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Why the Puffy Eyelids?

By Jennifer I. Hui, MD

Our eyes are the focus of our face. It is natural to want to appear our best – rested and bright eyed! But sometimes puffiness and bagginess make us look – and feel – tired. We may even be perceived to be ill or angry.

Although a very small percentage of our skin’s total surface area, the eyelids are very important for our daily visual function. The heaviness of puffy eyelids may interfere with our ability to see clearly, causing fatigue with many normal activities such as reading, driving, and computer use.

There are a number of reasons why people may have a puffy appearance to the eyelids; the most common are age and hereditary factors. As we mature, our eyelid skin loosens and the support structures weaken, causing a fuller and less pleasing appearance. Our normal fatty tissues which protect our eyes may bulge forward and protrude. The skin texture changes and becomes more redundant and crepelike in appearance. These changes may interfere with our visual function – the excess tissue may block our peripheral vision and have a negative impact on our daily activities. If puffiness and excess fat/skin run in your family, you are more likely to be affected at an earlier age than other people. Regardless of the exact cause, surgery often improves function and appearance.

Another common cause includes obstructive sleep apnea (OSA). With OSA, patients stop breathing during sleep and their oxygenation levels drop. This cessation of breathing may be caused by airway abnormalities or a central cause (depressed respiratory drive). Patients with this condition are often required to wear a CPAP (continuous positive airway pressure) device in order to maintain proper breathing, airway function and oxygenation levels. However, the mask that most users wear contains a tight fitting strap which compresses the eyelid and cheek tissues. This constant prolonged pressure night after night may cause edema and puffiness of the lower lids.

Less common causes include prior dermal filler placement and systemic diseases. The hyaluronic acid-based fillers (Juvederm, Restylane, Belotero) may cause a delayed swelling in the eyelid region. This effect may be seen years after treatment. Many patients come in thinking they need eyelid surgery for their lower lid bags, but in fact their swelling is caused by a delayed response to their prior cosmetic treatment. In these patients, an injection of a solution to dissolve the hyaluronic acid-based filler usually resolves the situation. The results are seen almost immediately. The tissues may then be reassessed to see if additional surgery may be of benefit.

Systemic conditions that may worsen eyelid edema include high blood pressure, kidney disease and certain allergic conditions. Water retention and allergic reactions affect the eyelids disproportionately given the thin, delicate nature of this tissue.

It is good to know that puffy eyelids are not always a sign of aging and in some cases, the causes are multifactorial. A thorough examination and review of the medical history will help to pinpoint the causative factors and help guide an appropriate treatment plan.

Dr. Hui is the founder of The Eyelid Institute in Palm Desert. She is an Oculoplastic surgeon with a special interest in helping patients with eyelid, lacrimal and orbital conditions and can be reached at (760) 610.2677.

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