Eye bags: why they appear and when surgery is considered

The American Academy of Ophthalmology (AAO) explains it as follows: over the years, the tissues around the eye weaken and sag, allowing fat to move towards the lower eyelid, which looks swollen. Fluid can also collect in this looser tissue, increasing the swelling.

Other factors influence this process. The same source lists lack of sleep, dehydration, smoking, alcohol, allergies and fluid retention, which is more noticeable on waking or after a salty meal. There is also a family component: eye bags can be inherited.

They are generally harmless. The AAO advises seeking advice if the swelling hurts, itches, is red or does not go away. Cleveland Clinic recommends calling your doctor if dark circles or swelling appear under only one eye.

They are easily confused in the mirror, but they are three different things.

A bag is a bulge in the lower eyelid. It is usually caused by fat that has moved forward and, sometimes, excess skin.

The tear trough is the hollow beneath the eye. Cleveland Clinic notes that it creates shadows that make the eyes look more swollen, and the AAO adds that the swollen eyelid itself, the nose or the eyebrow can cast a shadow in the area.

Dark discolouration is a change in the skin. According to Cleveland Clinic, too much sun makes the skin produce more melanin, and with age the skin under the eye becomes thinner, revealing the blood vessels.

Distinguishing them matters because treatment differs. Lower blepharoplasty targets the bag and excess eyelid skin. It does not remove facial wrinkles, correct a drooping eyebrow or treat pigmented dark circles. Assessment therefore begins by identifying what is being seen.

It depends on the cause. For swelling and the factors that worsen it, the AAO suggests simple measures:

• apply a clean, damp, cool cloth around the eyes for a few minutes while seated;
• sleep for seven to nine hours, with the head slightly raised;
• drink less before bedtime and reduce salt;
• stop smoking;
• treat allergies and avoid rubbing your eyes.

For skin and colour, the AAO and Cleveland Clinic describe other options, such as laser treatment, chemical peels, some creams or fillers, aimed at the texture, tone or volume of the area. When the bag is caused by fat that has moved forward with age, the AAO mentions blepharoplasty, which removes or repositions it.

Lower blepharoplasty is lower eyelid surgery aimed at bags and excess skin. It makes sense when there is a bag, rather than dark discolouration, and expectations match what surgery can achieve. A suitable candidate seeks improvement rather than absolute perfection, is in good general health and has realistic expectations.

The incision may be placed below the lash line or inside the eyelid. From there, fat in the bag can be removed or repositioned to fill the hollow under the eye. This distinction, removal or redistribution, is the main difference between one lower blepharoplasty and another, and depends on examination. Excess skin is also removed when examination indicates it.

More than the eyelid is checked before surgery. Vision and tear production are assessed, and it is useful to know the ophthalmic history, particularly glaucoma, dry eye or retinal detachment. Thyroid disorders, hypertension and diabetes are considered risk factors, as are regular medication, allergies and smoking.

If you are also concerned about the upper eyelid, mention it at the same consultation. Upper blepharoplasty is a different procedure and the two can be considered together. If the eyebrow has descended, this is assessed separately: it is treated by a brow lift, rather than eyelid surgery.

Discomfort settles with medication. Swelling and bruising gradually ease, and relative rest is advised in the first few days. Returning to work, contact lenses and exercise is gradual. While swelling remains, what you see in the mirror will still change.

Oedema, bruising and temporary blurred vision are part of the expected recovery. General complications of blepharoplasty include infection, bleeding, dry eye, asymmetric healing and, exceptionally, changes in vision. The lower eyelid also has two specific complications: eyelid retraction, which exposes the white of the eye below the iris, and ectropion, in which the eyelid edge turns outwards. The result may not be as expected and may lead to another procedure.

These complications are exceptional. At the consultation, following medical assessment, they are explained individually according to each patient’s characteristics.