Incisional Hamra technique: how do under-eye puffiness and hollowing change? What research reveals about cautions

The Hamra technique with incision is a procedure that relocates the fat from under-eye puffiness into the hollow below without removing it, and also excises excess skin[1]. It allows puffiness and hollowing to be addressed at once and suits people with significant skin sagging (skin laxity)[1][2]. On the other hand, caution is needed regarding changes such as lower-eyelid descent or ectropion (outward rolling)[3][4].

What does the incisional Hamra technique do?

The surgeon makes an incision just below the lash line and repositions the fat that causes under-eye puffiness downward into the hollow beneath it[1]. Dr. Hamra popularized the method of relocating fat while maintaining its blood supply[1].

At the same time, the "incisional" approach allows excess sagging skin to be excised[1]. For patients with minimal skin excess, a transconjunctival approach (through the back of the eyelid) is also an option[1].

How does removing fat differ from relocating it?

With fat removal alone, puffiness may decrease but the under-eye area can appear sunken[1]. Research reports that fat removal can lead to under-eye hollowing and lower-eyelid retraction later[5].

Preserving and relocating fat is thought to create a smoother transition from the lower eyelid to the cheek[1]. Recent lower-eyelid surgery increasingly favors preserving and repositioning fat over removal[2].

How do you choose between the incisional and transconjunctival approaches?

The deciding factor is how much excess skin is present. The transconjunctival approach (through the eyelid lining) suits younger patients with minimal skin excess, while the incisional method suits those who need skin removal[1].

However, no controlled study has directly compared the two methods side by side, so superiority has not been established[1]. Textbooks recommend conservative skin removal[6].

What is the risk of lower-eyelid ectropion?

The primary concern is a change in lower-eyelid position. Textbooks state that the most common complication after lower-eyelid surgery is ectropion (outward rolling of the eyelid), occurring in 15% of cases[4].

With the skin-incision approach, earlier reports cited lower-eyelid position abnormalities in 15–20% of patients[3]. In contrast, a report of 265 patients using refined skin-cutting and lateral-canthus support techniques found that only 1% developed visible sclera[3].

Patients with pre-existing lower-eyelid laxity are at higher risk for ectropion[4]. Have the surgeon assess whether your eyelid has existing laxity before surgery.

What about swelling, recurrence, and limits to outcomes?

A systematic review of lower-eyelid surgery overall found no reports of serious complications affecting vision, and most complications were managed with observation or revision surgery[7]. The review also noted that more rigorous comparative research is needed[7].

In the 265-patient report, scar contracture requiring injection treatment developed in 1.9%[3]. The median observation period in that report was 120 days, so longer-term outcomes remain unclear[3].

The fat-repositioning technique has been noted as broad in dissection scope and technically demanding until the surgeon gains experience[2]. Recurrent under-eye puffiness from retained fat requiring additional surgery has been reported[2].

Regarding swelling, research on transconjunctival surgery reported that all patients experienced swelling that resolved within 8 weeks[8]. Direct data on swelling duration with the incisional method was not found in the available literature.

What should you confirm before proceeding?

During consultation, ask about the following points:

Skin excess: Is the skin sagging enough to warrant incision, or would the transconjunctival approach suffice?[1]

Eyelid laxity: Is lateral-canthus support needed to prevent ectropion?[3][4]

Fat volume: How will the amount to be relocated and any amount to be removed be determined?[2]

Recovery: What is the expected timeline for swelling resolution and what happens if revision is needed?[3][7]

Whether the incisional Hamra technique suits your under-eye area cannot be determined from an article alone. During examination, have the surgeon assess your skin excess, lower-eyelid laxity, and fat puffiness pattern to confirm whether the incisional or transconjunctival approach is appropriate for you.