What is the cause of the fat pad under my eye, and how can it be treated? (Photo)

Question

Hello Doctors, I have been battling with this bag under my right eye since I was about 21. That's when it started becoming more prominent. I am now 30, and the fat pad seems to have gotten worse. Upon feeling it with my index finger, I do indeed feel little pieces of "fat." They are soft & "squishy" (sorry) to the touch. The left eye has very little fat. What is my best option here? I am so self-conscious about it. People ask me if I'm tired, or if I got into a fight! Please help me. Thanks.

John J. Martin, Jr., MD · Answer

You can have a surgery done to move the fat pad into the tear trough.  This will eliminate the swelling and help to fill in the hollow below the fat.

James R. Gordon, MD, FACS, FAAO · Answer

Thank you for sharing your question and posting your photograph. You have  fat protruding forward in the lower eyelid. This can happen due to genetics or aging. The treatment is Blepharoplasty which is the removal of excess fat and tightening of the skin. This is commonly performed be Oculoplastic Surgeons. Recovery takes about 10-14 days. See an experienced Oculoplastic Surgeon for comprehensive evaluation and discussion of treatment options. Good luck,

Jason Emer, MD · Answer

There are many ways to treat dark circles, as well as under eye wrinkles and bags. It is important to note however, that the majority of times the cause for discoloration is genetic and due to the viability of the blood vessels below the skin. A combination approach is always needed to get the best results in this area and this includes: topical skin care, laser and/or radiofrequency treatments, and fillers if placed appropriately.  All my patients are on topical lightening agents, typically a vitamin C serum product in the AM and a brightening agent and/or a vitamin A based product in the PM. Sun protection is essential.Resurfacing and tightening are essential. My patients get offered a menu of options, for which a combination gives the best results. Light salicylic acid peels help give textural and pigment improvement; nonablative lasers (Fraxel or Clear + Brilliant) can be used to tighten and improve fine lines/wrinkles and crepe skin; fractional radiofrequency devices (Sublative, Viva) are cutting edge and improve texture, tone, and wrinkles with very little downtime; radiofrequency with pulsed electromagnetic fields (Venus) are amazing for puffiness and bags, in patients who do not want eyelid surgery; appropriately placed fillers can replace lost volume, cover up the vessels and fat pads below improving the appearance -- patients should pick a well experienced practitioner to prevent complications such as Tyndall (blue discoloration) and irregularities, one that uses a cannula for injection will help give results with little bruising or swelling; microsecond Nd:YAG laser treatments (Laser genesis) has produced dramatic improvement in discoloration in some of my patients and is safe in dark skin types, similar to the radiofrequency devices. For lifting, ablative laser resurfacing such as co2 laser combined with monopoloar radiofrequency deep heating (thermage) give amazing results. The key is for a patient to see a cosmetic dermatologist with experience in all the latest devices and techniques so the persons goals can be met by a combination approach of individualized treatments and skin care. In some cases, those who smile and have crepe skin or under eye wrinkles, a small amount of neurotoxin (botox, dysport, xeomin) strategically placed in the lower eyelid skin can improve wrinkles dramatically and give the eye a more "open" appearance.

Kenneth D. Steinsapir, MD · Answer

The best approach for many is to do this surgery from behind the eyelid.  This avoids a skin incision.  The fat sitting in the lower eyelid is advanced into the top of the cheek.  This reduced the volume in the lower eyelid and improves the hollow at the top of the cheek.  Surgery is very comfortable and is generally performed under light iv sedation on an outpatient basis.  There is no substitute for a personal consultation.

Anand G. Shah, MD · Answer

Hi there.  Please understand that the definitive answer rests with an in-person evaluation.  Over time, the fat pads in the lower eyelid do tend to prolapse forward.  Medically, this is known as fat pseudoherniation.One option to address this is lower lid blepharoplasty.  The trans-conjunctival approach to cosmetic lower eyelid blepharoplasty is very favorable. Instead of approaching the fat pads from the outside (trans-cutaneous blepharoplasty) the dissection is actually performed from behind, within the eyelid. The trans-conjunctival blepharoplasty is usually combined with an external skin pinch, to remove the redundant skin, once the fat pads are removed and deflated.Lower lid Blepharoplasty may be performed with a combination of local anesthesia as well as light IV sedation anesthesia. General anesthesia is not necessary, although patient preference should always be taken into consideration.Hope this at least provides useful information.  Good luck and best wishes.  Dr. Shah

Karol A. Gutowski, MD, FACS · Answer

A lower eye blepharoplasty with fat repositioning would give a long-term solution. Injections may give a short term solution (see case # 398 in the link below)

Geoffrey Kwitko, MD, FACS · Answer

The fat pad is due to orbital fat coming forward. The assumetry is striking. The right eye looks abut bigger as well.  Any history of thyroid disease ??  I would get a ct scan to evaluate the orbit.  The fat can be removed through a trans conjunctival approach.

Gerald Wittenberg, MSc, DMD (retired) · Answer

The 'eyebag' is actually a combination of the accentuation of the 'groove' under the eyelid and a fullness of the eyelid. This usually occurs when the cheek pad 'falls' which exposes the rim of the eye 'socket'. If you feel the 'groove', you will feel the 'rim'. Accentuating this factor is the fatty tissue in the lower eyelid. The most ideal and complete rejuvenating approach is to both lift the cheekpad and contour the fat tissue carefully. If you only remove fat tissue the eye appears more 'hollow'. This is particularly true when you have prominent eyes/eyeballs. The key to aging is to maintain natural fullness; and not reduce it. Tissue fillers can 'fill the  groove up' temporarily and can be a short term solution as well.

Amiya Prasad, MD - Account Suspended · Answer

I’m a cosmetic oculofacial plastic surgeon, board-certified by the
American Board of Cosmetic Surgery. I’ve been practicing in Manhattan and Long
Island for the past 20 years and under eye bags is one of the most common
issues we treat in our practice.

Your eye bags are caused by lower eyelid fat prolapse. This means that
the fat that is normally around your eyes pushed forward and creates a hernia.
Once the fat pockets have pushed out, it pushes out even further as time goes
on. There are numerous factors that can contribute to it getting worse but the
fact that you have a significant asymmetry clearly draws a lot of attention and
people asking you if you are tired.

When you look for solutions for under eye bags, it’s likely that you’ve
already tried the topical creams and moisturizers that are typically sold and
of course, those don’t work. When you’re dealing with a physical volume of fat,
nothing topical will make a difference. There are also options using various
types of hyaluronic acid fillers to camouflage the fat. This is unfortunately not
likely a benefit for you. In the absence of a physical exam, it seems pretty
obvious from your photo that the bag is too prolapsed out to hide it or
camouflage with a hyaluronic acid filler.

In our practice, for someone who’s young, we typically address this
problem through a procedure called a lower eyelid transconjunctival
blepharoplasty. The reason why I use the term transconjunctival has to do with
the approach. There are two ways to address fat pockets: from the outside
called transcutaneous approach, and from the inside called the
transconjunctival approach. For younger people, usually there is no issue with
extra skin and therefore there is no reason from my perspective to go and make
an incision on the outside. What we do is we address the fat pockets from the inside
of the eyelids so there is no external scar.

We also perform these procedures in our office facilities under local
anesthesia with LITE&trade; sedation so you avoid general anesthesia. A lot of
surgeons prefer general anesthesia. I have been doing this procedure for over
20 years and I have a lot of experience with it. I find that the experience of
the patient is better when they avoid general anesthesia, and are able to
recover a lot faster without the side effects of the medications. By avoiding
all the stress of general anesthesia by using local anesthesia with sedation, most
of our patients go back to work in less than a week.

I recommend that you meet with qualified, experienced cosmetic surgeons
and learn about the options. Get to know your doctor and get a sense of what
that doctor’s aesthetic and style are. Get a sense of what you can anticipate
your final appearance will be. What I explain to my patients is that when you
have this procedure done, because you had puffiness for so long, it’s hard to
imagine yourself without the puffiness and there’s a common concern of being
over hollow. Our goal is to achieve a look as if you never had the bags. This
means that the skin will naturally follow the contours as if there was no fat
prolapse there. I hope that was helpful, I wish you the best of luck, and thank
you for your question.

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