Under eye bag on one side when smiling. Should I have lower blepharoplasty?

Question

I have a more pronounced under eye bag under one eye. The appearance doesn’t bother me when I’m not smiling. But when I smile, the bag is much more pronounced on one side only. I’m 42 and it’s been like this for about 4 years. I tried fillers about a year ago and it did make the bag blend in when static (not smiling) but it still created an under eye roll when smiling. The asymmetry bothers me most. Should I get the a lower blepharoplasty for just the one eye?

Kenneth D. Steinsapir, MD · Answer

Unfortunately, if you offer yourself up for surgery, that is likely what you are going to get whether you need it or not. First your bag does not look like a fat bag. I could be the contour of your orbital rim plus herniated fat or something else. What could be that something else be. you ask? It could be your old hyaluronic acid filler. That stuff does not just go away. No it sits there and over time can hold a disproportionate amount of tissue water. Yes, your old filler could be responsible for this fullness. Since injecting this with enzyme is easier than having surgery, that is what I would do first.

Joseph Walrath, MD · Answer

Hi there!
I don't think there needs to be any overthinking on this.  There is a touch of extra fat in the lright ower lid medially.  This can be removed in 15 minutes with an office procedure.  I don't think you should waste time with filler if you are happy with the left side and want the right side to look like the left.  There is no incision externally.  It is quite possible in this configuration that you would experience mild swelling for a week or so afterwards.
Best,
JDW

Russell Bramhall, MBChB, FRCS(plast) · Answer

Hello,
Thank you for your question.  Since these lines are only present when you are smiling and exercising the facial muscles around your eyes it would be straight forward to improve this with injections of something like botox or dysport which reduce the movement.  Be careful to chose someone you trust and don't over do it.  The whole expressionless face that doesn't move at all is very much out of vogue so pick someone who understands your needs and will give you something natural.  You want to achieve something that looks good and treats your symptoms without it being obvious that you've had anything done.  People should be exclaiming how great you look afterwards without being able to put their finger on why!  
Good luck with it all anyway and definitely don't have a lower blepharoplasty just yet.

Jonathan Kulbersh, MD · Answer

Hello and thanks for the question. The wrinkle you are describing is a dynamic wrinkle - since it only appears when you smile. This means the muscles used to create your smile are also creating the wrinkle. Dynamic wrinkles are usually addressed most effectively using a neuromodulator like Botox or Dysport. The neurotoxin relaxes the facial muscle, smoothing away the line in the process. These injections take just a few minutes to complete and do not require any downtime afterward. Results typically last about three or four months before another session is needed. Make sure you work with a board-certified plastic surgeon who is also an expert Botox injector for best results.

Mehryar (Ray) Taban, MD, FACS · Answer

Lower blepharoplasty can be considered which is best done using transconjunctival technique with repositioning of the eye fat bags to surrounding hollow area. See an expert oculoplastic surgeon.

Toby Mayer, MD · Answer

Eyelid bag asymmetry-blepharoplasty for both eyelids or one? This is decided after an examination.

Malena Amato, MD, FACS · Answer

Dynamic wrinkles or those that occur when smiling may be better treated with Botox which will relax the muscle and possible filler. I recommend trying minimally invasive techniques before considering surgery. I recommend an evaluation by an oculoplastic specialist,  hope this helps.

Dan Landmann, MD · Answer

Thank you for your question and photos. As other doctors have mentioned, an in person exam would be necessary to determine whether the filler previously injected to the lower lid could be causing part of the problem. If so, depending on what type of filler, it could be dissolved with a series of injections. Then, different treatments could address different issues. I recommend lower eyelid blepharoplasty for patients who are bothered by under eye bags. If the issue is only when smiling, I consider botox, which relaxes the muscle that squeezes around your eye and causes a roll in some people- this can be injected in different amounts to each eye to address asymmetry. I would recommend seeing an oculoplastic surgeon who specializes in cosmetic eyelid surgery. Hope this helps!

Dan Landmann, MD, MSEE

Dan Landmann, MD, MSEE

Holly Chang, MD, FACS · Answer

I agree with some of the other doctors that an examination is needed to see whether the filler contributes to the contour irregularities.  But since you also have more "crows feet" lines on the R side when you smile, I do think that at least a part of the issue is due to dynamic muscle movements.  The most definitive treatment would be dissolution of the filler material followed by transconjunctival lower eyelid fat transposition blepharoplasty.  You will likely still want to have neurotoxin injections after surgery to enhance the symmetry with smile.  But if you're seeking partial improvement, non-surgical treatments alone may be sufficient to give you what you're looking for.

John A. Standefer Jr., MD, FACS · Answer

Hello and thanks for the question! The puffiness that your are concerned with is a fat pad. We all have them and they are supposed to be there. They are supposed to be behind a membrane called the orbital septum. The septum weakens with time and allows the fat pad to pouch out. The resulting puffiness causes us to look more tired and older than we are. Removing the fat pad will give you a less tired, more youthful appearance. One side can be done without the other if indicated but the cause of the difference should be evaluated. The puffiness is always worse it there is any nasal congestion from a cold, allergy attack, or sinusitis. The nose is also more congested on the side that we sleep on which can make one eye more puffy than the other. The puffiness can also be worse when our rings are tight or when we have more salt in our diet but that is usually bilateral. The fat pad can easily be removed via a transconjunctival blepharoplasty. The fat may be better utilized by transposing it under the "tear trough" to improve any trace of a dark circle. Fillers can often camouflage the puffiness, but removing the fat pad is much more definitive. My Best!John Standefer MD

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