Lower eyelid lift: dark circles and eye bags

How eye bags arise

Our eyes, like our hands, often give away our real age fastest. The connective tissue in the lid region, the lid skin and the muscle beneath slacken over time. As a result the fat from the eye socket bulges forward increasingly and eye bags appear. They arise either from the bulging of the orbital fat or from an excess of skin at the lower lid — or from both.

Depending on the degree, the eye bags look puffy and make us appear exhausted, tired and sad. This impression of tiredness does not disappear even after weeks of holiday, and remarks such as “Didn’t get much sleep?” become part of everyday life.

How those around us perceive us also affects daily life. The eyes in particular reflect our personality for other people. Eye bags and the listless expression they lend can be an obstacle between people.

In some people eye bags are not a sign of ageing but present from a young age. Several of our patients report that the bulges bothered them “even as a child”. That is treatable too — with the same technique.

Dark circles have several causes

“Dark circles” is an umbrella term for three quite different findings, each treated differently. Only the examination says which applies to you — and often two of them apply at once.

Why fat grafting often belongs

To counteract the age-related loss of tissue, the fat of the eye bags is repositioned towards the cheek where appropriate. If necessary we additionally graft the patient’s own fat from the thighs or the lower abdomen to the lid-cheek transition. That is not a second operation: it is harvested in the same session and in a small quantity.

In the case descriptions further down, fat grafting appears in almost every lower lid case — not because it is standard but because with this finding it almost always belongs to a harmonious result.

What we examine at the lower lid

The examination at the lower lid takes more work than at the upper lid, because more factors interact. We look at the lid region with you seated, because gravity then acts as it does in everyday life, and we work through it in order.

First: how far does the fat bulge, and does that change when you look up? Second: how much skin is in excess, and how much tension does it still have? Third: how firmly does the lid sit against the bone — a lid ligament that is too loose has to be tightened, or the lower lid will lose its position after the operation. Fourth: where does the cheek sit, and how deep is the groove at the transition? And fifth: what is the position of the eyeball relative to the bony rim of the socket — that determines how much tightening the lid will tolerate.

Only these five answers give the plan: an approach from inside or from outside, with or without a skin pinch, with or without tightening the lid ligament, with or without fat grafting. That is why the first consultation takes about an hour — and why the binding quotation is only settled afterwards.

The lower eyelid lift in detail

In a lower eyelid lift, slack skin, slack muscle and protruding fat are returned to their original position. The aim is not only to remove the so-called eye bags — in fact protruding fat — but to restore the harmonious transition between lower lid and cheek.

The correction is carried out as a day case. The procedure usually takes place under twilight sedation, with the region additionally numbed locally. A precisely placed incision then follows just below the lashes of the lower lid and — depending on how far the slackening extends — a few millimetres beyond the outer canthus. Through this approach the protruding fat is moved towards the cheek and the slack skin and muscle are tightened. Usually the lid ligament has to be tightened as well, to stabilise the position of the lower lid.

In some cases an adequate lower lid correction can be achieved through an approach on the inside of the lid. Then no skin incision is needed and no visible scar remains.

After the procedure physical exertion should be avoided; cooling eases the swelling. After about three weeks most patients are ready to be seen again.

Short and with little pain

A procedure under twilight sedation is no ordeal. You take in little of it, are somewhat awake now and again, but feel no pain. You are not fully unconscious and still feel comfortable. The reason is that an experienced consultant anaesthetist is with you from the start and gives you very strong but short-acting sedative and pain medication.

You are also given painkillers for home. Most patients, however, take them only on the day of surgery; afterwards they are usually no longer needed.

The first two weeks, day by day

The most common question after the operation is not whether it hurts but when you will look like yourself again. So here is the course it takes for most patients — as a guide, not a promise.

The transition from lower lid to cheek

At the lower lid the work does not stop at the lid margin. Between lid and cheek lies a zone that loses volume over the years: the cheek descends a little, and where there used to be a soft transition a groove appears. That groove casts a shadow — and many people perceive that shadow as a “dark circle”, although there is nothing wrong with the skin itself.

Anyone who only tightens in this situation makes the groove more obvious, not softer. That is why in many cases a lower lid correction includes moving the existing fat towards the cheek — and where that is not enough, a small fat graft. The fat comes from the lower abdomen or the thighs, is harvested in the same session and placed in very small portions.

This is exactly where the surgeon’s experience shows. The amount moved or added decides the difference between a face that looks rested and one that looks operated on. It is a matter of a few tenths of a millilitre.

What can be combined with eyelid surgery

The lid region does not stand alone. It often emerges at the examination that something else is contributing to the tired impression — and that both can be treated under one anaesthetic and with one recovery period. That is not a sales argument but arithmetic: two separate procedures mean two recovery times.

When we advise against it

Honest advice also says when a procedure does not make sense. We raise these points explicitly at the first consultation — and if one of them applies, you hear it from us before any dates are discussed.

A natural result through competence

Many people have deep and well-founded reservations about facial surgery, because mask-like results exist. The most common causes are skin tightened too far, insufficient tightening of the deep connective tissue, a wrong direction of pull, badly placed scars and failure to correct the age-related loss of volume.

These technical and analytical failings leave the typical marks of a poor lift: an unnatural expression, distorted brows, visible scars and a rejuvenation out of balance. All of that is avoidable with good planning and careful surgical technique. After well-executed eyelid surgery you do not look operated on or tightened but younger and fresher. People notice the change but not its cause.

That is why we ask you to bring photographs of yourself from about the age of 18. Many people believe that raising the brows automatically reads as youthful — that is not always true. With age brows sometimes rise and sometimes fall, and only rarely does the whole brow descend. Your own photographs show us which change has taken place in your case. That makes it possible to rejuvenate without changing.

Results of the lower eyelid lift

In both slider cases the approach was transconjunctival — through the inside of the lid, without a visible scar — and in each case fat was grafted to the lid-cheek transition.

Who operates on eyelids at the Kuzbari Centre

Three specialists at the centre operate on eyelids. Whoever advises you also operates on you — and sees you again at every check-up. You choose who you feel most comfortable with.

Frequently asked questions about the lower eyelid lift

Read on

Eyelid lift at a glance · Upper eyelid lift · Correcting hooded lids · Removing eye bags · Eyelid ptosis · Cat eye and fox eye lift · How your eyelid lift works · Cost · Private or public · Experiences · Videos