Under-Eye Bags: What Causes Them and How to Treat Them

Under-eye bags are one of the most common concerns patients bring to me, as they can make the face look tired and aged. Often, those affected have tried everything from expensive eye creams and serums to social media tips, the famous cold spoon trick, and grandma’s cucumber slices to get rid of their under-eye bags. In most cases, without success. The reason for this is that, in most cases, what’s behind them isn’t swelling, but rather tissue in the form of fat and skin that doesn’t simply recede or disappear overnight.

In this guide, I want to explain how under-eye bags form, what you can do about them yourself, which “tips” you should avoid, and how this mostly cosmetic issue can be corrected surgically. At my practice in Frankfurt am Main, I’m also happy to advise you personally.

What exactly are under-eye bags?

Despite what the name might suggest, under-eye bags actually have nothing to do with the tear duct system. The anatomical lacrimal sac (saccus lacrimalis) is relatively small, sits at the inner corner of the eye, and is responsible for draining tear fluid.

What is colloquially referred to as under-eye bags is actually bulging fat and sagging skin. The eye socket contains fat pads that protect the eyeball. This layer is held back by a very fine, taut connective tissue membrane called the orbital septum. Just like the skin, this membrane loses its elasticity with age, allowing the fat to push forward and eventually bulge beneath the lower eyelid. At the same time, the skin under the eyes becomes slack. Together, these two processes create under-eye bags. Fluid retention can further intensify their appearance.

What causes under-eye bags?

As is so often the case, genetics is the most important factor. It determines how stable your connective tissue is and how voluminous the fat pads around your eyes are. If your parents had under-eye bags, you’re more likely to develop them at some point too. The second factor is age. Over the years, the skin becomes thinner and loses collagen. The ring muscle around the eye (musculus orbicularis oculi) also loses tension, the orbital septum weakens, and fat protrudes.

Third, cheek fat naturally descends with age. This makes the groove between the lower eyelid and cheek appear even deeper, making the bulge more pronounced. If you naturally have little subcutaneous fat in your face, you may notice your under-eye bags earlier, since there’s little tissue to soften the appearance of the bulge.

Finally, lymphatic drainage plays a role — though differently than often claimed. At night, it works more slowly, which is why swelling is most pronounced in the morning. Alcohol, nicotine, salty food in the evening, and lack of sleep all intensify this fluid retention. However, this doesn’t cause genuine under-eye bags. At most, it makes them more visible for a few hours.

Is it possible to prevent under-eye bags from forming?

Only to a limited extent. As mentioned, whether fat bulges beneath the eyes is largely genetically determined. You can only influence how early and how noticeably the bags appear. To do so, you should maintain a healthy lifestyle, meaning:

• Consistent sun protection (UV radiation breaks down collagen)
• Avoiding nicotine (smoking accelerates collagen breakdown)
• Adequate sleep with your head slightly elevated (relieves the lymphatic system)
• Gentle care of the eyelid skin (avoid rubbing, remove makeup carefully)
• Moderate alcohol consumption (alcohol binds water in the tissue)

That said, you shouldn’t expect miracles. Once a bulge has started to form, these measures alone can no longer eliminate it.

What’s the difference between under-eye bags, dark circles, and eyelid swelling?

These three are usually lumped together, but their causes are fundamentally different — and so is the answer to what actually helps against each of these unwanted changes.

• Under-eye bags are bulging fat, sagging skin, or a combination of both. The bulge is clearly visible, can be felt, and remains present throughout the day.
• Dark circles are dark discoloration and shadows beneath the eyes. They’re usually caused by volume loss at the transition to the cheek. The skin itself isn’t discolored.
• Eyelid swelling is fluid accumulation, often caused by too much salt in the evening or an unhealthy lifestyle. This swelling typically subsides over the course of the day.

A simple rule of thumb: whatever changes over the course of the day is usually just fluid. Whatever remains constant is fat, sagging skin, or a combination of both.

When should I see a doctor about my under-eye bags?

If you’ve had under-eye bags for years and they’ve hardly changed, there’s no reason to see a doctor. The situation is different if swelling around your eyes appears suddenly or only on one side, or if your eyes appear to be visibly protruding. In this case, please see your general practitioner or ophthalmologist promptly for an examination. They can rule out underlying medical conditions.

An underactive thyroid, for example, can be behind these symptoms. This can cause the connective tissue throughout your body to swell, including the area beneath the eyes referred to as under-eye bags. Graves’ disease is another possibility. With this autoimmune condition, the eyeballs protrude from their sockets. Kidney disease or heart failure should also be considered. However, relatively harmless allergies can also be a cause.

Are there effective home remedies for under-eye bags?

No home remedy can do anything against genuine under-eye bags — that is, age-related or connective-tissue-related bulging fat and sagging skin. What grandma’s recommended cucumber slices or cottage cheese compresses actually provide is cooling. Cold temporarily constricts the blood vessels under the eye and slightly reduces morning swelling caused by fluid retained in the tissue.

Caffeine has a similar vessel-constricting effect, which is why it’s found in many serums marketed online and in drugstores against under-eye bags. Here too, the smoothing effect lasts at most a few hours. Caffeine has no lasting effect on the bulging fat tissue or skin firmness, so the eye area looks the same as before after a few hours.

Supposed “tips” from social media are often unhelpful and sometimes even dangerous. One example is the alleged secret tip of using hemorrhoid cream against under-eye bags. The cream is said to have a decongestant effect, but it belongs in the intimate area and has no business anywhere near the eyes. Here, in the worst case, it can cause severe eye irritation or inflammation.

Please also avoid:

• taking diuretic tablets
• other unknown ointments and tablets from dubious sources
• questionable “secret tips” from social media platforms like Instagram or TikTok

How can under-eye bags be removed?

The only effective treatment option is a surgical procedure known as a lower eyelid lift (blepharoplasty). From a medical standpoint, this is rarely necessary. That’s why I only recommend surgery if you’re bothered by these effects of natural aging and wish for a fresher appearance. I offer under-eye bag surgery via two approaches:

Via the conjunctiva (transconjunctival)

With this approach, I make an incision on the inside of the lower eyelid. Through this incision, I access the bulging fat and either reduce it or reposition it into the tear trough. The advantage of this method is that it leaves no visible scar and preserves eyelid tension. However, this technique doesn’t allow for skin tightening, which is why it’s better suited to younger patients who don’t yet have significant excess skin.

Via the lash line (transcutaneous)

With this approach, I make a fine incision along the lash line. Through this, I remove excess skin and fat. If needed, I tighten the muscle and reposition fat into the tear trough.

The modern approach is to reposition the fat rather than remove it. This way, the fat tissue smooths the transition from the eyes to the cheek, so the eye area doesn’t appear sunken.

If it’s mainly the shadows under your eyes that bother you, rather than the bulge itself, fat grafting using your own fat may be an option. I offer two preparations for this:

• Microfat is specially reduced autologous fat that improves volume deficits and thus softens shadowing.
• Nanofat, on the other hand, doesn’t add volume but has purely regenerative properties, improving the quality of the thin eyelid skin.