Under-Eye Bags

Under-eye bags are a common reason people seek out the care of an oculofacial plastic surgeon.  Our patients often complain that their puffy lower eyelids make them look old or tired.

What Causes Under-Eye Bags?

Puffiness of the lower eyelids is most commonly caused when fat in the eye socket bulges forward. Heredity, age, allergies, diet, and illness can cause the fat to bulge forward or swell.

  • Heredity (the natural anatomy you are born with): This is the most common cause. Some people naturally have more fat under the eyes.  If your parents or siblings have under-eye bags, you might too. 
  •  Age: This is the second most common cause. The fat in the lower part of the eye socket is held back by a firm barrier call the orbital septum.  With age, the orbital septum weakens and allows the fat in the eye socket to bulge forward, causing the appearance of under-eye bags. 
  •  Allergies: Some people only have bags under their eyes during allergy season. Allergies occur when your immune system reacts to a foreign substance, such as pollen.  When you are exposed to an allergen, your body releases a chemical called histamine.  Histamine is responsible for itching, but also causes the blood vessels in the eyes and eyelids to swell. This brings extra fluid to the eyelids and can make the under-eye area look puffy.
  •  Diet: You may notice your under-eye bags become more prominent after eating pizza or salty junk food. Salty and starchy foods can cause fluid retention.  When the fat in the lower eyelids hold on to more water, under-eye bags can look bigger.
  • Medical Conditions: Most of the time, under-eye bags are a cosmetic concern. However, a sudden change in the eyelid appearance can be a sign of health problems. Some medical conditions including heart, kidney, and liver problems can cause the body to retain more water which can make the eyes look puffy.  Some patients with high or low thyroid hormone levels can also have a condition call Graves Disease, which can cause changes in the appearance of the eyes including swelling and a wide-eyed appearance.  If your under-eye bags seem to have come on “all of a sudden”, see your doctor to evaluate you for these and other health conditions.

While most people with under-eye bags can blame puffy fat, there are other anatomic or structural causes for under-eye bags and dark circles, such as:

  • Orbital Retaining Ligament: The area of the lower eyelid that looks like a dark circle under the eyes is created by a strong band that attaches the eyelid skin and muscle down to the underlying bone. This is called the orbital retaining ligament. It is responsible for keeping the lower eyelid attached to the bone beneath. Aging changes in the lower eyelids and cheeks including loss of subcutaneous fat in this area can cause hollow grooves to develop creating the appearance of dark circles.
  • Sagging Lower Eyelid Skin and Muscle: The lower eyelid skin is the thinnest in the body, which also means it is most prone to wrinkling. Extra lower eyelid skin can cause the under-eyes to look tired or baggy.

orbital realignment diagram

Under-Eye Bag Treatment

There are many ways to treat lower eyelid bags ranging from changes in diet to surgery.  See below to learn more about the options.

Diet and Lifestyle Changes

Cutting salty and starchy foods from your diet, reducing alcohol intake, and treating allergies can improve the appearance of the lower eyelids in some people.

Under-Eye Creams

Under-eye creams can provide some improvement in the appearance of the under-eye area. Unfortunately, most of these improvements are temporary and only last as long as the product is on the skin.  There are a few ways that topical creams work: 

    1. Hydration: A good moisturizing eye cream will hydrate the outer most layer of the skin which can improve the appearance of fine lines.
    2. Reflectivity: Creams with reflective particles cause light to bounce off the skin and result in a brighter appearance to the under-eye area.
    3. Vasoconstriction: Some products contain caffeine or other ingredients that temporarily shrink the blood vessels in the skin, which can decrease the appearance of puffiness.  Since these compounds do not penetrate deep into the muscle or fat of the eyelid, they provide very little improvement.
    4. Film-Forming Polymers: Some eye creams improve the appearance of under-eye bags by acting like “invisible shapewear”.  The eye cream is applied and contracts as it dries, which tightens the skin and reduces under-eye bags.  The downside is that these products only work while they are in place, often leave a white residue on the skin, and are deactivated if liquid-based make up is applied on top (such as cover-up or foundation). 
    5. Pigment Reducing Creams: Some topical eye creams contain ingredients that reduce the amount of pigment in the skin, which can brighten the under-eye area.  These creams work in a variety of ways, but most work to decrease the amount of melanin (skin pigment) produced by the melanocytes (pigment producing cells) in the skin.  These products take months to see a visible difference and only work on the darkness in the skin caused by melanin in the top most layers of the skin.  Some people have darkness of the skin caused by hemosiderin (iron) deposition, which is not as well treated by these creams. 

Dermal Fillers

Under-eye hollows can often be improved with tissue filler injections such as Restylane, which is a gel made of hyaluronic acid.

This treatment is performed in the office.  During the treatment session, the area is first numbed with topical numbing cream.  The under-eye area is then cleaned and the treatment is performed with sterile technique to reduce the risk of infection.  Your surgeon will use either small needles or a cannula (blunt tipped needle) to place the filler into the under-eye hollows in the area of the orbital retaining ligament (see above). 

This immediately improves the appearance of dark circles and can make lower eyelid bags look less prominent.  Treatment of the under-eye area with tissue filler is a common procedure, but it is an “off-label” treatment, meaning that while these products are FDA approved for use in certain areas of the face, they are not specifically tested and approved for use under the eyes. 


Lower eyelid blepharoplasty is a surgery that can be performed to provide long-lasting improvement in lower eyelid bags. While surgery is an excellent option for many patients, it is not the best choice for everyone. 

Consult with an experienced oculofacial plastic surgeon to discover the best option for your particular case.  It is important that your surgeon considers the amount of puffy fat in the eyelid, the amount of extra skin or wrinkles, the extent of the dark circles under the eye, if there is any looseness to the eyelid structure, the position of the eye relative to the cheek, and if there are any eye conditions that would make surgical treatment contraindicated.

Surgical Technique

Transconjunctival or transcutaneous incision?

While there are a number of ways lower eyelid blepharoplasty can be performed, the oculofacial plastic surgeons at the Aesthetic Center at Virginia Eye Institute prefer a transconjunctival, or scarless, technique. When using this technique, the fat is removed or repositioned through an incision that is made on the inside of the lower eyelid.  Our surgeons prefer this technique because it does not leave any scars on the eyelid skin and carries less risk of complications.

Fat removal or fat repositioning?

In some cases, excess fat simply needs to be removed to achieve the best possible cosmetic result. In other cases, fat need needs to be moved from the area of puffiness into the area of hollowing to provide the best possible results – this is called fat transposition blepharoplasty.  Talk to your surgeon to determine which option is best for you.

Dealing with extra skin and wrinkles

There are three main ways that extra skin on the lower eyelids is treated: laser resurfacing, surgical skin removal, and acid peels. The best option for you will depend on the amount of extra skin, the depth of your wrinkles, the texture of the lower eyelid skin, the amount of pigmentation in your skin as well as the tendency for your skin to tan when exposed to the sun.

CO2 fractional ablative laser resurfacing is the treatment of choice for most patients as it tightens the skin and reduces the wrinkles for a natural looking result without any scars.  In some skin types, CO2 laser can cause temporary darkening of the skin, which can be treated with the topical creams discussed above.

Very rarely, CO2 laser resurfacing can result in a permanent lightening of the skin – this is a complication that is uncommon with newer lasers and was more commonly seen with the older laser technology.  Trichloracetic acid peels (TCA) can be used as an alternative to CO2 laser for skin tightening, but is not commonly used in our practice since CO2 laser yields superior results in our hands. In patients for whom CO2 laser cannot be performed, a small “pinch” of skin can be removed by making a careful incision hidden under the eyelashes of the lower eyelid. Care needs to be taken to avoid taking away too much skin, as this can cause the lower eyelid to pull downward, resulting in eye irritation and an unattractive appearance.

For examples of our surgical work, click here.

Tightening of loose or sagging eyelids

As we age, the structure and stability of the lower eyelid weakens. In some patients, a loose lower eyelid is obvious as the lower eyelid sags downward. In other cases, the looseness of the eyelid is only seen when it is pulled downward with a finger – the eyelid can be easily pulled away from the eye and does not return quickly back to the eye.  In these cases, the loose eyelid needs to be tightened at the time of surgery.  If the eyelid is not tightened, there is increased risk of it pulling downward as it heals – a problem that is both uncomfortable and unattractive. 

For most patients, the eyelid can be tightened with minimal or no scarring via an internal canthopexy. In this procedure, the lower eyelid is tightened through the upper eyelid incision or a very small incision made in a smile line near the outer corner of the eyelid. 

For patients with very loose lower eyelids, a stronger procedure called a lateral tarsal strip may need to be performed. This surgery tightens the eyelid through an incision in the outer corner of the eyelid.  This can be performed that the time of your blepharoplasty surgery or in a staged fashion if recommended by your surgeon.

If you have any questions about under-eye bags or how to get rid of them, contact us at 804-287-2022.