Puffy Eye Bags that Appear When Smiling can be Caused by a Muscle. Eye bags are most commonly caused by lower eyelid fat prolapse, which when the fat around the eyelids becomes displaced and protrudes forward. In the case of this lady, however, Dr. Prasad thinks that her puffiness under the eyes have more to do with the activity of the muscle underneath—the obicularis oculi muscle. This muscle becomes engaged when people smile or squint, so when a person smiles, an accordion effect of the cheeks pushes upwards to compress the skin, and it creates a bulge under the lower eyelash line. In such a case, fillers or fat grafting is not applicable because adding volume to this area may only accentuate the problem. In this case, a neurotoxin such as Botox or Dysport may be of more help, as these are designed to relax the muscle and reduce its activity. Since these types of medication have a short activity lifespan (3-6 months), it makes it more convenient for the patient to choose to continue the treatment or stop it altogether.
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