What would the most effective under eye treatment: surgical, non-surgical and non-invasive? (photo)

I am 27 and my under eyes have progressively been getting worse; dark under eye circles, under eye bags, big blue veins and puffiness. Make up does not really help cover it and people constantly ask if I have black eyes or telling me I look like I haven't slept. I am getting married in 5 months and would like to see some decent results by then. Thank you!

Doctor Answers 7

Fillers can camouflage mild eye bags, but yours are bigger and require surgery, but no trace of surgery will be visible

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As a cosmetic oculofacial plastic surgeon practicing for 20 years, I constantly deal with puffiness under the eyes. Puffiness under the eyes is caused by something called lower eyelid fat prolapse - fat that is normally around the eyes that pushes forward and creates a bulge that is constantly there. Bags under the eyes automatically makes one look like they’re older, tired or they lack energy.

Currently, there is an alternative for a limited amount of puffiness where we can use a filler to try to camouflage it. Unfortunately, for your situation, the puffiness is significant enough that you would need to undergo a surgical procedure. Being someone in your 20s, most likely that procedure would be a transconjunctival blepharoplasty where the fat pockets are addressed from the inside of the eyelids. By doing that, there is no external incision. We do this procedure under local anesthesia with LITE™ sedation for faster healing and recovery, in contrast with a lot of surgeons who prefer to do their procedures under general anesthesia. I’ve always been an advocate for quick recovery and natural results and this procedure is actually in some ways comparable to a less invasive or non-invasive procedure. I would even argue that the majority of our lower eyelid blepharoplasty patients look better than a lot of people who get injectables under their eyes who have big bruises that last for weeks.

We have also been able to evolve our treatment for puffiness under the eyes with a strategy that helps skin quality. Skin quality under the eyes, the fine lines, wrinkles and the hollowness have always been a challenge and the typical treatment would be a laser treatment. We have mircofractional CO2 laser and I have been using it more strategically in balance with another method that we do to help skin quality using platelet-rich plasma. Platelet-rich plasma is your own blood that is drawn like a regular blood draw for a blood test, then spun down to concentrate the platelets which have the healing and growth factors. These factors improve the vascularity, the backbone of the skin and collagen production. I have been very impressed when we combine platelet-rich plasma with our blepharoplasty procedures on how good the patients look. So we would do lower eyelid blepharoplasty with platelet-rich plasma concurrently to help with the skin quality.

After all of this is resolved, you would then decide if you want to add any volume in any area that would be strategic. A hyaluronic acid filler like Restylane and Juvederm would be used. However, we do it a little bit differently - we would combine it with platelet-rich plasma because we have observed a synergistic benefit. There’s more volume correction and more natural tissue growth that is better than either component of PRP or hyaluronic acid on its own.

At this point, it’s best if you do some research and find qualified experienced cosmetic surgeons who you feel comfortable with. Have a consultation, get to know them and move forward with your solution. Since you have a wedding planned, the sooner you do this, the better. I hope that was helpful, I wish you the best of luck, and thank you for your question!

New York Oculoplastic Surgeon
4.4 out of 5 stars 80 reviews

The most effective treatment for baggy lower eyelid

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Based on your pictures, in my opinion, lower eyelid surgery, arcus marginalis release and fat redistribution would give the best aesthetic, long lasting, predictable and consistent outcome. This will correct both the bagginess and hollowness of the lid/cheek junction. 

Eric In Choe, MD
New York Plastic Surgeon
4.6 out of 5 stars 51 reviews

Hualu-Blepharoplasty versus Surgery

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A  transconjuctival lower eyelid blepharoplasty with release of the ligaments and preservation/redraping of the fat compartments over the bony structure is more indicative in your case. However hyaluronic acid filler injections are a conservative alternative that can improve the contour and camouflage to a certain extent the fat prolapse.  I would recommend a monophasic filler like Belotero as it has better distribution within the soft tissues. Even if you opt for a surgical approach, fillers might be still necessary to further refine the eyelid-check junction contour.

Costas Papageorgiou, MD, FACS
London Oculoplastic Surgeon

Lower lid options?

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Fillers often can produce a nice temporary cosmetic improvement in some patients, but not all. They certainly do not achieve what a well performed blepharoplasty will do.

Fillers can help improve the cosmetic appearance but you will get only a temporary and limited improvement with them. A better and long standing correction would be achieved with a blepharoplasty of the lower lids: Conservatively removing any excess loose skin that may be present, contouring the bulging fat pads, which are generally inherited, unrelated to weight, and tend to protrude more with time, and smoothing the tear troughs with micro-fat grafts or fat repositioning.

Keep in mind that following advice from a surgeon on this or any other website who proposes to tell you exactly what to do based on two dimensional photos without examining you, physically feeling your tissue, assessing your desired outcome, taking a full medical history and discussing the pros and cons of each operative procedure would not be in your best surgery. I would suggest that you find a surgeon certified by the American Board of American Plastic Surgery and one who is ideally a member of The American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.

Robert Singer, M.D., FACS

La Jolla,California

Robert Singer, MD
La Jolla Plastic Surgeon
4.6 out of 5 stars 22 reviews

Lower eyelid bags

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There appears to be a significant bulge of lower eyelid  fat prolapsing forward along with a depression at the eyelid-cheek junction. Therefore I would probably recommend a cosmetic lower eyelid blepharoplasty performed through the inside of the lower eyelid(called a transconjunctival blepharoplasty) followed in a few weeks after surgery by lower eyelid hyaluronic acid gel fillers like Belotero or Restylane to fill any depressions that may remain at the eyelid -cheek junction. 

Joel E. Kopelman, MD, FACS
Ridgewood Oculoplastic Surgeon

Options to treat lower eyelids

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Your photos appear to show fat causing the puffiness under your eyes.  If this is the case, it could be improved surgically, with lower blepharoplasty or a filler could be injected under the bags to help camouflage them.  The result from surgery would be longer lasting and deal with the root of the issue whereas the filler would be temporary and improve the appearance by filling the depressions under the bags.  If you went with a filler, I would recommend one of the hyaluronic acid products.

Michael I. Echavez, MD
San Francisco Facial Plastic Surgeon
4.5 out of 5 stars 18 reviews

The answer very much depends on your physical examination.

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You look like you have the classic lower eyelid pillows.  Classically with was addressed with transconjunctival lower blepharoplasty.  More recently this has evolved into transconjunctival lower eyelid arcus marginalia release surgery where the lower eyelid fat is preserved and transferred as a living pedicle into the lower eyelid to fill the tear trough hollow.  The physical exam is very important because what looks like lower eyelid herniated fat may be the bony orbital rim, in which case you will be very disappointed with surgery.  Now having said that, if your skin quality is good, fillers are a very reasonable alternative to lower eyelid surgery.  This also reduced the pressure to have a surgery just months before your wedding.  Just remember that the filler service is a bit fussy so you need to find the right injector and get this done now!  With the wedding so close, I recommend exploring the filler.

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

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.