Age 32, what procedure would correct the puffiness and shadows under my eyes? (Photo)

Thank you for reaching out with your concerns. From your description and the photo, it seems that you are dealing with both pseudoherniated fat pads and malar edema, which can contribute to the puffiness and shadows under your eyes. To address these issues comprehensively, a combination of treatments may be considered.
For the pseudoherniated fat pads, a surgical procedure known as lower blepharoplasty could be effective. This procedure involves repositioning or removing the excess fat causing the puffiness, and adjusting any excess skin. However, addressing malar edema requires a different approach. Laser treatments can indeed help improve edema by promoting lymphatic drainage and reducing inflammation. Antihistamines can be beneficial since the edema is histamine-mediated, not necessarily due to allergies. If you have had filler in the past to this area, dissolving the filler may help (and then undergo fat grafting to restore volume if desired).
Considering your desire to avoid prolonged treatments, a surgical approach might offer more immediate and lasting results for the fat pad issue. However, for the malar edema, a combination of laser treatments, antihistamines, and possibly hyaluronidase injections (such as Hylenex) could be explored to help manage the edema. It's important to consult with a skilled facial plastic surgeon who can tailor a treatment plan to address both concerns effectively while taking your preferences into account.

Additionally, sometimes the dissolving enzyme is not helpful for undoing the effects of temporary gel fillers. Please consider Consulting with another reputable specialist so you can get a second opinion. I hope this helps. Sincerely, Dr Joseph

Thank you for reaching out and sharing your concerns. Based on your description, it sounds like this is primarily a genetic issue, rather than one caused by fillers or skin laxity. Even at a young age, the three fat pockets in the lower eyelid can protrude through the orbicularis muscle, creating persistent puffiness and shadows under the eyes.
The most effective solution in your case would be a lower blepharoplasty, specifically a transconjunctival approach. This technique allows us to remove or reposition the fat pockets without any external incisions, preserving the natural structure of your eyelids. Since you don’t appear to have excess skin, this would be an ideal option to correct the issue while maintaining a youthful, natural look.