Puffy lower eyelids can be due to any number of anatomic factors. The eyelid is made up of several anatomic layers, including skin, muscle and fat. Any one of these structures can contribute to puffy lower lids and any or all of these structures may need to be addressed surgically in order to eliminate puffy lower eyelids. Of course, other factors such as allergies, lack of sleep, salt intake and alcohol intake can all contribute to puffy eyelids. These things cannot be addressed surgically.
For decades, the standard method of performing lower eyelid surgery (or
lower blepharoplasty) involved making an incision in the skin just below the eyelashes. Excess fat, muscle and skin was removed and the incision was closed with stitches. The scar is almost invisible. With this method, however, it was not uncommon to see too much skin removed, resulting in the lower eyelids hanging like a hound dog's.
About twenty years ago, a method of lower eyelid surgery known as
transconjunctival lower blepharoplasty became popular. The
"transconj bleph" involved making an incision on the inside of the lower eyelid, eliminating the need for a skin incision. The
transconj approach gave access to the fat only, however. The skin and muscle could not be addressed from this approach. To get around this limitaion, plastic surgeons began doing a "skin pinch" to get rid of any extra skin of the lower eyelid. Small forceps (resembling small tweezers) are used to "pinch" the skin, so that is stands up in the air. This extra skin is then cut off using scissors. The incision is then closed with stitches and, as with the standard blepharoplasty described above, the scar virtually disappears. Another advantage of the
transconj approach: there was less scar tissue that formed during the healing process, since the muscle was not touched at all (only the skin and fat).
A potential disadvantage of the two procedures described above is the accidental removal of too much fat (or skin). If too much fat is removed, the lower eyelids begin to look hollow, which is not a youthful look. A youthful eye has just the right amount of fullness, somewhere between puffy and hollow.
In the last several years, a procedure known as
lower Eyelid Fat Transposition has become very popular. As the name suggests, the lower lid eyelid fat is not removed, but it is transposed, meaning that it is shifted from one location to another. Many people that complain of dark circles actually have a problem known as a deep
nasojugal groove. This groove extends from the corner of the eye near the nose and extends toward the cheek. Because a shadow tends to fall in this groove, it appears as a "dark circle." Instead of removing any fat, the fat is simply slid down (transposed) into the nosojugal groove and secured into place with stitches. This technique preserves the fullness of the youthful lid, but takes some of the fullness and simply puts it where it is needed.
I have been performing this procedure for the last several years and the results are excellent. There are still many situations where removing fat or muscle or skin are appropriate, of course. But in general, the trend is toward removing less and less fat from the lower eyelid.
