Genetics is the first. Some families develop fat bags in their twenties, because the septum is thinner or the fat pads larger from the outset, and no habit alters that. In a Korean analysis of 108 patients presenting for lower eyelid surgery, fat prolapse was the leading finding across the age range and not only in older patients. ³

Sun exposure is the second. Ultraviolet light activates the enzymes that break down collagen and elastin, and the thin lower eyelid skin loses both faster than anywhere else on the face. A looser skin envelope reveals a bag that firmer skin would hold flat.

Smoking is the third, because nicotine constricts the small vessels that supply the skin and the chemicals in smoke accelerate the breakdown of collagen. In a study of 79 pairs of identical twins with different smoking histories, the smoking twin scored worse for lower lid bags, upper lid skin redundancy and malar bags, and the difference was visible after five or more years of smoking. ⁴

Allergy is the fourth. Chronic allergic rhinitis keeps the lower lids congested and prompts eye rubbing, and repeated rubbing stretches the thin lid skin over time.

Weight is the fifth. Weight gain enlarges the orbital fat and the cheek fat around it, whereas weight loss does not reliably reduce orbital fat once it has expanded.

Eye creams hydrate the skin and can thicken it slightly, but they do not reach the septum or the fat. My article on eye creams and cold compresses for eye bags covers what they can and cannot do.

Facial exercises work the muscle in front of the fat, and repeated squeezing of the lower lid, if anything, stretches the skin further.

Eye massage and rollers move fluid for an hour. They do not move fat and do not strengthen the septum.

Sleeping on the back prevents fluid pooling, which is worthwhile for a fluid bag, and has no effect on the fat.

No study has shown that an oral collagen supplement firms the orbital septum.

• Non-surgical eye bag removal: price, what happens and FAQ
• Eye bag treatment in Singapore: every option reviewed
• Is it an eye bag or a tear trough?
• How non-surgical eye bag removal actually works
• How long non-surgical eye bag results last
• When tear trough filler helps and when it does not
• Can eye creams, sleep or cold compresses remove eye bags?
• When dark eye circles are caused by allergic rhinitis
• How dark eye circles are treated
• What Emface Eyes does for the eye area
• Scarless eye bag removal: procedure, recovery and fee
• Eye bag removal cost in Singapore

The simplest way to distinguish fluid from fat is to photograph the eyes on waking and again at 6 in the evening, under the same light, for two weeks, while reducing salt and alcohol and sleeping with the head raised on a second pillow. A bag that is visibly smaller in the evening photographs, or smaller by the end of the fortnight, is fluid. A bag that is identical in every photograph is fat. My article on eye creams and cold compresses for eye bags sets out the test in detail.

Searches for how to get rid of eye bags naturally are looking for a way to remove the bag without attending a clinic. For a fluid bag the measures above are the natural treatment, and they are effective. For a fat bag no natural measure reduces orbital fat. Creams cannot reach it through the skin and the septum. Massage cannot drain it, because fat is solid tissue rather than fluid and does not drain. Cucumber slices, tea bags and cold spoons cool the skin and achieve nothing beyond that. Facial exercises move the orbicularis muscle in front of the fat and leave the fat behind it unchanged. A multispecialty systematic review of under-eye treatments found that topical products and home measures address skin quality and fluid, and that herniated orbital fat requires a procedure. ⁴ Stating this plainly spares patients months of effort and considerable expense.

Two conditions are commonly called eye bags and are neither fluid nor fat.

The first is a tear trough. A hollow groove between the lower lid and the cheek casts a shadow that is read as a bag. Reducing fat deepens a hollow and makes it more visible. A hollow is treated with filler, and the difference is explained in my article on eye bags versus tear troughs.

The second is dark circles. Pigment in the skin, or thin skin over the blood vessels beneath it, makes the lower lid look dark without any bulge. The treatment is directed at the colour rather than at fat, and my dark eye circles review covers it.

Treating the wrong one of these is the commonest reason for an unsatisfactory result after eye bag treatment.

• Non-surgical eye bag removal: price, what happens and FAQ
• Eye bag treatment in Singapore: every option reviewed
• Is it an eye bag or a tear trough?
• How non-surgical eye bag removal actually works
• How long non-surgical eye bag results last
• When tear trough filler helps and when it does not
• Can eye creams, sleep or cold compresses remove eye bags?
• When dark eye circles are caused by allergic rhinitis
• How dark eye circles are treated
• What Emface Eyes does for the eye area
• Scarless eye bag removal: procedure, recovery and fee
• Eye bag removal cost in Singapore

An eye bag is orbital fat pushing forward through a weakened orbital septum, the thin fibrous sheet that normally holds the fat within the eye socket. Working from the inside of the eyelid outwards, the layers are the conjunctiva, the lower lid retractors, the orbital septum and then the fat. The fat is not within the lining. It lies behind two further layers of tissue, which is why a surgeon removing it through the inside of the eyelid must incise the conjunctiva and the retractors to reach it.

A laser held against the conjunctiva heats the conjunctiva. Whether any energy reaches the tissue beyond it depends on the wavelength, because each wavelength is absorbed by a different tissue component at a different depth.

The erbium YAG wavelength of 2940 nm is absorbed by water more strongly than any other wavelength used in aesthetic medicine. On wet tissue the energy is therefore spent within the first fraction of a millimetre. The non-ablative SMOOTH mode used in the published inside-the-lid protocol delivers the energy as a train of low-energy pulses that warm the surface of the lining without ablating it, and the heat does not propagate beyond the lining.¹ The retractors are not reached, and the septum and the fat behind them are not reached.

The neodymium YAG wavelength of 1064 nm penetrates further, but it is absorbed by water and haemoglobin and only weakly by fat. Fat absorbs selectively at wavelengths around 1210 nm and 1720 nm, and lasers designed to target fat were built at those wavelengths for that reason.² A 1064 nm beam applied to the lining of the lid heats the wet lining and the blood within it. The small fraction of the energy that reaches the fat passes through it largely unabsorbed, so the fat is not heated to a temperature at which fat cells are damaged.

With either wavelength the fat pad is untouched. No mechanism exists by which this pass can remove an eye bag, and that conclusion stands before any clinical evidence is considered.

HIFU and skin tightening cannot remove an eye bag, for the same reason. High-intensity focused ultrasound (HIFU), Thermage and the other heating devices bundled into eye bag packages heat the dermis or the deeper support layer of the skin, and neither layer contains the fat. One HIFU series in 15 patients treated infraorbital skin laxity and reported tighter skin at six months, and fat was not measured.⁷ Tighter skin over the same fat pad gives a smoother surface for a period of months. The bag remains, and in a younger patient with firm skin and a true fat bag there is no laxity for a tightening device to act on.

4D eye bag removal in Singapore is sold per session, and most packages recommend a course of several sessions with maintenance sessions afterwards. I do not quote other clinics’ prices. The relevant question is what the fee purchases, which is warming of the eyelid lining and skin. A course that does not reach the fat is expensive at any price, because the eye bag still requires treatment when the course ends, and the cost of that treatment is added to what has already been spent.

The two treatments I use that act on the fat itself are priced as follows, before GST. AGNES with Secret RF, which reduces the fat pad through the skin with an insulated radiofrequency needle, is $2,500 with reviews at 4 and 8 weeks included. Scarless eye bag removal surgery is $2,988 plus a day surgery facility fee of $500 to $1,000. The full list is on my eye bag removal cost page.

Only a treatment that reaches the fat removes an eye bag. Four situations are distinguished at examination.

For a mild to moderate fat bag with firm skin, insulated microneedle radiofrequency delivered into the fat pad reduces the bulge. The insulated needle releases heat only at its tip, so the fat is heated and the overlying skin is spared. A published series measured the reduction in the bulge on three-dimensional photography and found it maintained at 24 weeks.⁸ This is the non-surgical eye bag removal I perform, and in my patients the result typically holds for 3 to 5 years.

For a large bag, loose skin or a lax lower lid, scarless eye bag removal through an incision inside the eyelid removes or repositions the fat directly, and leaves no visible scar because the incision lies on the conjunctival surface.⁶

A fluid bag is worse in the morning and flattens by midday, because fluid pools in the loose tissue of the lower lid overnight and drains once the head is upright. No device is effective on fluid, and the cause, usually allergy or lifestyle, is addressed instead.

For a tear trough hollow without a bulge, filler is the correct treatment. Filler placed beside a true fat bag adds volume next to the protrusion, and the lower lid can look fuller rather than flatter.

Which of these applies is decided at examination, from the amount of fat protrusion, the quality of the skin, the tone of the lower lid and the position of the eye relative to the cheek. My review of every eye bag treatment in Singapore sets out how I choose between them. For the home measures that work on fluid, and why none of them works on fat, see my article on how to get rid of eye bags.

• Non-surgical eye bag removal: price, what happens and FAQ
• Eye bag treatment in Singapore: every option reviewed
• Is it an eye bag or a tear trough?
• How non-surgical eye bag removal actually works
• How long non-surgical eye bag results last
• When tear trough filler helps and when it does not
• Can eye creams, sleep or cold compresses remove eye bags?
• When dark eye circles are caused by allergic rhinitis
• How dark eye circles are treated
• What Emface Eyes does for the eye area
• Scarless eye bag removal: procedure, recovery and fee
• Eye bag removal cost in Singapore

Botox changes the nose in motion, whereas filler changes it at rest. A tip that sits low at rest and drops further on smiling may require both. In a series of 95 patients treated with filler for a drooping tip, Botox was added for the depressor septi nasi in 45% of cases, with high satisfaction scores and no significant side effects. The choice of filler for the tip is described on best filler for the nose.

Mild tenderness and a small bruise at the injection point are the usual side effects. The muscle sits close to the upper lip, and too large a dose can therefore alter the smile or the movement of the upper lip for a few weeks. The dose is kept very small to prevent this.

The price of a Botox nose tip lift is quoted at the consultation, as the dose depends on the strength of the muscle. Botox for other areas is described on Botox in Singapore.

The most serious problem after nose filler, a blocked vessel, usually shows within the first hours to days. Swelling, bruising and lumps can take a week to assess. For a patient flying home two days after treatment, the treating clinic is no longer within reach when these signs appear.

Three questions should be answered before booking abroad.

1. Who do I contact if my nose turns pale or dusky after I fly home?
2. Which product and how much will you inject, and will you give me the sticker?
3. Is the filler hyaluronic acid, so a doctor in Singapore can dissolve it?

Prices in Seoul are often lower per syringe, but the difference narrows once the flight, the hotel and the cost of any follow-up visit are included. In Singapore, HA nose filler at my practice costs $1,200 per syringe and Radiesse $1,400, both before GST and both including the review. The treatment is described on nose fillers in Singapore.

Hyaluronidase is an enzyme that breaks down HA. It is injected at several small points along the bridge, into the area where the filler sits. Most of the filler softens within 24 to 48 hours. A second session is sometimes required for filler that has been present for years or has formed a capsule, as the capsule limits the spread of the enzyme. The swelling from the injection settles over a few days.

Treatment of a blocked vessel follows a different protocol, in which high doses of hyaluronidase are given across the whole affected area and repeated at intervals until the skin colour returns. My practice has its own hyperbaric oxygen therapy (HBOT) chamber on site, which can raise the oxygen supply to the affected skin while blood flow is restored.

I wait at least two weeks after dissolving before placing new filler, which allows the swelling to settle and the true shape to be assessed. The new filler is placed deep on the bone in the midline, in a smaller amount than before, and most patients require less than they had originally.

HA fillers differ in firmness and in cohesivity, the degree to which the gel holds together. A firm gel with high lift resists compression by the skin and maintains height on the bridge. A cohesive gel stays where it is placed rather than spreading sideways. Both properties are necessary in the nose, whereas a soft gel designed for lips or fine lines spreads and widens the bridge. International consensus recommends highly cohesive, elastic HA fillers for nasal augmentation in Asian patients.

Juvederm Volux (VYC-25L) is one of the firmest HA fillers in the Juvederm range, designed for structural support of the chin and jaw. In a study of 61 patients treated for nasal shape with a grid approach, Juvederm Volux achieved high correction scores that were maintained to six months, with bruising as the main side effect and no cases of skin necrosis, the tissue death caused by a blocked vessel.

• The bridge requires a firm, high-lift gel placed deep on the bone and cartilage, where it holds a straight line.
• The tip requires very small amounts, around 0.05 to 0.1 ml at each point, of a gel that provides support without adding bulk.

I place HA with a needle rather than a cannula, down to the periosteum (the lining of the bone) on the bridge, in small deposits of about 0.05 ml. A needle allows more accurate placement at this depth, where the filler lies below the main blood vessels.

HA nose filler costs $1,200 per syringe before GST, including the review. Most noses require one syringe. The treatment is described on nose fillers in Singapore, and a longer-lasting option that cannot be reversed is described on Radiesse nose filler.

The immediate effect of the gel lasts several months, and the collagen response then extends the result. In facial studies Radiesse has lasted a year or longer. In the nose, where there is little muscle movement to disperse it, Radiesse tends to last longer than HA. It is fully broken down by the body in time and is not permanent.

HA can be broken down within hours by hyaluronidase, an enzyme that acts on HA only, whereas Radiesse is unaffected by it. Sodium thiosulfate has dissolved CaHA in laboratory studies, but it is not an established treatment.

The nose is among the areas of the face where the blood supply is most at risk from filler. If Radiesse were to block a vessel, treatment would depend on restoring blood flow by other means, set out in an international expert consensus, without the simple reversal that HA offers. My practice has its own hyperbaric oxygen therapy (HBOT) chamber on site, which can raise the oxygen supply to the affected skin while blood flow is restored. An unsatisfactory shape likewise cannot be corrected until the body breaks the Radiesse down.

Polycaprolactone (PCL) filler cannot be dissolved either, and its use in the nose is supported by only two small studies, of 10 and 12 patients. I use PCL filler in the deep areas of the face, described on PCL filler in Singapore, and HA or Radiesse in the nose. HA products are compared on best filler for the nose.

Radiesse costs $1,400 per syringe before GST, including the review. Most noses require less than one syringe. The nose filler treatment itself is described on nose fillers in Singapore.

Three non-surgical treatments cover the first three causes. Each is described below, and the sagging eyelids treatment page compares them side by side with prices.

AGNES with Secret RF, the non-surgical eyelid lift

AGNES uses an insulated W needle passed over the dermis of the eyelid to heat the skin around the double eyelid, so that the collagen contracts and rebuilds and the lid lifts. The insulation confines the heat to the needle tip, which protects the skin surface and the eye beneath. Secret RF, delivered through an insulated cannula over the fold, heats and reduces the bulky tissue that weighs a heavy lid down. Together they work especially well on a heavy eyelid, the thick lid under loose skin, because each treats a different layer. The treatment is one session under numbing cream and a small local injection, takes about 20 minutes, causes two to four days of swelling, and allows a return to work from day two. Read about the AGNES with Secret RF eyelid lift.

Thermage FLX Eyes

Thermage FLX Eyes delivers monopolar radiofrequency through a 0.25 cm² eye tip, with a shield on the eye and nothing entering the skin. The tip heats the dermis in bulk while the surface is cooled, so that collagen contracts at once and new collagen forms over the following months. Thermage FLX is FDA-cleared for the non-invasive treatment of periorbital wrinkles including the upper and lower eyelids. In its 72-patient trial, 88 per cent of patients had upper eyelid tightening and 86 per cent had less hooding after one session, with no serious adverse events [1]. The upper lid skin tightens and the double eyelid fold shows more clearly. Downtime is little to none. Thermage FLX Eyes at The Clifford Clinic.

HIFU Eye

Focused ultrasound placed under the brow and along the outer eye heats small points in the support layer beneath the skin, which contracts as it heals and lifts the brow by a millimetre or two, opening a hooded lid from above. It complements the eyelid treatments rather than replacing them, and it can be performed with Thermage at the same visit. I use Tightan 2 for this, with numbing cream, no downtime, and one session a year. HIFU in Singapore, the full guide.

Which treatment for which droopy eyelid

Droopy eyelid exercises, creams and home devices

Exercises work the muscles, and a droopy eyelid caused by loose skin is a collagen problem rather than a muscle one. Creams hydrate the surface and do not reach the dermis where the collagen sits. Tapes and glues lift for hours, and the repeated pulling stretches the thin lid skin further over time. Home tightening devices are too weak to heat the dermis and are not designed for the eyelid. Sunscreen and not rubbing the eyes slow the loosening, because ultraviolet light and friction both break down collagen. None of these measures lifts a lid that has already dropped.

Surgery for droopy eyelids, when it is needed

Excess skin is removed by upper blepharoplasty. Ptosis is repaired by shortening the levator muscle or reattaching its tendon. A brow that has dropped a long way is repositioned by a brow lift. An eyelid that has never had a fold is given one by double eyelid surgery. All four are performed at The Clifford Surgery at the same address, and I refer there at the first consultation when the cause is surgical, rather than after a course of energy treatment that cannot correct it.

The AGNES with Secret RF eyelid lift costs $2,500 a session before GST, one fee for both devices, with the consultation fee waived when treatment goes ahead and two reviews included. Thermage FLX Eyes and HIFU for the eye area are quoted at consultation. Upper blepharoplasty and ptosis surgery at The Clifford Surgery are quoted by the surgeon. An eyelid trial offered elsewhere at about $250 is usually a partial treatment on a single device.

Common and temporary

Redness and swelling are common after HIFU and settle within a few days. Bruising and tenderness can last a little longer [8, 9].

Less common but more serious

• Burns and blisters. These happen when the gel is uneven and leaves air gaps, or when the energy lands too close to the surface [3, 8].
• Nerve symptoms. Energy over the jawline, the temple or the forehead can cause temporary numbness or weakness of the muscles that move the face [3, 8].
• Pigmentation. Dark patches can follow HIFU in Asian skin, and they are more likely if the skin is exposed to sun afterwards. In one study of 49 Chinese patients, two developed pigmentation on the forehead [9].
• Fat loss. Heat in the wrong layer, or repeated shots on the same spot, can melt fat and leave a hollow cheek [3, 8].

The US FDA lists pain, redness, swelling, blisters, burns and nerve damage as possible complications of ultrasound body contouring. It advises against treating broken or compromised skin [4].

A home device also skips the assessment. Nobody checks whether the loosening comes from the skin, the fat or the bone, or whether a spot or lump in the area should be seen by a doctor first. Nobody follows up if something goes wrong. I would keep any home device off the jawline, the temples and the area around the eyes. How clinic HIFU goes wrong is covered on the HIFU risks page.

How the clinic machines differ from each other is covered on the HIFU machines page. For a gentle clinic option with no downtime, Sygmalift HIFU is the one I use.

Not every ultrasound device for the face is HIFU. LDM, or Local Dynamic Micro-massage, is a clinic treatment that uses two or three ultrasound frequencies, such as 3 and 10 MHz, without focusing the beam. It works on the skin itself and does not aim for the SMAS.

In a multicentre study of 39 adults, 8 to 12 LDM sessions improved fine and coarse wrinkles, pores and skin firmness. The only side effect was brief redness [6]. The study was not randomised, and one author was from the company that makes the device. That author has proposed that LDM rebalances the enzymes that break down collagen and raises the heat shock proteins that help skin cells repair [6, 7].

My clinical perspective

LDM is excellent for the skin and stimulates many of the proteins that help with skin ageing. It is not a lifting treatment. The Clifford Clinic offers LDM for skin ageing and for eczema. Bellasonic is also excellent for skin ageing.

• Anyone who wants a real lift. A home device will not deliver it.
• Anyone with a thin face, where heat in the wrong place can hollow the cheek.
• Anyone with recent filler or threads in the area. Do not use a home device over them, as it can cause excess blistering or infection.
• Anyone with broken, inflamed or infected skin in the area.