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Is eyelid surgery the answer to get rid of puffy eyes?

Q:

I wake up with puffy eyes every morning.  The puffiness has started to become very noticeable now.  I work at the computer and stare at the screen for about 10-12 hours a day.  Can this be causing the puffiness?  If so, what should I do in this situation?  Is eyelid surgery indicated?  Please advise.

A:

If by puffy eyes, you mean bags under the eyes, then yes, surgery can improve your appearance.

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.

M.M. Law, MD

A:

There are a number of reasons for people to have puffy eyes. Some are genetic and anatomical, while other reasons can be related to other factors such as allergies, poor sleep, intermittent swelling from fluid retention, and crying. Eyelid surgery, also called blepharoplasty, works well when there is a true excess of skin and/or fat around the upper and lower eyelids. Essentially, the skin and fat bulges in front of the lid itself. Other factors which may cause this look include eye brow descent, where the eyebrows start to drop and create heaviness on the upper eyelid, or upper eyelid ptosis (drooping), which means that the upper eyelid muscles are weak and the resting upper eyelid position is lower than ideal. For the lower lid, many patients complain of puffy lower eyelids or dark circles in the situation of hollowness. This means that rather than a redundancy of skin and fat of the lower eyelid, the situation is quite the opposite. In these cases, the orbit is noticed from loss of facial volume, genetics, or cheek tissue descent, unmasking the orbital structures and looking like a dark circle or sometimes a puffy lower lid. Darkening of the lower lid can occur from pigmentation, or color changes can occur from the robust capillaries in this thinned-skin area. In the situation of hollowness, sometimes fillers can be used to fill the depth of the depressions, which can improve the look of the orbit. Consulting with a board certified plastic surgeon will be the best way to establish what is causing your puffy eyelids so that a treatment plan can be recommended.

H.A. Brown, MD

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