It is not uncommon for patients to consult with an oculoplastic surgeon regarding surgical solutions for their puffy eyelids. Many, if not most, have tried the usual home remedies, such as cucumber eye pads, tested creams recommended by their friends, and even seen a dermatologist, to no effect. When nothing seems to work, the next logical step is to seek an eyelid specialist who can offer a more effective and permanent solution.
During the first consultation, the goal is determining the “where and when” of puffy eyelids. Are the eyelids puffy in the morning after a night of poor sleep, or are they always puffy? Do the eyelids become puffy after a salty meal or from lack of rest? Additionally, identifying the site is just as necessary. Some people notice that only their upper eyelids are puffy, while others complain that their bags are worse and usually swollen upon awakening.
Most importantly, the eyelid specialist must distinguish between puffiness, fluid accumulation, inflammatory conditions, or systemic disease. Fluid tends to accumulate while lying down, as during sleep, from lack of rest, or with a salty diet. An inflammatory disease of the eyelids will cause more than just puffiness; true inflammation will produce pain, redness, and tenderness of the area to the touch. Its cause may be an infection or the presence of a mass underneath the skin. Prompt medical attention should be sought in these cases. It is also essential to rule out systemic disease as a cause of persistent puffiness around the eyes. A complete blood count, renal function tests, and TSH are good places to start.
If the conditions mentioned above have been ruled out, one must look at the anatomy and physiology of the periocular area. Puffiness in the upper eyelids is generally caused by congenitally droopy brows or the descent of the eyebrow fat pad.
Raising the tail of the brow will reposition the retro-orbicularis oculi fat pad, or ROOF, and will improve puffiness indefinitely. This outcome can be elegantly and effectively achieved with an endoscopic brow lift. Alternatively, prolapse of the lacrimal gland, a condition common in older patients, may also cause puffiness in the upper eyelids. The diagnosis is clinical, and its surgical treatment has a high success rate.
Regarding the lower eyelids, two areas are generally responsible for puffiness. The most familiar culprit is bags under the eyes. Bags are pockets of orbital fat, i.e., fat in the eye socket, that prolapses forward or becomes visible with age. In younger patients, it is more commonly caused by poor bony support from the maxilla. These bags are typically more pronounced in the morning or with poor rest. Crying will also increase puffiness. Finally, patients with chronic allergies or sinusitis will notice their bags puff up with congestion. Lower eyelid blepharoplasty with fat transposition is the best surgical treatment to reduce puffiness and improve the appearance of bags.
A special mention must be made concerning lower eyelid malar mounds and festoons. Malar mounds, also known as malar edema, are fluid-filled pockets that form beneath the outer corner of the lower eyelid in the cheekbone region. These mounds are areas of chronic tissue swelling or accumulation of lymphatic fluid. Unfortunately, surgical or otherwise, there is no good treatment for these bulges.
Festoons are the bane of the oculoplastic surgeon’s existence. You can think of them as an overgrown malar mound. Festoons are very noticeable and extremely hard to conceal with makeup. Many non-surgical therapies have been designed to treat them, such as lasers and radiofrequency injections of anti-inflammatory agents. Injection of hyaluronic acid fillers should be avoided at all costs as this generally worsens the festoon. Most are mildly beneficial in the best case and potentially harmful in the worst case. Surgical techniques for festoon management include midface lifts, fat injections, and direct excision. Poor outcomes, a long recovery, or significant scarring are not uncommon. Therefore, most eyelid surgeons would agree there is no perfect treatment for festoons.
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