Puffy Bags under eyes only when smiling. Any suggestions? (photos)

Question

I am 36yo. The lines that are formed under my eyes when I smile have progressed downward over time. It looks like I have puffy bags underneath my eyes when I smile only. Will a lower lid blepharoplasty be a good solution for this? Will it affect the way my eyes look when I am not smiling? (both pictured). Would a skin flap lower blepharoplasty or transconjunctival blepharoplasty work better for what I am trying to accomplish?

Larry S. Nichter, MD, MS, FACS · Answer

Although you can camouflage the problem in certain cases with fillers, a blepharoplasty is generally recommended.
Patients who would benefit from a blepharoplasty include those who experience:
	•	Excessive, sagging, or wrinkled upper or lower eyelid skin.
	•	Excess upper eyelid skin that interferes with vision.
	•	Loss of your natural upper eyelid crease
	•	If you have puffy pouches of fat in the upper or lower lids that create a tired or aged appearance.
	•	Orbital Rim Show: visibility of the bone under the eye sometimes contributing to a dark ring or shadowing.
Normally, everyone has a small amount of fat around the eyes. If the quantity of fat increases or the local tissues stretch and weaken, the fat begins to bulge producing “bags.” Occasionally this bulging is seen in young patients and is an inherited family trait, and not a result of aging. These changes have a profound effect on one’s appearance giving a tired or haggard appearance. An attractive face with these early signs of aging can affect a patient’s self-image, attitude and sense of well-being.

Barbara L. Davies, MD, FACS · Answer

Hi there!    You have great eyes!  I think your changes bother you more than other people notice .. . that being said:  it looks like you have two things going on - at rest, you have a mild tear trough deformity (in the picture, it seems to show more on your right than your left, but that could be lighting .. .).  If that is what's happening, a judicious bit of filler would help fill the small hollow and lessen the shadow (my favorite is Restylane, . . . just don't let anyone do Juvederm near your eyes - causes very very prolonged swelling).  With animation (when you smile) you get a bit of bunching up of the lower lid - this is most likely from hypertrophic or thick muscle.  You could try a very careful bit of botox to see if you could decrease some of the activity of the muscle or you could do a blepharoplasty to actually remove (debulk) some of the muscle.  This would need to be done with an incision on the outside of the lid just under your lashes - this incision can hide very nicely.  A strip of muscle - just a few millimeters - can be removed to debulk the area and decrease the activity.  I would probably separate the skin from the muscle and might not remove any skin.  One has to be very cautious with lower lids to not cause increased scleral show (too much of the white of the eye showing) or outright ectropion (the lid pulls away from the globe) - those can happen inredibly quickly with overly aggressive tissue removal.  Now - a transconjunctival bleph keeps the incision inside BUT it only addresses the fat pad, and that's not your major issue and it would NOT fix the bunchiness.  As most surgeons will say, it is very hard to evaluate photos on the web, and you WILL need a personal evaluation before you can make final plans, but these are all my thoughts based on your pictures and questions.  Good luck!

Puffy Bags under eyes only when smiling. Any suggestions? (photos)

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Puffy Bags under eyes only when smiling. Any suggestions? (photos)

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