Under Eye Bags: What are my options?


Under eye bags can be a problem at any age, even starting in the teens for some people. Lower Eyelid treatment varies depending on the different components that are present.

There are 6 common findings when talking about lower eyelid cosmetic options.
1. Most commonly, bags refer to bulging or puffiness immediately under the lower eyelashes. This is usually orbital fat that has nothing to do with weight gain or weight loss but exists to cushion the eyeball. It is held back by a membrane but as we age, or because of genetics, the membrane can weaken and the fat starts to push forward. If that’s all that is present, an incision can be made on the inside of the lower eyelid and the fat can be removed. This is called a transconjunctival blepharoplasty and takes 30 minutes to perform. Alternatively, using a filler such as Belotero around the bag can camouflage it’s appearance and also works very well. Neotensil, a topical application, also works well in young individuals with little to no extra skin but with lower eyelid bags. The medication is applied to the lower eyelid and it tightens the lid and ‘pushes’ the bag inward and lasts for a day; a great option before a big event.

Rarely, younger individuals, even in their teens, may notice bunching of the skin under the eyelid that they consider bags but it primarily is noted upon smiling.  This is the orbicularis muscle which is the eyelid muscle.  In some individuals, the muscle forms a roll under the eyelid and it can be prominent.  Treatment of the roll with a small amount of Botox, Dysport, or Xeomin can minimize the roll prominence.

2. Item #1 is usually associated with a shadow or hollowing just below the bag. The shadowing or hollowing below the ‘bag’ occurs because of a different type of fat pad. There is fat on the bone below the ‘bag’ and that recedes as we age. The shadow occurs because you have some fat receding and the fat cushioning the eyeball starts to move forward which creates a shadow below it. Some people refer to this shadowing as their hollow, dark circle, or tear trough. Again, this hollowing can be filled to decrease the fat lost in this area. This can be performed with fillers such as Belotero, Perlane, or Voluma, fat injection, or using a tear trough implant. It can also be filled by reusing some of the fat that is removed from the ‘bags’ at the time of a lower eyelid blepharoplasty, and placed into the tear trough region as a fat transplant or transposition.

3. Some individuals, usually over the age of 40, have excess skin from losing elasticity over the lower lid. You can gauge how much extra skin you have by pinching the skin on the outside of the eyelid after opening you mouth as wide as you can without pulling the eyelid margin away from the colored part of the eye. If you still have extra skin after the maneuver above, then extra skin can be removed or resurfaced with a laser or peel depending on how much extra skin there is as part of your lower eyelid lift, or blepharoplasty.

4. Many individuals have overlying skin color changes which may include brown spots, generalizd redness, or blue-tinged puffiness near the inside of the lower eyelid. The redness or blue-tinged puffiness can be related to inflammation from rosacea or from fluid accumulation and extra veins or vessels in the area. This is difficult to treat and is not considered an indication for surgery. Lasers or light treatments along with topical creams and makeup make this a better treatment option. Brown spots, on the other hand, can be easily treated with peels or lasers and can be performed at the same time as surgery.

5. Individuals over the age of 40 sometimes demonstrate lower lid laxity. This refers to having some ‘white’ showing between the colored part of the eye and the eyelid and/or a mild ‘bowing down’ of the outside of the lower eyelid margin. These individuals are at risk of having the lower eyelid ‘drop’ lower after surgery if it isn’t tightened at the time of surgery. Some individuals have a prominent eyeball or globe, and these individuals are also at risk for a lower eyelid ‘drop’; this is a specialized situation and these individuals need a different type of eyelid tightening that can also be performed with their blepharoplasty.

6. Lastly, many individuals have a malar mound. This is an area of puffiness that sits over the cheekbone, close to the lower eyelid and acts like a sponge. This area can change with electrolyte and fluid changes in the body. This is not something that can usually be treated with surgery. Many women complain of swelling that they see in the morning or after a night of drinking or salty food or with allergies, that comes and goes; this swelling is associated with the malar mound. This area is difficult to treat though we have had some success using ‘volumizing’ fillers deep under the mound to ‘squeeze’ some of the fluid out of the mound itself to flatten in. Also, using the same fillers, lifting the entire eyelid complex over the cheekbone also seems to smooth out this area. In some individuals, tightening the lower eyelid muscle at time of surgery seems to diminish the appearance though this doesn’t help everyone.

The lower eyelid area is a complex structure and seeing a facial specialist versed in different issues of the lower eyelid and experienced in complex reconstructive and cosmetic eyelid surgery is of paramount importance to get a natural contour and balanced result.
Article by
Atlanta Facial Plastic Surgeon