Lower Blepharoplasty for Bags from Muscle?

I am scheduled for an upper and lower eyelid lift for bags under my eyes. The bags are not fat. My doctor says it is muscle, and although he cannot remove the bag, he can make it less noticeable by removing skin. Does this sound accurate?

Doctor Answers 16

Lower Blepharoplasty not recommended for you

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I don't recommend a lower blepharoplasty in your case. You have a negative vector, which means that your lower orbital rim and cheek are posterior to your lower eyelid. A standard lower blepharoplasty would create a greater depression below the eye and might even cause your lower eyelid to retract.

I recommend adding volume to your lower tear trough and eyelid/cheek junction. Your surgeon can use a hyaluronic acid filler or micro fat grafting. I would also suggest that you consider Botox to adjust your eyebrow height rather than an "upper eyelid lift".

I would recommend that you have a second consultation with a Board Certified Plastic Surgeon who is knowledgable with these types of tear trough corrections.

Newport Beach Plastic Surgeon
4.9 out of 5 stars 50 reviews

Lower blepharoplasty may be an option

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Hi Daisy,

From the single profile view you have forwarded with you question, it is difficult to fully answer your question.

However, what are you looking to accomplish with eyelid surgery? Do you have a clear understanding of what your doctor is looking to accomplish ( i.e are the two of you on the same wavelength?)?

You have a slightly heavy upper eyelid fold. How much of your upper eyelid fold does your doctor plan on leaving? You definitely what to preserve the upper eyelid fold. It actually looks like you don't need upper eyelid surgery at all, just a conservatively done endoscopic forehead lift.

It is true that removing lower eyelid skin can smooth the lower eyelid skin. However, you have very poor support for your lower eyelid. So a lower eyelid surgery that removed skin may leave your lower eyelid pulled down after surgery. You are very youthful, and I might recommend filling the lower eyelid with filler only rather than recommending surgery.

You obviously are not fully comfortable with your surgeon given the fact that you are posting on this site. I would encourage you to get some second opinions before having surgery. Consider seeing an ASOPRS fellowship trained eye plastic surgeon. Good luck and feel free to re-contact the Realself community.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Midface dermal fillers would help you considerably

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Looking at your picture, I think you could benefit from midface injections of fat or dermal fillers. These injections can also help smooth out the cheek-lid junction and improve your lower lids problems. This is just a thought and may be less drastic that the other procedures you are considering.

Surgery may not always be the answer for eye area rejuvenation

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There are both surgical and non-surgical options to rejuvenate the area around the eyes. Non-surgical treatments such as Botox Cosmetic, Restylane, and Juvederm can help in the early stages of the aging process. Although these treatments are not permanent, Crow’s feet, Furrows and Dark circles can be softened and often eliminated with these treatments.

The eye is surrounded in the orbit by fat. The fat surrounding the eyeball is a very low density fat, unlike the fat in the rest of the body. The eye floats on this fat like a ping-pong ball in water inside the orbit. A membrane under the eyelid holds that fat in position. As we age, that membrane weakens and the fat behind it bulges forward. This bulging of the fat, especially noted in the lower eyelids, gives one a tired, droopy appearance. Eyelid surgery attempts to correct this problem by sometimes removing the excess skin, tightening the muscles and the removal or repositioning of this fat.

Another critical portion of the aging process involves the cheek pad (midface). As the cheek pad falls, the lower eyelid droops and the nasolabial folds appear deeper. Removal and/or repositioning of the cheekpad fat may improve the appearance of the eyelids as well.

A consultation with a board-certified plastic surgeon will determine the procedures best suited to achieve your desired results. If you are hesitating, seek a second opinion about what should be done to feel more comfortable about your surgical decision.

Lawrence Scott Ennis, MD, FACS
Pensacola Plastic Surgeon
5.0 out of 5 stars 162 reviews

Does not look like you need any surgery

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Judging by your picture, which might not be ideal, it does not look like you need any surgery on your eyelids, upper or lower. Removing the skin can create problems that you don't have now, and your upper lids look fine on this picture. Sometimes, a little drop of Botox can make the muscle ridge less prominent on lower lids, and it might be all you need.

Stella Desyatnikova, MD
Seattle Facial Plastic Surgeon

Lower eyelid lift for muscle

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To start, it would be helpful to see a picture from the front as well a picture with you smiling.

If when you smile there is a roll under your lashes, this would be consistent with an overactive muscle which can be addressed by thinning out the muscle at the time of surgery.  From the side view, it also appears you have a hollow just below your lid which is referred to as a tear trough deficiency.  This may be improved upon by either an injection of a filler or taking some fat from the lower lid and transposing it into the hollow.  I would discuss this further with your physician so that you have a complete understanding of the goals and realistic expectations of the results.

Roger J. Friedman, MD
Bethesda Plastic Surgeon

A lower eyelid blepharoplasty is not done for muscle

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A lower eyelid blepharoplasty is not done for muscle. Normal lower blepharoplasty is performed primarily for removal of fat bags in the lower lids and a very minimal pinch of excess skin on the lower lids, if necessary. No muscle is removed from the lower lids. If that is done, the lower lid can retract and give a more hound dog look.

William Portuese, MD
Seattle Facial Plastic Surgeon
4.8 out of 5 stars 157 reviews

Several options for your under eye bags

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You may need lower blephoplasty and cheek lift with tear trough implant. You have weakness of the cheek bone under the eye, and not enough support for the eye fat pockets. You will benefit from injectable that will last 1-11/2 years. The other option is lomer eyelid with the use of tear trough implant. Please get multiple consultation.

Kamran Khoobehi, MD
New Orleans Plastic Surgeon
4.7 out of 5 stars 152 reviews

Muscle bulge causing eye bags usually requires modification of the muscle during blepharoplasty.

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From the side view photograph you provided you look very young to e considering blepharoplasty.

If you send me a frontal face view photograph which is a close up that includes your eyes, nose and forehead, i can give you a better opinion. Just send as an email attachment to my website listed above.

Lower eyelid blepharoplasty is a serious operation and one which should not be approached lightly. If you have bulging muscle causing the "bag' appearance, then a routine skin blepharoplasty will not help.

One can do a modified blepharoplasty in which some of the excess orbicularis muscle is excised, but this is certainly more complex than a routine blepharoiplasty.

My question is whether you need a lower blepharoplasty at all. Personally I would suggest a second opinion by a board certified platic surgeon. You are very young to have an invasive procedure on your lower eyelids if you really do not need it.

Lower blepharoplasty can weaken the support of your lower eyelid and create a "sad eyed " appearance if the procedure is not done in an expert fashion.

I would get another opinion. As I said, I am happy to review pictures of your eyes taken from the front view and can tell you more based on that.

A transconjunctival blepharoplasty (incison on the inside as opposed to the outside) with an arcus marginalis release and fat grafting can improve dark circles and puffiness of the eyes and does not weaken the lower eyelid. That is the only technique I use on a younger person like you, because I think it is very important to leave your lower eyelid support intact.

I would consider volume enhancement

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Looking at your photo, I would consider fat grafting for volume enhancement of the under-eye hollows. Alternative, injectable fillers represent a viable non-surgical option.

Personally, I am not sure that skin removal will be very effective in improving the "bags". In fact, it is the volume deficiency underneath them that benefits from correction.

Frank P. Fechner, MD
Worcester Facial Plastic Surgeon
4.6 out of 5 stars 48 reviews

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.