Help Deciding What to Do About Under Eye Aging...are They Bags or Sunken Eyes??

I'm 31 years old. I have noticed under eye circles and puffiness. It's worse in the morning and gets somewhat better by the evening. I have tried various creams seeing minimal results. When I smile and with a lot of concealer they are not as noticable. I went to a board certified plastic surgeon yesterday and he said they are not bags, but, are hollow eyes. He suggested sculptra. I am nervous about sculptra after reading many neg reviews. Are they hollows or bags? What is safest fix?

Doctor Answers 10

Don't have fat or sculptra for these areas.

Visible product in the under eye area are among the most common reasons people see me in consultation.  Fat grafters mean well.  Perhaps they actually have a few patients who did perfect with fat grafting.  However, I see so many individuals with bad fat grafting results, that I can't recommend the procedure.  The reality is that the lower eyelid hollow area that needs filling is too thin and does not hide things that get lumpy very well.  This is also true for Sculptra.  In fact, this is a direct quote from the package insert for Sculptra: 

• SCULPTRA Aesthetic injection in the peri-orbital area has not been studied. An increased risk of papules and nodules has been reported in published literature after injections in the periorbital area.

So the FDA advises against treating this area with Sculptra and so do I.  So what is good for this area.  The answer is the hyaluronic acid fillers.  In particular Restylane seems to be the best product for this area.  It is forgiving and can be adjusted after the fact if necessary.  Yet it tends to stay where it is placed.  The service can last a year or more.  The key is to find a highly experienced injector to provide this service.  This is not a treatment that the doctor should turn over to a nurse.  This is facial sculpting and requires a detailed knowledge of facial anatomy to get the best possible results.

Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

31 Year Old with Bags Under Her Eyes

I feel you have a anatomical issue.  The structures below your eyes slightly protrude causing a sunken look at the junction of your lower lid and cheek.  Less agressive ways to handle this would be:

  • avoid excessive massage
  • avoid excessive use of moisturizers and when using them refrigerate them prior to usage
  • try a Tripeptide Based Serum for your lower lid

I would personally not recommend Sculptra but I would use Restylane placed precisely at the lower border of your eye bag (lower fat pad). This would form a more subtle transition from your lower lid to your cheek and give a smoother appearance. Under no circumstance would I recommend a lower eyelid lift at your age.   


Joseph Rucker, MD, FACS
Eau Claire Plastic Surgeon
4.7 out of 5 stars 20 reviews

Eye hollows

Please be careful with Sculptra as it can lead to permanent problems.  The areas around the eyes are not meant for use with this product and if complications occur they are hard to deal with.  I see this often in my practice and do not have a lot to offer in terms of resolving the problem.  Fat injections can work but you have a higher incidence irregularities than with reversible Hyaluronic acid fillers - the best option.

Please be weary of Sculptra in this area.


Dr. Massry

Guy Massry, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 47 reviews

May need some fat removal from the "bags"

Sounds like you have lower eyelid bags with a hollow area below the bags known as a "tear trough." You may need some fat removed from the "bags" and at the same time, some placed in the hollow areas.

Robert E. Zaworski, MD
Atlanta Plastic Surgeon
4.9 out of 5 stars 60 reviews

Hard to say in photo

hard to say in photo but whether its a transconjuctival fat removal for bulging fat or a tear trough requiring filler, sculptra under the eye is not ideal and agree with restylane. having said that sculptra in the upper cheek will definitely be a good choice to increase the volume and make the lid/cheek junction improve.

Rafael C. Cabrera, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 1 review

Fat bags of the lower eyelids

 Yes, from your photos you do have fat bags in the central and medial fat pockets of the lower eyelids.  These are in the early stages and are not severe but are noticable.  A Transconjunctival lower Blepharoplasty (eyelid surgery) would remove these fat bags in about 30 minutes using an incision on the inside of the lower eyelid.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.6 out of 5 stars 24 reviews

Treatment of tear troughs

Your posted photos indicate they are both. There is some protrusion of the fat pad in the lower lid near the nose on each side. There is also hollowing if the middle and outer thirds of the lower lids, seen best in the last 2 photos. I think most would agree that the current best treatment is a filler. Most doctors would agree sculptra is not the injectable of choice for this area and prefer a hyaluronate here.

My response to your question/post does not represent formal medical advice or constitute a doctor patient relationship. You need to consult with i.e. personally see a board certified plastic surgeon in order to receive a formal evaluation and develop a doctor patient relationship.

Aaron Stone, MD
Los Angeles Plastic Surgeon
5.0 out of 5 stars 1 review

Lower lid bags

Fillers are probably the way to go. I would suggest something more forgiving than sculptra or fat. Restylane would likely be a good choice for this area. The hyaluronic acid fillers (like Restylane and Juvederm) are to some extent reversible if you find you don't like the effects.

Hugh McLean, MD
Mississauga Plastic Surgeon
3.8 out of 5 stars 7 reviews

Based on your photos, you appear to be a good candidate for a lower eyelid Injectable Filler treatment.

I read your concern and reviewed your photos. Your eyelid skin is the thinnest and most delicate, so it's typical to see more lower eyelid puffiness in the morning after being horizontal. During waking hours, gravity will pull the excessive puffiness out of your eyelids, so they will look best at the end of the day. If you have significant fluctuation in the appearance of your eyelids, you may want to bring this to the attention of your PCP to make sure you're not retaining too much fluid.

Your photos demonstrate fairly common lower eyelid grooves, just beneath the puffiness. In many patients, an Injectable Filler treatment may effectively fill the grooves and lead to a smoother, more youthful lower eyelid appearance. My personal preference is to use Silikon-1000, an off-label filler, for permanent results.

I hope this is helpful for you.

Regards from NJ.

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 418 reviews

Aging lower eyes: fat loss vs bags

Given your age (31), it is likely you had this appearance most of your life.  To me, it looks like your under eyes are hollow as a result of having insufficient fat along your lower eyelid and upper cheek.  This is a very common problem we see and in our practice fat transfer is what we use to treat it. The reason is, fat belongs in that area and when it is not there in sufficient quantities, the eyes look drawn and tired. In many cases, the volume loss gives the impression that  you may actually have a bags.  If you remove the bag (blepharoplasty) your eyes will look worse.  I personally don't like to inject sculptra too close to the eyes due to the risk of nodule and papules.  Although, I like it elsewhere.

  However, keep in mind fat transfer around the eyes can be very tricky, so do your homework and seek a surgeon who does this routinely and gets excellent and consistent results.  The results are expected to be essentially permanent. 

You can see many before and afters on our site to understand the difference between adding volume versus removal of fat (blepharoplasty) in cases like yours. 

Good luck. 

Dr. Karam

Amir M. Karam, MD
San Diego Facial Plastic Surgeon
4.6 out of 5 stars 114 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.