Lower Blepharoplasty. Too young? Are there better options? Fillers/lasers? (Photos)
Doctor Answers 9
The twenties or thirties is not too young for eye bag surgery as it's a genetic trait, and not due to aging
Thank you for your question. You submitted 2 photos and state you’ve undergone previous surgeries at age 29-30. At the time you discussed the possibility of addressing the puffy appearance of your under eye area, or eye bags. You were told by doctors then you were too young for eye bag surgery, and you are now 32-years-old and the eye bags really bother you. You now ask when is the right age for eye bag surgery, as well as alternatives like fillers and lasers.
I can certainly give you my approach to patients like yourself in my practice. A bit of background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I’ve been in practice in Manhattan and Long Island for over 20 years and dealing with under eye bags is something we do all day, everyday in our practice. I’ll give you a little understanding first what your issue is, then the approaches based on the anatomy of this area.
The appearance of puffy under eye bags is based on an anatomic issue called lower eyelid fat prolapse, which means fat normally around the eyes pushes forward and creates these bulges. Many years ago, the solution was fairly straightforward - it would always be surgery, and a question of when to do the surgery tempered with the relative risk. However, we now live in a time of a variety of additional tools in our toolbox that includes injectable hyaluronic acid fillers.
Once you understand this is a hernia of fat, it can be addressed by reduction one hand, or blending in the other. When I see a patient like yourself, if the fat pockets are very subtle and only push out a little, then hyaluronic acid fillers such as Restylane have some value in a blending type of strategy. The challenge is not to put more than is appropriate because otherwise, it can make the under eye bag look worse. Many people come to my practice to have these under eye bag areas treated after they’ve gone through injectable fillers by a well-meaning doctor, but unfortunately they had so much filler that it made their bags look worse. We actually use an enzyme called hyaluronidase to dissolve the filler and see what the real anatomy is, then do a more definitive procedure.
The definitive procedure where the fat is reduced, sculpted or repositioned, or combination of all, which is generally recommended for someone young like you is a transconjunctival blepharoplasty. This means I reduce, reposition, and sculpt the fat from the inside of the eyelid which gives you a more definitive, long-term benefit. Fillers by nature have to be consistently repeated, which is fine when you have a situation where there isn’t a better surgical option, and I often use fillers in many situations like that, but under eye bags is not one of them. When someone is beyond a certain threshold of fat prolapse, it is best to do a surgical procedure.
When it comes to the appropriate age for surgery, there will be different opinions by different doctors of what they believe. From my perspective, the optimal age is when you have the problem. We have operated on patients as young as 14-years-old who had significant under eye bags, but that’s more of an exception. At your age range, it is perfectly fine - we routinely address lower eyelid fat pockets in people in their 20’s and older, so your age is not a limiting factor here.
In terms of the relative risk, for many surgeons, the only way they do this operation is with general anesthesia, meaning a tube is placed in your throat and you are paralyzed. With that understanding, a lot of people are hesitant to do surgery.
More than 20 years ago, I developed a system in my practice so we can do these procedures under local anesthesia. In our practice in Manhattan and Long Island, we have accredited surgical facilities so we actually do these procedures with a little sedation to give you enough relaxation, but at the same time you are not under general anesthesia. For our patients, their main desire is to maximize the results, do it in a safe way, and recover as quickly as possible.
We do these procedures also using a regenerative technology such as platelet-rich plasma (PRP). This is the healing and growth factors concentrated from your own blood which activates your own stem cell activity to improve skin quality and texture, as well as facilitate healing from the surgery. Last but not least, for someone with lighter skin, we often also use something called fractional CO2 laser or fractional erbium laser to help improve the skin quality and texture from the epidermal and dermal side.We are trying to do a global rejuvenation of the eye area - we address the fat pockets, the tissue quality with platelet-rich plasma (PRP), and we improve the color,quality and crepiness of the skin with laser.
To really determine what is optimal for you, a proper evaluation is necessary. With the surgical option, people go back to work typically in less than a week. I would advise you meet with qualified, experienced specialists - surgeons who could offer both the injectables and surgical options. Look at their before and afters, and learn about the way they like to do the procedures. See if you’re comfortable with the aesthetic style, approach, the anesthesia, and ultimately with the results you see in their individual before and after pictures. Also understand there are additional complementary procedures that adds to the to the whole being greater than the sum of its parts, which is where the platelet-rich plasma (PRP) and fractional lasers procedures come in. I hope that was helpful, I wish you the best of luck and thank you for your question.
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You are not too young
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From your photographs, I would not recommend fat removal; filling of the hollow areas beneath what appears puffy will provide you with a better look. Filling can be done using your own fat or injectable fillers.
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In young patients and in those without excess skin, I prefer a transconjunctival approach, where the incision is made on the back surface of the eyelid (incisions are not visible) and the fat is contoured and in some cases may be transposed (moved) over the rim of the lower eyelid or into the tear troughs.
Fillers may may also help camouflage these contours. It is difficult to make a definitive recommendation regarding surgery vs. filler based on photos alone.
The wrinkles you notice are the result of lower eyelid muscle contraction. These can be treated to some degree by very careful injection of Botox into the muscle. This will need to be repeated about every three months. Laser resurfacing or chemical peel of the lower eyelid can also help. Nothing can make these disappear permanently.
As with all procedures, it is very important that you seek out in-person consultation. Photos alone cannot give all the information necessary to recommend the best procedure(s) for your individual needs. I recommend you consult with a board certified facial plastic surgeon, oculopastic surgeon, or plastic surgeon who is experienced in blepharoplasty.