Hamra technique: who is it for? The mechanism and limitations of flattening under-eye puffiness and hollowness without cutting the skin

The Hamra technique is a procedure in which the surgeon enters from the inside of the lower eyelid, relocates the fat beneath the under-eye puffiness into the hollow below it without removing the fat, and flattens the area[1][2]. It is suitable for people who have distinct puffiness and hollowness and minimal skin sagging[2][3]. Excess skin and fine surface wrinkles cannot be addressed by the Hamra technique alone[3][4].

What does the Hamra technique do?

Under-eye puffiness results from the orbital fat around the eyes protruding forward. In the Hamra technique, this fat is repositioned and fixed into the groove (tear trough) directly beneath the puffiness[2][5].

Because the incision is made in the conjunctiva on the inner side of the eyelid, no scar remains on the skin surface[1]. The distinguishing feature is that reduction of puffiness and filling of hollowness can be accomplished simultaneously in a single procedure[2].

How does it differ from surgery that only removes fat?

The main difference is whether the hollowness can be corrected. With fat-removal-only methods, the groove may become more prominent or the under-eye area may appear sunken[1][6].

The Hamra technique preserves the fat and redirects it into the hollow, so it can minimize the difference between puffiness and hollowness[2][6]. However, in people with excess fat, over-repositioning can cause the cheek area to become too full, and some reports describe methods of partial adjustment and reduction[7].

Who is it suitable for, and who is it not?

It is suitable for people in whom the under-eye puffiness and tear trough are clearly defined and skin sagging is not prominent[2][3]. In a study of 26 patients, those candidates showed an average satisfaction score of 5.69 out of 6 at the 6-month follow-up, a high result[2].

On the other hand, in people with minimal puffiness, there is less fat to reposition, and improvement of the tear trough may be limited[5]. People with skin laxity or muscle sagging may benefit from combining the procedure with skin excision or laser treatment[4].

What should you know about complications and downtime?

With skin-incision methods from the outside, complications such as lower eyelid retraction and ectropion (the lid turning outward like sticking out the tongue) are significant concerns[1]. Transconjunctival access is often chosen because these complications are less common[1][8].

In the 26-patient study, no ectropion or infection occurred; mild asymmetry appeared in one person and diplopia (double vision) in two, but both resolved within one week[2]. Repositioning fat beneath the periosteum has been reported to sometimes cause prolonged swelling[8].

What should you confirm during the consultation before undergoing the procedure?

Whether the Hamra technique is appropriate depends on three factors: the volume of fat in the puffiness, the depth of the tear trough, and skin laxity[5][3][4]. It is difficult to distinguish which is the main cause by looking in the mirror alone

During consultation, confirm whether your under-eye area is suited to the fat-repositioning method, how it compares to fat-removal-only or skin-excision methods, and how long swelling will persist