Behind the skin of the lower eyelid and the muscles of the eye socket, there is a membrane like the inferior orbital septum, which acts as a retaining wall to prevent fat from bulging out of the lower eye socket. When fat accumulates excessively, or when this inferior orbital septum becomes weak, the fat in the eye sockets will bulge out and form “lower eye bags”. Generally speaking, bags under the eyes will make people look older and less energetic. Under-eye bags can be classified as congenital or acquired. Congenital under-eye bags appear in the late teens and early twenties, most of them are caused by more fat in the lower eye sockets or weakness of the lower orbital septum tissue, and there is usually no laxity in the lower eyelids. In these cases, the fat can be removed via the conjunctiva within the eyelid and there will be no scarring outside the eyelid. If there is slight skin laxity, CO2 laser can be used to tighten the skin to remove fine lines. Acquired eye bags usually appear around the age of 30, mostly due to the aging and relaxation of the skin, muscles and lower orbital septum. In some cases, the canthal ligaments are lax, causing the white of the eye to be exposed, or even the lower eyelid to flip out, commonly known as “lower trichiasis”. In this case, it is not appropriate to remove the fat from the bags through the conjunctiva, as this will only result in more and more obvious wrinkles on the lower eyelids and more severe tear troughs, making the orbits more sunken and hollow. For this type of acquired puffiness, a fat-preserving lower eyelid blepharoplasty should be performed in two ways: for less severe aging, the protruding fat can be surgically pushed back into the eye socket and the lower eye socket can be reinforced with sutures. If the tear trough is obvious and the cheeks under the orbit are sunken, it is appropriate to resurface the bag of fat, which is done by cutting the skin along the lower edge of the eyelashes of the lower eyelid, separating the fat, covering the lower edge of the orbit and the tear trough with some of the fat, then suspending the connective tissue and orbital muscle and removing excess muscle and skin, and then suturing the wound. This is the only way to improve the bags, tear troughs and hollowing of the orbits. In cases where the canthal ligaments are lax, the outer canthus must be fixed at the same time to avoid eyelid ectropion. If the cheeks are also lax, a combination of a midface lift and lower blepharoplasty is required to achieve a more satisfactory result. Lower Blepharoplasty Most people in good health can undergo plastic surgery to remove bags under the eyes, but it is important to tell your doctor if you have previous eye problems or have recently undergone laser vision correction surgery. It is generally not advisable to undergo lower eyelid surgery within six months of laser vision surgery. There are basically two types of lower eyelid plastic surgery: 1, traditional lower eyelid plastic surgery The surgical incision refers to the location of the lower eyelid 2mm below the eyelashes, through the eyelid, muscle and orbital septum to reach the fat layer of the eye belly, and then the appropriate amount of fat will be removed from the eye belly, the surgery can also remove the excess eyelid and tighten the lower eyelid, suture wound is completed. This surgery is suitable for patients with obvious eye bags and sagging eyelids that require skin removal. For patients with congenital bags that do not require skin removal, the surgical incision can be designed within the conjunctiva. The lower eyelid is turned over, and the laser or electric knife is used to reach the fat of the eye belly directly through the conjunctiva and remove the excess fat without sutures. (Trans-conjunctival removal of eye bags before and after surgery contrast photo) 2, the lower eyelid plastic surgery to retain fat For people with acquired eye bags and tear trough is not obvious, consider pushing the protruding eye bags fat back to the eye socket, using the principle of repair “small intestine gas” to strengthen the lower orbital septum. For people with acquired eye bags and obvious tear sulcus, removing the fat will only make the eyelid more hollow and the tear sulcus more obvious. In recent years, it has been changed to retain the fat and fill the tear sulcus and cover the lower orbital rim by protruding part of the eye bag fat to create a better result. Lower eyelid surgery is performed under local anesthesia and takes about one to three hours. After the surgery, there will be swelling and bruising around the eyes. The stitches will be removed five to seven days after surgery and most patients can return to work. In general, complications after surgery are uncommon and are mostly minor and temporary, such as the first few days after surgery. For rare but serious cases such as ectropion, failure to close the eyes tightly, etc., other surgical corrections may be required.