We’ve all heard that the eyes are the “window to the soul,” and as the focal point of your face, they’re the dominant facial feature we tend to notice first. But when your under-eyes appear tired, chronically puffy and swollen, it’s like your windows are dressed in poor attire—sun-stained curtains and drooping blinds adding unwanted age to your face. The good news is there’s a way to breathe new life into your tired under-eyes.
According to New York plastic surgeon Mokhtar Asaadi, MD, this area is complex. “The area below the rim of the eyelid is divided into three main categories,” Dr. Asaadi explains. “The malar mound, malar edema and festoons.”
“You could be experiencing that tired, puffy look in any one of these areas, but each of them ultimately requires its own treatment,” he says.
What Causes Under-Eye Bags?
If you’ve had tired-looking eyes for a long time, even since childhood, you might be dealing with chronic puffiness of the malar mound.
“This is usually congenital, meaning you’ve had it since early childhood and it’s likely a family member also has it,” Dr. Asaadi explains. “The main pathology of the malar mound is a fat collection under the lower lid that creates this puffiness… it can be under or over the orbicularis muscle.”
Moving further down the face, puffiness just above the cheekbones is typically related to malar edema, which is the accumulation of fluid that can worsen when exposed to allergens. “Malar edema is also very common in people with hypothyroidism, often called Hashimoto’s Thyroiditis,” Dr. Asaadi explains. “We diagnose this through a pressure test and a lateral pull test to see if the puffiness doesn’t go away completely.”
Lastly, if the eye bags you’re dealing with are characterized by loose skin, you could be dealing with festoons, caused by aging. “During a lateral pull test, the festoon will disappear completely, as we are dealing with laxity of the muscle,” Dr. Asaadi explains.
Why Temporary Solutions Like Fillers Can Make it Worse
Because each of these areas requires a different approach and the entire area is so delicate, some patients end up with less-than-desirable results from pursuing treatment.
“Many of my patients have previously had fillers or fat grafting done. Others have tried to correct the problem with lasers or heat treatment,” Dr. Asaadi explains. “Probably 65 percent of my patients I see for malar bags have had a previous treatment that worsens the situation and makes it harder to correct.”
According to Dr. Asaadi, incorrect treatment in this delicate area can lead to the buildup of scar tissue. “I call it subdermal fibrosis,” Dr. Asaadi explains. “This scar tissue that forms under the skin interferes with the lymphatic system in this area, potentially leading to more puffiness.”
While nonsurgical treatments may contribute to the buildup of scar tissue, surgical solutions can also result in poor outcomes.
“You will see retraction of the lower lid, called ectropion,” Dr. Asaadi says. “This is not a problem with the surgery itself, but some part of the strategy is wrong. You need to stay in the lateral part of the face where there is no facial nerve. Then, you can completely remove the malar bag and address the anterior septal fat that many of these patients have, which we first discovered in 2019. The skin itself has no role in the treatment of malar bags.”
The Permanent Solution
With so many ways for correcting eye bags to go wrong, how exactly does it go right?
“I noticed that the condition of the anterior septal fat I was seeing was abnormal,” Dr. Asaadi says. “This is almost like a wasp’s nest; it’s very adhered to the muscle and when I take them out, we see much less swelling after surgery.”
The amount of this fat under your eyes varies from person to person, but many struggling with eyebags have it.
“I recently treated a patient where the anterior septal fat was protruding through the muscle all the way to the skin,” Dr. Asaadi says. “You must correct according to the patient’s need. And while not all of them have this kind of fat, about 70-80 percent do.”
This is excellent news for those who have tried various ways to correct eye bags without success.
“I’ve had patients who have undergone blepharoplasties or received 10 injections of filler only to have their problem worsen,” Dr. Asaadi explains. “These patients are desperate to correct this problem. With close attention to detail, conservative and careful incisions and a full understanding of the area, you can correct malar bags. Many patients feel like it’s a miracle.”
