I am turning 50 next month and want to have an undereye procedure to remove the bags under my eyes. I've seen two plastic surgeons. One suggested laser blepharoplasty and the other an under eye incision. I'm confused now. Is laser blepharoplasty better than undereye surgery? I would appreciate any suggestions or clarification regarding these two procedures.
Traditional Blepharoplasty Vs Laser Blepharoplasty for Eye Bags?
Doctor Answers (39)
Happy Birthday! There are many ways to treat undereye bags
Hello, you look great. The best "plastic surgery" is smiling, and your smile makes you look very young.
Now as far as your under eye area - it is difficult to advise you based on this picture alone. If you have minimal fat under your eyes then a fractionated carbon dioxide laser such as Fraxel re:pair gives great results alone. If you have excessive skin, then it can be combined with a skin "pinch" excision. If you have a lot of fat protrusion then a transconjunctival approach (from inside your lower eyelid) incision is best to remove or in some cases reposition the fat. If there is hollowness under the eye that is creating the "bag", then carefully placed filler such as Restylane (temporary), or your own fat (permanent) can smooth out the bag and give you a youthful lower eyelid and cheek.
"Laser" blepharoplasty can mean different things. When used as a cutting tool, laser blepharoplasty is not much different from "scalpel" blepharoplasty, other than using the laser as a scalpel. The laser can be used to make the transconjunctival incision or to make the lower eyelid incision. With the laser incisions there is initially less swelling and bruising, but by the second to third day, the healing, swelling and bruising is the same as scalpel incisions.
Again, with the old traditional CO2 lasers and the new Fractionated CO2 lasers, laser resurfacing of the crepe skin of the lower eyelid gives great smoothing of the skin without any incisions in the skin.
I began this answer by trying to make matters less confusing for you, but have likely made you more confused than ever. The most important thing that you can do is choose your surgeon most carefully and be sure that your expectations meet your surgeon’s expectations and ability. Be well and keep showing your beautiful smile.
Surgery for Eye Bags
As with skin removal, I believe that the reduction (NOT total removal) of lower lid fat pads should be conservative. Excessive removal of lower lid fat pads results in a hollowed-out appearance that makes blepharoplasty patients look tired or even ill. I see quite a number of eyelid surgery patients who require structural fat grafting of the lower lids to improve that very problem following an over-aggressive lower blepharoplasty in the past.
In some case lower lid 'bags' can be improved by repairing or reinforcing the soft tissues that normally hold them back. Additionally, excessive lower lid fat can sometimes be mobilized and transposed inferiorly to fill in periorbital hollows or depressions such as the 'tear trough' at the medial junction of the lower lid and cheek.
Some eyelid 'bags' involve redundant muscle tissue which must be removed and/or repositioned, usually in patients who are in their sixties or older. This is performed through an under-eyelid (sub-ciliary) incision which is extended laterally into the 'crow's feet' area.
Structural Fat Grafting of the Lower Lid
As mentioned above, it is very important to preserve (or restore) soft tissue volume in the lower lid. When I review with eyelid surgery patients some photographs from their twenties, in most cases we find that years ago there was no visible demarcation between lid and cheek, but instead a smooth, gently convex curve extending downward from the lower lid margin.
In patients who have developed deep 'tear troughs' at the junction of the lower lid and cheek, adjacent to the side of the nose, the meticulous grafting of fat harvested from the patient's abdomen, hips or thighs can build this area back up and nicely restore a more youthful contour. In some blepharoplasty patients this depression or 'hollow' extends horizontally across the entire junction of the lower lid and cheek, and this must be corrected to obtain the ideal postoperative result.
In select patients, lower lid rejuvenation may consist of conservative reduction (not removal) of the lower lid fat pads or 'bags', in combination with structural fat grafting of the 'tear trough' hollow immediately below. As with all aesthetic surgical procedures, it is absolutely essential to customize the surgical plan to the specific needs of every patient.
Laser blepharoplasty vs transconjunctival vs subciliary vs cheeklift
The laser offers no proven benefits when used as a cutting tool except slower healing.
Of the options for your lower eyelids, if there is just a small amount of puffiness, transconjunctival (from inside the eyelid) reduction in fat combined with a peel of the lower lids or CO2 laser resurfacing conservatively for the entire face to avoid color changes should be considered.
In patients with a great deal of undereye skin, we have found that a limited incision superficial cheeklift, often with LiveFill (non-traumatized fat-fascial graft from the patient's own tissues) graft preserves eye shape much better than a subciliary (below the eye) incision.
Traditional skin-muscle lower eyelid surgeries or skin only lower eyelid surgeries often lead to a rounding of the eye or pulling down in the corners of the eye.
Fat preserving surgeries are now the rule in many practices, and techniques like the arcus marginalis release with fat repositioning are also possible.
Your doctor should be able to discuss the pros and cons of each of these procedures with you.
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Traditional Blepharoplasty Vs Laser Blepharoplasty for Eye Bags?
Good question, and some basic definitions would help here. "Traditional" blepharoplasty probably refers to making an incision just underneath your eyelashes with a knife, taking out the fat pockets, and then removing the excess skin. This method leaves a scar underneath the lower eyelid, and is probably still the most common method of lower eyelid blepharoplasty.
The other method of treating lower eyelid fat is through a transconjunctival incision (making a cut inside your lower eyelid so there's no visible external incision). If you have excess skin after the fat's been addressed then it can either be pinch excised or lasered to smooth it.
Lasers can be used in many forms: to make the incisions, to debulk the fat, and to resurface the wrinkled skin once the fat (or eyelid bags) are removed. The bottom line is you have to know what exactly the surgeon means when he/she says laser blepharoplasty or traditional blepharoplasty.
From your photograph the only thing I can discern is that you have a prominent pretarsal orbicularis (the muscle underneath your eyelid is active and thick), and I can't tell whether you have a lot of puffiness or not. Here's the questions that you have to address regarding your lower eyelids:
1. how much puffiness do you have in your lower eyelids
2. Is the puffiness due to herniated fat? To a prominent muscle? Both?
3. How much extra skin do you have? Does it worsen when you smile?
4. How does your lower eyelid transition into your cheek? Is there a deficiency there? By this I mean do you have a hollowness there or do you have what we call tear troughs?
5. How tight is your lower eyelid? If you pull it down does it snap back into place or do you have to blink a couple of times before it returns to its original position?
The answers to these basic questions are important, because if you think your lower eyelids make you look older, and you don't have much lower eyelid fat or excess skin, then you could get away with using injectable fillers (your own fat, Restylane, Perlane, Juvederm, etc.) to correct the hollow lid-cheek junction and "fill" the tear troughs. In other words, you may not even need surgery!
If the problem is too much lower eyelid fat, then you can have that removed, repositioned, or simply tucked. I definitely wouldn't put an incision in your lower eyelid if you have poor lower lid tone or laxity.
My philosophy with lower eyelids is to laser the loose skin, reposition the fat (if necessary), and shorten the length of the lower eyelid (the distance from the lashes to where the eyelid meets the cheek). The shorter the lower eyelid length, the younger you look.
Hope the prolix answer was helpful.
Ramtin Kassir, MD
"Laser Blepharoplasty" may be a marketing gimmick
There are two things your doctor may have meant when he recommended "laser blepharoplasty."
- He may have been referring to using a fractionated laser, such as Fraxel, that will rejuvenate the skin beneath your eye. This is a very easy and straightforward procedure since it involves no incisions, and your healing time will be very fast.
- Your doctor may have meant using a laser to make the incision for a lower Blepharoplasty. If this is the case it is probably a marketing gimmick as in my experience there is no difference in bruising, blood loss during the procedure, or initial swelling than an incision made with a scalpel producing the same result.
If you have a hammer then all the world is a nail! Those that have a laser to cut through the skin will want to use it at every opportunity. It is a great marketing tool, but no better than doing it traditionally. The laser just cuts through the tissue a little differently. Both can give great results. Go with the doctor that you feel most comfortable with, and that has a good track record.
Laser transconjunctival lower blepharoplasty and laser upper lid surgery has many advantages
I respect the other opinions expressed above. However I have used the laser blepharoplasty exclusively for almost 14 years in over 2400 blepharoplasty cases and have my own opinion about the benefits which were published in my 2000 article in the plastic surgery journal:
Recent studies in Asia have also confirmed the benefits of laser blepharoplasty and in that study concluded that laser blepharoplasty was superior.
The benefits of the laser are two fold. The laser seals the blood vessels as the incision is made, I doubt that anyone would disagree that the bleeding is much less following the laser eyelid incision when compared to a scalpel incision. There just is no comparason, after the laser incision the surgical field is dry. This translates into less bleeding which means a quicker recovery for you the patient.
The second benefit of the laser blepharoiplasty is the ability to tighten and shrink the loose eyelid muscle and septum from beneath the lower eyelid through the transconjunctival (inside the eyelid) laser incision. This has meant that I have not had to make an external eyelid incision or remove lower eyelid skin on any of my 2400 cases during the past 14 years.
The external incision and skin removal weakens the lower eyelid and causes the sad eyed look or hound dog eyes after traditional blepharoplasty. In the before and after picture below of laser blepharoplasty to remove bags under eyes, no external skin incision or skin removal was done:
Finally, if there are skin wrinkles on the lower eyelid, I use a laser to do fractional laser resurfacing of the lower eyelid. This technique removes skin wrinkles and tightens the lid skin. This allows a more thorough rejuvenation of the lower eyelid skin than blepharoplasty alone. In the before and after picture of upper and lower laser blepharoplasty below, the laser was also used to resurface the lower eyelid skin.
Lasers are expensive and surgeons have to learn a new technique which is very different form scalpel blepharoplasty. The procedure requires expertise and know how. Younger residents who I have trained have adapted to the technique. in future years the laser blepharoplasty will become more commonly used.
Studies have shown that on average it takes 17 years for a new surgical procedure to become widely used. Since laser blepharoplasty was only published widely in 2000, it is still a new technique in limited use.
However the benefits are clear and documented.
Laser Blepharoplasty is a Marketing Term
The first thing that should be understood is that the laser and the scalpel are both surgical tools which can be used to perform upper or lower eyelid Blepharoplasty. Does the use of a laser lead to a superior result? No. If anything, the thermal energy associated with the CO2 laser will lead to a greater amount of swelling. What is most important is the Surgeon performing the procedure.
We should consider both of these are surgical procedures
We should consider both of these are surgical procedures. The laser assists when making incisions. Lasers can also improve the eyelid skin by tightening the skin and reducing fine lines. Incisions from laser show no difference than traditional incisions.
Many surgeons favor a posterior transconjunctival approach
I suspect that the different suggestions had to do with where the incision might be placed. The plastic surgeon offering the laser blepharoplasty may have been discussing a transconjunctival approach to the lower eyelid herniated fat. Another approach is a lower eyelid skin crease incision. Much depends, as has been discussed, with what the problem is.
Many now favor a posterior transconjunctival approach which can be accomplished with a CO2 laser, cutting cautery, etc. Fat can then be conservatively excised and/or repositioned over the lower orbital rim to soften the transition between the lower eyelid and cheek. If some skin needs to be removed an anterior "pinch" skin excision can be performed leaving the underlying orbicularis muscle intact and thus reduce the risk for inferior retraction of the lower eyelid, which can be a difficult problem to solve.
Looking at your photo you appear to have some thinning of the overlying lower eyelid skin revealing the underlying contracting orbicularis muscle which causes the wrinkles in this area. I agree with a former comment that this is accentuated by your lovely smile. This can often be improved non-surgically by injecting small amounts of BOTOX into the orbicularis muscle in the lower eyelid...something not previously mentioned.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.