliable as surgery for the upper lids.

The traditional lower lid blepharoplasty operation uses an incision just under the lower eyelashes. The skin and muscle are lifted up as a flap. This reveals the excess fat which is removed. The skin and muscle flap are then pulled upwards and outwards. Any excess skin is cut off and the wound stitched.

The operation has two problems:
1) The scar is often visible where it extends out beyond the lower eye lashes.

2) There is commonly a slight rounding or pulling down of the outer part of the lower eyelid edge where it meets the eyeball. Usually, this is subtle, but it still detracts from the results, giving a tell tale `operated' look. Sometimes this is severe causing watery, irritated eyes as well as an alarming appear acne. Patients who already have some rounding, or who have flabby lower lids are particularly at risk.

Because of these problems, many cosmetic surgeons have abandoned this operation. Instead, an incision is made on the inside of the eyelid. This allows access to the fat through the 'roof' rather than through the `front door'. Usually, CO2 laser is used to make the incision, minimising bleeding and bruising. CO2 lasers seal small blood vessels as they cut. The fat is then removed. It is important not to take away too much fat or a sunken appearance can result. No stitches are needed, and the scar is invisible since it is on the inside of the eyelid. If there is fine wrinkling of the lid, skin laser resurfacing can be performed at the same time. This should be done with an erbium laser, as this gives equally good wrinkle improvement as the CO2 laser but with quicker healing and fewer complications.

If there are folds of excess skin no laser will remove them. The skin can be cut out with a scalpel. Provided the scar is kept within the thin lid skin, and does not extend out too far, it will be virtually invisible after a few weeks. Using these techniques there is usually little or no pain afterwards, and most people are back to work within a week.

Eyelid surgery carries a small risk of bleeding behind the eye that can affect vision. To minimise this, avoid aspirin, excess vitamin E and anti-inflammatory such as Voltaren and Nurofen two weeks before the procedure.

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