What are the treatment options for under eye bags?

Treatment of Under Eye Bags

For true under eye bags caused by orbital fat prolapse, surgical intervention (blepharoplasty) remains the definitive treatment, while non-surgical options like hyaluronic acid fillers can effectively camouflage the appearance by addressing associated tear trough deformities.

Understanding the Anatomical Basis

Under eye bags are not a single entity but rather a combination of anatomical problems that require different treatment approaches:

• Orbital fat prolapse contributes 48% to the appearance of under eye bags and is the most common structural cause 1
• Tear trough depression and cheek descent account for 52% of the cumulative contribution, often creating the illusion of bags by casting shadows 1
• Skin laxity and sun damage contribute 35% to the overall appearance 1
• Eyelid fluid accumulation accounts for 32% of cases 1
• Men more commonly present with prolapsed orbital fat and tear trough deformity compared to women 1

The average patient has multiple contributing factors, with no single anatomic problem dominating in most cases (average uniqueness score of only 38%) 1.

Non-Surgical Treatment Options

Hyaluronic Acid Filler Injection

Hyaluronic acid fillers effectively conceal under eye bags by filling the tear trough depression, thereby eliminating the shadow that accentuates the appearance of orbital fat prolapse 2:

• Use cross-linked hyaluronic acid filler (15mg/mL concentration) injected into the tear trough region 2
• Both needle and cannula techniques can be employed in the same session for optimal cosmetic outcomes with reduced side effect risk 3
• Treatment not only improves periorbital hollowness but remarkably conceals the bulge of infraorbital fat pads without forming lumps or irregularities 2
• This approach serves as an excellent alternative to surgery for appropriate candidates 2

Topical Epidermal Growth Factor (EGF) Serum

For mild cases or as adjunctive therapy:

• Apply EGF serum to the infraorbital area twice daily 4
• Clinical improvement becomes evident after 12 weeks of consistent use 4
• Patients reported 25-75% improvement in appearance, with most noting milder under-eye bags compared to baseline 4
• This represents one of the few topical agents with evidence for reducing under eye bag appearance 4

Conservative Measures (Limited Efficacy for True Bags)

The following measures from ophthalmology guidelines address eyelid inflammation and edema but have limited direct effect on structural under eye bags:

• Warm compresses applied for 5-10 minutes once or twice daily can reduce eyelid edema when present 5, 6
• Gentle eyelid cleansing with diluted baby shampoo or hypochlorous acid (0.01%) cleaners addresses inflammatory components 5, 6
• Artificial tears and topical perfluorohexyloctane manage associated dry eye symptoms that may accompany periorbital concerns 5

Important Clinical Considerations

Patient Selection for Non-Surgical Treatment

• Younger patients (20-50 years) with primarily tear trough deformity are better candidates for filler treatment 3
• Patients over 50 years more commonly have skin laxity and midface descent requiring different approaches 1
• The extent of fat prolapse, skin elasticity, and midface descent determine whether surgical intervention should be recommended 1

Safety Precautions

• Patients with advanced glaucoma should avoid excessive pressure during any eyelid manipulation to prevent increased intraocular pressure 5, 6
• Patients with neurotrophic corneas require proper counseling to avoid corneal epithelial injury during any periorbital treatment 5, 6
• When using warm compresses, ensure water temperature is warm but not hot enough to burn the skin 5, 6

When to Consider Surgical Referral

• Significant orbital fat prolapse that cannot be adequately camouflaged with fillers 1
• Severe skin laxity and sun damage requiring tissue removal 1
• Triangular cheek festoons (13% contribution to appearance) 1
• Markedly asymmetric or recurrent swelling in the same location (to exclude malignancy) 6

Treatment Algorithm

1. Assess the dominant anatomical problem: Determine whether tear trough depression, fat prolapse, skin laxity, or fluid accumulation predominates 1
2. For tear trough-dominant cases: Initiate hyaluronic acid filler treatment to camouflage bags 2, 3
3. For mild cases with minimal structural changes: Trial topical EGF serum twice daily for 12 weeks 4
4. For inflammatory or fluid-related edema: Implement warm compresses and eyelid hygiene measures 5, 6
5. For significant fat prolapse with skin laxity: Refer for surgical evaluation as non-surgical options will have limited efficacy 1