Swelling Below Lower Eyelids? (photo)

You have what we call lower eyelid fat prolapse
that has nothing to do with body fat but rather it’s the fat that’s
anatomically surrounding your eyes. There are two types of fat around the eye: intraconal fat that's directly behind the eye
and extraconal fat that surrounds the eye. These fat pockets prolapse and push
forward and is called herniated fat. Typically with patients like you, we would
do a procedure called a transconjunctival blepharoplasty where we remove excess
fat that has pushed forward from the inside of the eyelid. Some of that fat is
also repositioned to strategically address the contour of the lower eyelid.When you come into my office, I first
understand the support system of your lower eyelid. One of the key elements of
lower eyelid surgery, especially when someone gets older, is the loosening or
the laxity of tissue around the eye. It’s not just about relative excess skin
but there’s a critical anatomical structure called the lateral canthal tendon.
The lateral canthal tendon is what anchors the outer corner of the lower
eyelid. When you have any surgery under the eyes, there’s a risk that this
tendon might be affected and pulls the eyelid down called lower eyelid
retraction or lower eyelid ectropion. My evaluation would involve determining
whether or not you require any type of support procedure of the lower eyelid
such as a lateral tarsal strip or lateral canthoplasty.I would also assess the relative amount of
excess skin. When under the eyes has a
lot of wrinkles, it’s not because of excess skin but because of skin quality.
To enhance skin quality, we would do fractional CO2 laser to tighten skin and
stimulate collagen using thermal energy. It also resurfaces some of the skin to
restore fresh new skin to the eyelid. If there’s extra skin, we would do a skin
pinch excision done by excising a very thin amount of skin underneath the
eyelashes. This way, I preserve the integrity of the orbicularis oculi muscle
which is very important to support the lower eyelid. Lastly, if the lower
eyelid is still loose, I reinforce it by doing lateral tarsal strip. It is important that you understand that there
are multiple aspects to rejuvenate or enhance the appearance of the lower
eyelids. I suggest that you seek an experienced cosmetic surgeon who performs a
lot of eyelid surgery is familiar with the concepts of eyelid support. The
surgeon should also be able to do many different techniques to customize a
procedure according to what the patient needs.

The swelling present on the lower lids represent herniation of fat in 3 compartments on each lower lid. To correct this a trans-conjunctival approach is used to remove fat herniation from inside the eyelid. Excess skin is then removed from an incision located directly below the eyelashes. This incision was closed with tissue glue. For examples please see link below

The bulging or "sacks" under your eyes are due to fat that is bulging forward. This fat is a part of the normal fat that surrounds, cushions and protects the eyeball itself.  As we age, two things occur that make this bulge appear to be worsening. 1) The thin barrier of tissue (called the orbital septum) that keeps this fat from pushing forward weakens as we age, allowing the fat to be pulled (by gravity) forward. 2) The tissues just below this bulge are also being pulled downward by gravity, leaving a depression where it used to be. This depression creates a greater contrast with the bulge above it and makes it look even worse.

Filling in the depression with either filler (like Restylane or Juvederm) or injected fat or by transposing some of the excess fat that is pushing forward will make this look much better. Transposing the fat with a surgical procedure gives the longest-term results. Most people with the problem also have the lower eyelid skin tightened at the same time. However, I wouldn't tighten the skin unless you take away some of the loose upper eyelid skin at the same time.  Tightening both at the same time gives a more balanced rejuvenation effect.