The Eyes, Explained: Hooding, Under-Eye Bags, and More with Dr. Sarah Avila

A year ago, Dr. Sarah Avila did my eyelid surgery, and the questions haven't stopped since. So I finally brought her on to answer them. Dr. Sarah Avila is the board-certified oculoplastic surgeon who performed my own upper eyelid surgery, and after all the questions that experience generated, I knew I had to bring her on. An oculoplastic surgeon specializes entirely in the upper face and everything to do with the eyes: the eyelids, brows, the lacrimal (tear) system, and the eye socket.

We start with something most people never consider, that the eyes have to function before they can look good. From there we get practical. We get honest about the non-surgical options too: when under-eye filler genuinely helps and when it backfires, what PRP and PRF can and can't do, and her candid, study-informed take on PDGF, the injectable that's everywhere in Miami right now. We talk about the skin pinch trend and why she's seeing complications from it, when surgery is genuinely the better value, and why she'll never give you a "trendy" result.

A quick and important note: this is an educational conversation about aesthetic and surgical options, not medical advice, and it reflects our guest's clinical perspective. Every concern discussed is deeply individual, and as Sarah says, there's no substitute for a real, in-person consultation with a qualified provider.

Whether you've thought about eye surgery or just want to understand what you see in the mirror, this one is full of clarity.

Additional info:

A landmark study published in PLOS ONE analyzed data from 16,408 adults to measure the exact mental health impact of dry eyes. The researchers found the following risk metrics:

Suicidal Ideation Risk (Diagnosed DED): Patients with a clinical diagnosis of dry eye disease had a 1.24 times higher risk (an increased odds ratio of 24%) of experiencing suicidal thoughts.
Suicidal Ideation Risk (Severe Symptoms): Patients experiencing active, painful dry eye symptoms had a 1.47 times higher risk (an increased odds ratio of 47%) of suicidal thoughts compared to healthy peers.
Depression Risk: Those with active dry eye symptoms had a 1.50 times higher risk of developing clinical depression.

FAQs

Why do my eyes look tired even when I'm rested?

"Looking tired" is rarely one thing. It's usually a combination of factors: loss of bone and fat volume over time, skin becoming more lax, and descent of the brow. Because several things are usually happening at once, understanding the full picture, ideally with a qualified provider, matters more than targeting any single feature.

What's the difference between hooded eyelids and a drooping eyelid?

Hooding refers to excess or loose skin on the upper eyelid, often influenced by the brow pressing down from above. A drooping eyelid (ptosis) is when the eyelid margin itself sits low over the eye. They're different concerns addressed in different ways, which is why telling them apart is a key part of a professional evaluation.

How can I tell if my brow is contributing to my hooding?

At home, you can look in the mirror with your face relaxed and notice where your brow sits relative to the bony rim of your eye socket. If gently lifting the brow relieves the hooding you see, the brow may be playing a role. This isn't a diagnosis, but it helps explain why addressing eyelid skin alone sometimes leaves a lingering heaviness.

What actually causes under-eye "bags" and "dark circles"?

These catch-all terms can stem from very different causes: prominent veins beneath thin skin, true pigmentation, genuine hollowness from lost volume, or puffiness from fat that has shifted forward, often more than one at once. Because the causes differ, so do the solutions, and a treatment that helps one cause can worsen another.

Is under-eye filler a good idea?

It depends entirely on the cause. Filler can help in cases of true under-eye hollowness, particularly when the mid-face is balanced at the same time. But in someone with puffiness, herniated fat, or uncontrolled allergies, it can lead to complications. The eye area has the thinnest skin on the body and is unforgiving, so candidacy, product, and technique all matter enormously.

When is surgery a better choice than a non-surgical treatment?

When a concern is structural, driven by shifts in fat, skin, or the eyelid itself, non-surgical treatments often can't deliver what's needed, and a surgical approach may offer a more meaningful, lasting result. Some concerns respond to lifestyle or skin-quality treatments; others don't. Knowing which category yours falls into is what a thorough consultation is for.

Why do some eyelid surgeries get covered by insurance and others don't?

Insurance generally covers eyelid surgery only when excess skin or a drooping eyelid is significant enough to obstruct vision, measured by specific vision testing. That covers removing skin for functional reasons. The cosmetic aspects, scar quality, blending with the brow, addressing fat and crease, are typically not covered, which is a key thing to understand going in.

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