29 yr old female considering lower eyelid blepharoplasty. Am I a candidate? Is there an alternative/superior solution? (photos)

I have significant under eye puffiness/bags/creases/discoloration. I inherited these unfortunate physical traits, they have been present since birth. This is an issue not remedied by massage, creams, cosmetics, or sleep. I only occasionally drink wine, consistently get a full night's rest, eat well, have never smoked, take good care of my skin, drink plenty of water. I'm looking for a procedure that will address the excess fat, lift sagging skin, & remove the lifelong wrinkles. Please advise.

Doctor Answers 14

Lower eyelid bags

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It appears that you have prominent medial fat pads. Transconjunctival blepharoplasty with fat repositioning would move the fat pad into your tear trough, smoothing out the eyelid-to-cheek junction and removing the shadow in the lower lid.  

Salt Lake City Oculoplastic Surgeon
5.0 out of 5 stars 7 reviews

Options to remove under eye bags

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There are a few approaches to treating under eye bags. Classically plastic surgeons would just remove some of the lower eye fat  to smooth the area. This often works well, at least for a while, but we've found that over time one can develop an overly hollowed out appearance. 

In situations in which there isn't an excessive amount of fat a great option is to improve the lower eyelid volume which ends up better covering the normal existing eyelid fat. 

In some people there is both too much eyelid fat and not enough surrounding soft tissue coverage. In these cases a plan involving a combined approach in which a lower eyelid blepharoplasty is done to remove some excess fat along with facial fat grafting to better fill in the deficient areas of the lower eyelid and cheek.

It's hard to say what would be the best approach in your case based off of just your photos. You do have a component of volume loss that could be treated with a soft tissue filler (such as restylane) or facial fat grafting. An in person exam would allow for a better assessment as to whether any excess lower lid fat is present that needs to be removed.

You can check out my web reference below to see a great example of a patient of mine who had her lower eyelid bags treated with facial fat grafting alone (no eyelid fat was removed).

Congenital lower eyelid fat prolapse

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Lower eyelid transconjunctival blepharoplasty with fat repositioning [not excision] would give you an excellent result. Additional volume in the cheek region with fat grafting would also be helpful.

Though laser resurfacing can sometimes help in this area to improve the pigment changes, in your case, because of your darker skin tone, it can be more risky.
I've attached photos of a similar anatomic problem in a young patient.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 41 reviews

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Puffy lower eyelids

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We are fortunate these days to have many corrective measures available to us that in general, have an excellent safety profile.  Around the eyes, these are the options that usually work best:

Fillers for hollows:  I like restylane in the tear trough and this can mask the puffiness that you have and is a reasonable non-surgical options to get some immediate improvement.  I have seen this filler last more than eight years in this area.  I don't think permanent (Artefill) or semi-permanent fillers are as safe in this region (search sculptra on realself).

Surgery:  Transfer of the fat (incision hidden on the inside of the lower lid) from the puffy area into the hollow tear trough area is a procedure with a very high likelyhood of solving your concerns based on your photos (the variety of angles really helps give us some clues about how this looks in 3D).  It is my experience that this procedure is highly successful with minimal risk especially if performed by someone who does alot of these procedures around the eyes.  An oculofacial plastic surgeon would be an excellent choice.

Laser: Resurfacing of the skin in this area can help reduce or get rid of wrinkles and sometime improve the darkening (hyperpigmentation) of the skin.  The skin may be hyperpigmented for a short time in the early post operative period. This is generally easily managed with topical medication.

Botox:  Neurotoxins such as Botox are generally fabulous at controlling wrinkling around the eyes.  These can be used alone or in combination with other therapies.  I tell patients not to have botox beneath the eye when they have lower lid puffiness until the fat herniation has been surgically managed or the botox may actually make that area look worse.

As you can see.  Multimodal therapy directed at each of the individual problems can give patients a very natural improvement of the facial features they are unhappy with right now.

Lower eyelid blepharoplasty with fat repositioning looks like a good surgical alternatives.

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The puffiness of the lid skin be corrected with eyelid surgery. This is a familial feature not one of aging. There appears to be a hollow near the nose they could be treated by using some of the periorbital fat rotated into that position. This will obviate the need for filler in the future.

29 yr old female considering lower eyelid blepharoplasty. Am I a candidate? Is there an alternative/superior solution?

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Most expert experienced artistic plastic surgeons have a variety of procedures at their disposal to produce excellent cosmetic results in the appropriately selected patient: temporary fillers, micro-fat grafts, and blepharoplasties. There is no one best procedure. Each has benefits and potential drawbacks.

Following the advice of anyone who would presume to tell you what to do based on limited 2 dimensional photos without taking a full medical history, examining you, feeling and assessing your tissue tone, discussing your desired outcome and fully informing you about the pros and cons of each option would not be in your best interest. Find a plastic surgeon that you are comfortable with and one that you trust and listen to his or her advice. The surgeon should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS). You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California

Options for Improving Tired Lower Eyelids

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In aesthetic practice, we commonly see patients who complain of dark circles under their eyes or lower eyelid bags. There are usually three anatomic causes for a tired-appearing lower eyelid: bulging fat, excess skin, and volume loss. With surgery, excess skin can be trimmed, bulging fat can be removed or repositioned, and volume can be returned to areas of hollowing. Non surgical options include hyaluronic acid fillers such as Restylane and Belotero to restore volume to the hollows under the eyes and lasers or peels to tighten the eyelid skin.

In your case, you would be an excellent candidate for a surgical lower eyelid lift or treatment with injectable fillers depending on your goals and expectations. A consultation with an experienced eyelid surgeon should help you find a treatment that is right for you.

Options for lower eyelid bags giving tired appearance

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You are an excellent candidate for transconjunctival lower blepharoplasty with fat repositioning, where the bags/fat is moved/repositioned to fill the hollow area underneath it (dark circles).  Another nonsurgical option would be to leave the bags alone and fill the hollow area with filler injection instead. See an oculoplastic surgeon.

Fat and discoloration

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Thank you for your question and humorous photo commentary.  You have the option of using a filler such as Belotero or Restylane to fill in the tear trough hollow or blepharoplasty to remove or reposition the fat that is causing the noticeable bulge.  In addition to the deepened tear trough, you have discoloration of the lower lid.  The reddish purple can be caused by allergies or simple heredity.  Fillers and blepharoplasty will not improve this.  I would recommend allergy testing to determine if there is an identifiable allergen that you can avoid or treat.  If not, then consider moving forward with treatment.  You may also want to try a product such as Teamine by Revision to help with the discoloration.  Best of luck!

Lower eyelid fat

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You have some visible fat in the lower eyelids.  This creates a shadow so it looks like you have a dark circle.  At age 29, a good option is to put some filler into the depressed area, the tear trough, which will help smooth out the area so you wont' notice the fat, and the darkness should look better.  A more long term option is to do a lower eyelid surgery with fat repositioning where the fat is moved into the tear trough.   

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.