Unpacking Lower Eyelid Bags

An astounding number of people, myself included, HATE their undereye bags.


“They make me look so tired.”

“I’ve spent thousands of dollars on eye creams and nothing works. I can’t hide them with make up.”

“They make me look and feel older than I really am.”

“I’m interviewing for a new job and I want to look younger and feel more confident.”


Let’s begin by discussing true fat prolapse, which is what we think of as the classic “eye bag.” The lower eyelid contains 3 fat pads – the nasal, central, and lateral fat pads which typically have a round or cigar roll contour. These fat pads are part of the normal anatomy of the lower eyelids but, depending on genetics, skin quality, and the eye socket bony anatomy, the fat pads can appear prominent even in youth or they can bulge forward over time as the skin, muscle, and deeper tissue layers become thinner and stretched out. Think of it like a corset or Spanx…if your corset has lost its strength, it can’t flatten the belly anymore.


Eyelid fat compartments diagram (From Tan KS, Oh SR, Priel midface for the aesthetic surgeon. In: Massry GG, Murphy aroplasty and periorbital rejuvenation.)


Surgical treatment of true lower eyelid fat prolapse is generally called “lower blepharoplasty.” Older techniques favored by general plastic surgeons involve making a skin incision under the lash line through which skin and fat are removed. This subtractive surgical approach carries a higher risk of complications such as eyelid retraction (where the eyelid is pulled down) and tends to leave patients with volume loss and hollowing over time. Unfortunately, a portion of my practice is devoted to fixing these post-surgical problems.


My preferred surgical approach to address lower eyelid fat prolapse uses a transconjunctival incision hidden on the back side of the eyelid. Through this hidden incision, I release the ligaments that tether the tear trough hollow and unroll the fat pads into pedicles (or skirts). Instead of cutting the fat out, which is technically easier but sacrifices valuable tissue in an area of the face where volume is critical, I reposition the fat pedicles into the tear trough hollows and midface to create a smooth appearing lower eyelid that transitions seamlessly into the midface. This is demonstrated by these before-and-after photos:




Unfortunately, the appearance of "eye bags" is not always due to simple fat prolapse. Over the years I’ve come to realize that people use the term “eye bags” to mean a lot of different things. Let me show you some different types of “eye bags” that patients have carried into my office.


CREPEY SKIN TEXTURE +/- PIGMENTATION



Surgery is not the answer here. Instead, skin quality needs to be improved with resurfacing, radiofrequency microneedling, and topical products. In the right hands, platelet rich plasma (PRP), platelet rich fibrin (PRF), small doses of neurotoxin, or even superficial filler injections may help.


DARK CIRCLES



In most cases of “dark circles,” at least 50% of the issue is volume loss creating a hollow and a shadowing effect. Precise and artful placement of dermal fillers can dramatically improve the hollowing, thus eliminating whatever darkness is caused by the shadowing effect. Darkness that is intrinsic to the skin cannot be cured with surgery or fillers. But improving the deeper contours makes it easier to use make up to cover up pigmentation that is intrinsic to the skin. Topical lightening agents can also help.


MALAR MOUNDS AND FESTOONS



Some people tend to swell at the junction where the thin skin of the lower eyelids meets the thick skin of the cheek. This is called a malar mound. You can envision this tissue as a sponge that loves to soak up and hang on to fluid. When the fluid becomes chronic and migrates superficially, it can cause the skin to sag, creating a festoon. Rarely, in fair skin individuals who can accept a thin scar, low-hanging festoons can be directly excised. But in most patients, malar fluid is not treated surgically. This is a notoriously difficult problem to solve. Physicians have tried myriad methods to treat this area, including injectable chemicals, deep fillers to squeeze the tissue from behind, and electrocautery needles, all with limited success. Over the past several years, I and other oculoplastic surgeon colleagues have found significant success using deep, high-energy, radiofrequency microneedling to dry this spongy tissue and intentionally create adhesions to scar the spongy spaces closed.


POORLY DONE FILLER/FAT TRANSFER



As I’ve alluded to, lower eyelid blepharoplasty surgery is not the only treatment for “eye bags.” Owing to pharmaceutical company marketing and the general desire for treatments that carry less downtime, volumizing treatments for the tear trough have become more popular. The theory is sound: leave the bag alone but simply camouflage its appearance by filling the areas around the bag! In the right patient, tear trough dermal filler injections give great results. In fact, it is one of my favorite in-office treatments to administer. But you know the saying “too much of a good thing?” Well, with the increasing popularity of tear trough fillers, I’m seeing increasing numbers of patients who are overfilled, or who have nodules/lumps due to grafted fat or the wrong type of filler material injected into this delicate area.


I hope I've been able to show you that lower eyelid rejuvenation is a complex and nuanced topic. The best place to start is with a thorough in-person consultation to understand the patient’s unique anatomy and define the problem(s). Then we discuss the relevant treatment options, considering the patient’s aesthetic goals, budget, and capacity for downtime. I see myself as the patient’s guide – giving an estimate of the degree of improvement that can be achieved with each treatment option, the longevity of the treatment, and the costs associated so that they can make an informed decision. For example, if surgery is the gold standard and gives 95% improvement, perhaps dermal filler will give 60% improvement in a patient with limited cheek bony support. Or, if a patient wants to undergo radiofrequency liposculpting and microneedling treatments for the entire face and neck, they may be a good candidate for radiofrequency liposculpting of the eye bag area as well.


Are you ready to unload your lower eyelid baggage? Please contact my office to schedule a consultation and let’s make a plan to finally drop those eye bags!