I have bags under eyes when I smile. Which would you recommend; fat grafting or fillers? (photos)

Hi there I am just about to turn 24 and I have hollowness under my eyes which im sure is the reason why my skin wrinkles together when I smile. I am starting to get crows feet and signs of aging and I don't want to age this badly this early. I have attached some photos and I am hoping that someone will be able to give me there opinion. I want a permanent or as permanent as I can get fix. I am not worried about money I want suggestions please. I hope someone can help I don't want to age badly :(

Doctor Answers 5

Under eye bags/rolls

I never like to consult based on photos but what your photos seem to show is very common.  Some people, when they smile, have a very strong orbicularis muscle the "bunches up" a bit under the eye.  It's not a fat pocket, although sometime it can be related to losing volume around the eyes as we age.  Firstly, there is nothing "wrong" with your smile and it doesn't age you, from what I can tell in the photos, but if it bothers you, seek out a consultation with a board certified oculoplastic surgeon and injection specialist.  This is usually treated very effectively and without significantly changing your smile with a few units of botox injected just under the skin over the overactive muscle.  While the treatment is not "permanent", you don't want permanent treatments on your face (trust me) because your face changes slightly every few months as you age and what looks good now, may not look good 5 years from now.   That said, this "off label" use of botox or one of the other neuromodulators has a long term effect because after a series of treatments (usually patients come in 3 times per year) the muscle in the area becomes weaker and atrophies and in my experience, patients need less and less treatment (or none at all as they age).  It is not a risk free treatment though because if too much botox is injected in this area, the eyelid can droop or retract down, and that is not an attractive look.  So it's essential to be treated by someone who has experience with these types of treatments.  DO NOT , in my opinion, have surgery to remove the muscle or thin it out.  It almost never looks natural and often causes all types of problems years down the line.

I hope that helps and best of luck!

New York Oculoplastic Surgeon
4.7 out of 5 stars 66 reviews

Don't fit square pegs into round holes

In order to most effectively apply our treatments for people there are a few simple, basic tenets that we MUST understand and follow, lest we create more problems than we solve.  The first of these is that with every problem, we must be able to understand the anatomy of the area intimately and be able to correlate that anatomy with the problem.  The second is that we must be able to find a treatment that is oriented toward altering that anatomy in a way that will actually address the issue at hand.  Third, and perhaps most importantly, we must put aside our egos, our fantasies about what we would LIKE to have happen versus what reality is, and our misconceptions about what our treatments can and can't do and honestly assess the true expectations of what our treatments can actually accomplish. These things are hard to do in all honesty, but they are vital, and they are what separate excellent cosmetic doctors from mediocre ones.  Technical skill is important, but in my opinion it may not even be as important as authentic judgment and restraint.  Just because you CAN do something doesn't always mean that you should.  I've seen some disastrous results from colleagues who I consider to be technically excellent, but who, for whatever reason, decided to attempt the wrong procedure for the wrong problem; they executed the plan perfectly, but it was the wrong plan.  I think you're probably getting the idea now without my further beating of the dead horse.  You are a young man, and your face is changing, no question.  Trust me, it will continue to do so for the rest of your life, despite what any doctor does.  The key here is to A) be rational in your choices of what you do (and sometimes that starts by being rational in your choice of doctor) and B) resist the temptation to act like a "spoiled brat" and have a temper tantrum because you want something and you are being told that you can't have it.  If a doctor (with experience) is telling you he can't do something, there's probably a reason behind that (it's called experience).  Your youth is one of the most beautiful things about you now; it's fresh and natural and still very much alive and well, but it can be destroyed with a stroke of a needle or scalpel applied ill-advisedly.  Think subtle right now, think conservative right now, light touches, maybe a bit of Botox to soften dynamic creases around the eyes, a temporary filler here or there first to try out the idea of volume correction before committing to a more permanent modality like fat grafting.  You have a LOT of time, young man, believe me, and you need to find a doctor who is responsible with someone your age and can advise you wisely, develop a relationship with you for the long term, and guide you along the way so that as a need arises it can be addressed properly.  "Aging badly" is a very subjective judgment.  Sometimes those who age "badly" are the ones who try hardest not to show some signs of aging.  I'll ask you to compare the following:  George Clooney and Brad Pitt versus Bruce Jenner, Burt Reynolds, Kenny Rodgers, Wayne Newton, etc., etc, you get the picture (I hope).  Good luck to you.

Joseph L. Grzeskiewicz, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 87 reviews

The leading treatment for this is nothing. These are normal.

You will look freakish if you do not have these rolls under the eyes.  Don't let someone freeze these with botox.  This fullness is a normal part of your smiling face.  People you interact with are looking for these cue to let them know you mean you smile.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Eyes: high real-estate

The eyes are the area that people look at 80% of the time during a conversation. So this is prime Real-estate. You are young so you want to be conservative. There are some temporary and simple things you can try to improve your look but I would be careful and make sure to not over do it at such a young age. 

 You are correct that a portion of your issue is volume loss but likely not significantly so yet. This takes time to evolve as we age. A portion sounds like it is orbicularis muscle activity from what you explain. Botox is a simple and temporary thing to try for the crows feet and could possibly be all you need. I also think you would benefit from laser treatments to the skin around the eye.  You have fair skin and there is likely an aspect of sun damage to the area. This is best treated with laser treatments in my hands. 

I am with you that a permanent and natural volumizer is the best. Fat is giving wonderful results of the periocular area and we are learning more and more about the benefits of fat. The skin is rejuvenated because along with the fat we transfer stem cells, cytokines and growth factors. This is part of the reason I like the combination of fat transfer with laser. Laser resurfaces the skin and then we rejuvenate it from beneath with the fat and stem cells.

Fills are an option but the results will be subtle and short lived. 

Hope this helps.

Best of luck,


Benjamin Caughlin, MD
Chicago Facial Plastic Surgeon
5.0 out of 5 stars 10 reviews

Under eye hollowness and bags

I see that what you are describing under your eyes in the photos when you are smiling is actually a roll from your muscle which some cosmetic physicians refer to as a "banana" or "jelly" roll.  The leading treatment for that roll is Botox, but I realize that is temporary and you are interested in something more permanent.  By masking the under eye with filler or fat transfer you will also likely mask some of the roll.  I recommend always trying a temporary filler first to make sure you like the look.  Restylane in the tear trough will last about a year.  Fat transfer may be more lasting or permanent but is also higher risk of lumping or not taking evenly and requiring correction.  Correction with fat transfer is more invasive than hyaluronic acid fillers. 

Karen Stolman, MD
Sandy Dermatologic Surgeon
5.0 out of 5 stars 7 reviews

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