Objective <p>To explore a reasonable grading system for puffy eyelids and corresponding clinical management strategies.</p> Methods <p>We retrospectively analyzed 132 patients with puffy eyelids who underwent double-eyelid blepharoplasty at the Department of Plastic and Laser Cosmetology of Hunan Provincial People’s Hospital from January 2023 to June 2024. Patients were classified into mild, moderate, or severe based on preoperative appearance and intraoperative anatomical characteristics. Depending on the severity, either the three-point method or the incision method (orbital septum method) was selected for double-eyelid blepharoplasty, allowing for targeted treatment of the orbital fat and retro-orbicularis oculi fat (ROOF). Postoperative follow-up was conducted&#xa0;at 3 months to 1 year to assess the appearance of the double eyelids, complications, and patient satisfaction.</p> Results <p>Of the 132 patients, 68 cases were mild, with 55 treated by the incision method and 13 by the three-point method; 34 cases were moderate, with 29 treated by the incision method and 5 by the three-point method; and all 30 severe cases were treated by the incision method.&#xa0;Only 1 case required revision surgery postoperatively, with an overall satisfaction rate of 99.24%. There were no serious complications such as hematomas or infections, and all scars healed well.</p> Conclusion <p>Establishing a clear grading system for puffy eyelids based on preoperative appearance and intraoperative anatomical characteristics, and formulating corresponding surgical plans according to these grades, is a reasonable and feasible clinical strategy.</p> Level of Evidence IV <p>This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors <a href="http://www.springer.com/00266">www.springer.com/00266</a></p>