Treatment Options for Under Eyes (Age 21)? (photo)

I have excess undereye skin combined with a lack of volume that gives me a slightly gaunt look and excessive creasing in the thin skin under the eye if i laugh or smile too much. Profile is most disconcerting, you can see a bulge and I can feel the inferior orbital rim. Went to a derm and he acknowledged the issue but felt was too young for fillers. Attached a pic of how I'd like it to look. Would blepharoplasty or fillers be more efficient? Should I consult a derm, occuloplastic surgeon, both?

Doctor Answers 8

Treatment Options for Under Eyes (Age 21)? (photo)

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Thanks for sharing your pictures-
Surrounding your eye is a muscle called the orbicularis occuli which is attached to your cheek bones by a retaining ligament.  Excess congenital fat below your eyes is herniating out and tenting out the muscle with the exception of where it is attached manifesting as the hollow you dislike commonly known as the "Tear trough deformity".

Fortunately this can be corrected or at least improved.
Treatments used could be aimed at filling the hollow or removing the excess fat.

Fillers used could be temporary such as restylane etc, or permanent- potentially transferred some of the herniating fat and/or using it or other as a graft.
A transconjuctival blepharoplasty (excision within your inner eyelid with no visible scars) could also be used to successfully remove the excess protruding fat creating a smother contour and softening the way light reflects off your cheek.

I hope you are successful in getting the result you want.
Warm regards,

Dr Quinton Chivers

Eye bags can be removed without any scar from surgery, but stretching the eye skin like your picture can't be done in surgery

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I want to address the maneuver that you did to lift the skin to show how your eyes look when taut. This is one of the most common things that people do, but as surgeons we are not able to mimic the exact same tone and tension that you want. There’s movement in this area of the face, and even if someone aggressively pulls the skin and stitches it, unfortunately, the skin would stretch back and the scar can get widened. I can tell you about experiences of patients who come to me from other practices where the scar got wide because the original doctor tried to stretch the skin.

I did notice that there does appear to be some puffiness under your eyes. If this puffiness is constant, then most likely you have something called lower eyelid fat prolapse. This is when the fat that’s normally around your eyes has pushed forward.

If you already eliminated some causes of puffiness that make the puffiness worse such as sinus problems, allergies, smoking and being around second-hand smoke then you’re probably a good candidate for transconjunctival blepharoplasty. In this procedure, the fat pockets that have pushed forward can be addressed from the inside of the eyelid. We reduce and remove a certain amount of fat and even reposition it to a certain level. At the same time, the rest of the skin and anatomy remains the same. I also suggest less invasive things like topical skin creams, proper skin protection and doing things that are good for your health that may be beneficial to you at this age.

Amiya Prasad, MD
New York Oculoplastic Surgeon
4.4 out of 5 stars 80 reviews

Lower eyelid bag treatment

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From your photos, it appears that you would do well with injection of a hyaluronic acid filler (Juvederm or Restylane), which will fill in those hollows, augment your cheeks, and give you less of a gaunt appearance. 

Jason J. Hall, MD, FACS
Knoxville Plastic Surgeon
5.0 out of 5 stars 12 reviews

Bags under the eyes

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A great simple treatment would be Restylane injections. These work very well to reduce the appearance of bags under the eyes. Typically, results last 3-6 months, if not longer.

Alternatively, a blepharoplasty would give a long-lasting result.

Robert S. Bader, M.D.

Robert S. Bader, MD, FAAD
Boca Raton Dermatologic Surgeon
5.0 out of 5 stars 3 reviews

Under eye bulge at 21

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Thank you for your question about your low lid bulges.

  • You have excess lower lid fat that is inherited, not aging.
  • This creates the furrow beneath.
  • transconjuntival lower lid blepharopasty to remove excess fat and redrape the remaining fat is the best approach,
  • You should consult  a Board Certified Plastic SurgeonFacial Plastic Surgeon or Opthalmologist (oculoplastic surgeon). Hope this helps.

Options for under eyes

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From your pictures, it appears that there are two issues.  One is the depression you have in the tear trough area and the other is that there is some fat herniation above, which causes some puffiness.  In general, there can be two methods to help with this.  One is blepharoplasty, to deal with the herniated fat, and the other is using a filler to help with the depression in the tear trough.  My recommendation for you would be to try a filler, like Restylane, first.  This is simpler and easier than surgery and could improve your appearance to the point where you wouldn't need the surgery.  You can always do the surgery at a later point if needed.  

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

Your personal diagnosis is only half correct.

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It appears that your big issue is that you are missing bone projection at the orbital rim or possibly lack deep buccal fat support at the top of the cheek.  Restylane and Perlane are the best treatments for this.

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

Blepharoplasty or fillers

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Based on your photos it looks like the main problem is very significant hollowing in the tear trough area and the portion of your upper cheeks closest to the nose. There is also some fat herniation in the lower eyelids, though I feel this is a secondary problem. I suspect other doctors will have very different opinions about this.

I try to avoid surgery in patients your age, when possible. I would recommend trying filler injections into the tear trough and upper cheeks to help blend the eyelid-cheek junction. Lower eyelid surgery could always be performed at a later date if you did not meet your goals with filler injections alone. The reason I dont like surgery as an initial approach here is that you have a very youthful face with great volume and I would hate to see you with thinned out, skeletonized lower eyelids. I would prefer to add volume here rather than subtract volume with surgical removal of fat. Other doctors may recommend repositioning fat from the lower eyelid into the tear trough, which I think is  reasonable. In my own experience, I find that injecting Restylane produces more predictable results, but this is definitely my own preference and other doctors will feel differently.

Unfortunately, neither surgery nor filler injections is likely to get you to look like the picture on the right. A lower eyelid always looks better when you pull it tight. When you pull an eyelid that tight with surgery, there is tension on the wound which wants to pull the eyelid back in the other direction. The eyelid may look perfect when you leave the operating room, but the eyelid will quickly start returning back to its prior position.

I would recommend getting multiple opinions and going with whichever doctor you feel the most comfortable with. Best of luck.

Mitesh Kapadia, MD, PhD
Boston Oculoplastic Surgeon
4.9 out of 5 stars 183 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.