Best long-term treatment for under eye bags and puffiness (photos)

Hi there! thank you for your query and pictures. 
The ageing process, alongside volume loss in the face can result in worsening in the appearance of eye bags. 
Non-surgical options here include the use of hyaluronic acid based dermal fillers carefully placed around the orbital rim and localised fat pads to reduce the appearance of eye bags. Personally I use cannula technique which reduces the risk of bruising and swelling and carry out a sessional approach as I find results are optimised over a period of time. 
Other options here include lower lid blethroplasty however this is a surgical procedure incurring potential risks.In terms of treatment longevity, I re-treat most of my tear trough clients around once a year. The surgical option with yourself would be more of a long term fix. 
Make sure you visit a suitably trained non-surgical practitioner for consultation as this is an advanced procedure. 
I do hope this helps and good luck!Dr Rupert

Thank you for your question. You are looking for a long-term treatment for puffy under eye bags, dark circles, wrinkles below your eyes when you smile. You state you developed them over the past 2 years, and are almost 39-years-old.
I can certainly give you some guidance based on your photos alone, without the benefit of a physical exam. I’m Dr. Amiya Prasad. I’m a Board Certified Cosmetic Surgeon and Fellowship Trained Oculoplastic Surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years. I’m known as a specialist of the eyelids, so eye bags, under eye wrinkles, and dark circles are things I treat for patients every day in my practice.
Looking at your photos, you do appear to have significant puffiness under your eyes, along with some wrinkles and a little darkness under the eyes. There are two treatments for puffy under eye bags that are always present: camouflage them with filler, or remove and sculpt the fat that causes the puffiness. Eye bags occur when fat that is normally around the eyes to cushion the eyeball prolapses forward, and herniates under the eyes, causing a puffy look. Since you want a long-term solution, and the puffiness is significant, I would recommend a lower eyelid blepharoplasty, which is a surgical procedure to remove and sculpt the fat. Filler treatment is more appropriate for mild under eye bags, and also requires maintenance. I do this with a more specialized technique called transconjunctival blepharoplasty, where I remove and sculpt the fat from the inside of the lower eyelid, so no external incision is made. It’s important to leave a little of the fat when doing this procedure to prevent a hollow look under the eyes, so sculpting with an artistic touch is important for a continuous contour under the eyes. This technique gives a more natural appearance, as most surgeons perform eye bag surgery where an external incision is made in the lower eyelid, right below the eyelashes in a technique called transcutaneous blepharoplasty. Not only does this technique risk a slightly visible scar, but it can also compromise the lower eyelid support structures, causing the lower eyelids to look pulled down.  Lower eyelid blepharoplasty is a more definitive, long-term procedure when compared to fillers because once done, the fat doesn’t come back, and results can last for many years.
Many doctors who perform the transcutaneous technique also remove some eyelid skin to try to improve wrinkles. However, this can pull the lower eyelids down even more, leading to an expensive and extensive revision surgery by an eyelid specialist like myself. Wrinkles under the eyes are often mistaken as a problem of skin quantity, but they are actually an issue with skin quality. To improve skin quality, I apply non-surgical treatments like platelet-rich plasma, or PRP, which is derived from your own blood, and consists of wound healing and growth factors that are used to heal cuts. When applied in the under eye area, PRP can thicken thin eyelid skin, stimulate collagen, and improve blood supply. This can help improve both the wrinkles and the dark circles under your eyes, and the overall skin health is improved. I can also apply a laser such as fractional CO2 or Erbium laser to tighten and resurface the skin, and also stimulate additional collagen.  
Although I can’t see your upper cheeks clearly, I would also examine this area to see if it is also hollowing due to age. As we age, we lose volume in the face, notably the cheeks. If the upper cheeks are hollow in an area called the eyelid-to-cheek junction, it can affect the results after lower eyelid surgery or filler. To possibly balance out this area, I may consider adding a little filler in the upper cheek so your eye area doesn’t look hollow.
I advise you meet with cosmetic surgeons who are highly experienced in lower eyelid surgery, and its complementary treatments for wrinkles and dark circles. Ask for the transconjunctival procedure by name, as it is practiced by few doctors, but can avoid unnecessary complications. Once you find a doctor you are comfortable with, you can move ahead with treatment. I hope you found this information helpful. Thank you for your question.

A combination approach will give the most improvement. Fillers like (Belotero, Volbella, Restylane Silk) , lasers, and Microneedling/PRP can improve under the eyes. My patients try to get non surgical treatments to avoid surgery. We use PRP and stem cells there often.Deep wrinkles can be improved with a combination of Botox and/or fillers for the lines themselves and to build anatomical support with Sculptra for collagen building. Ultherapy is a great skin tightening device, but works best in combination with other treatments like J Plasma, RF treatments, lasers, Microneedling/PRP, salt facials, Cosmelan for skin tightening and improve skin tone. I recommend getting a formal evaluation with an expert. Best, Dr. Emer