Fat Pocket Above Cheeks? Lower Eyelid Problem? (photo)

Thank you for your question. I believe you will get the most improvement with a combination of fillers, lasers and microneedling/PRP. If this approach does not work then you will need to have alower lid blepharoplasty. I recommend having a consultation with an expert to discuss your concerns and to determine the best treatment plan for you. Best of Luck!

 

Puffiness under the eyes can be caused by many things (multifactorial).  I agree with you - it looks like your area of concern is malar edema/festoons (swelling) rather than classic lower eyelid fat pads/bags. 
Malar edema can be caused by a number of issues including genetics, aging, fluid retention, salt retention, lifestyle, alcohol, allergies, sleep, and unknown reasons.  Without a doubt, malar edema is a difficult problem.  Traditional lower eyelid lifts (blepharoplasty) do not fully correct malar edema and can make it worse.  Injections with kenalog (steroid) or 5-FU and taping may help but I have not seen them completely treat this area.  Fillers can sometimes blend and camouflage the area but this treatment is variable.  Direct excision of the festoon is the best definitive treatment but you are trading the puffiness for a scar.  Usually that is reserved for more prominent festoons.  The scar can be camouflaged, thin, and the pinkness will fade.  You have to consider how much the area bothers you and discuss this with your surgeon.    
I would consider a consultation with your primary care doctor to evaluate any underlying conditions that can cause salt retention or fluid retention.  If you have bad allergies, you may be a candidate for allergy treatments beyond an antihistamine.  I also recommend a consultation with a qualified surgeon for an exam to discuss your options.