42 year old with horrible under eye hollowness and severe wrinkles. What would be the best procedure to fix them? (Photo)

There are many ways to treat dark circles, as well as under eye wrinkles and bags. It is important to note however, that the majority of times the cause for discoloration is genetic and due to the viability of the blood vessels below the skin. A combination approach is always needed to get the best results in this area and this includes: topical skin care, laser and/or radiofrequency treatments, and fillers if placed appropriately.  All my patients are on topical lightening agents, typically a vitamin C serum product in the AM and a brightening agent and/or a vitamin A based product in the PM. Sun protection is essential.Resurfacing and tightening are essential. My patients get offered a menu of options, for which a combination gives the best results. Light salicylic acid peels help give textural and pigment improvement; nonablative lasers (Fraxel or Clear + Brilliant) can be used to tighten and improve fine lines/wrinkles and crepe skin; fractional radiofrequency devices (Sublative, Viva) are cutting edge and improve texture, tone, and wrinkles with very little downtime; radiofrequency with pulsed electromagnetic fields (Venus) are amazing for puffiness and bags, in patients who do not want eyelid surgery; appropriately placed fillers can replace lost volume, cover up the vessels and fat pads below improving the appearance -- patients should pick a well experienced practitioner to prevent complications such as Tyndall (blue discoloration) and irregularities, one that uses a cannula for injection will help give results with little bruising or swelling; microsecond Nd:YAG laser treatments (Laser genesis) has produced dramatic improvement in discoloration in some of my patients and is safe in dark skin types, similar to the radiofrequency devices. For lifting, ablative laser resurfacing such as co2 laser combined with monopoloar radiofrequency deep heating (thermage) give amazing results. The key is for a patient to see a cosmetic dermatologist with experience in all the latest devices and techniques so the persons goals can be met by a combination approach of individualized treatments and skin care. In some cases, those who smile and have crepe skin or under eye wrinkles, a small amount of neurotoxin (botox, dysport, xeomin) strategically placed in the lower eyelid skin can improve wrinkles dramatically and give the eye a more "open" appearance.

You can consider either nonsurgical (filler injection in hollow under eye area) or surgical option (lower blepharoplasty with fat repositioning and skin pinch). See an oculoplastic specialist.

You appear to be a good candidate for fat preservation lower blepharoplasty and likely fat transfer. This would flatten the small lower eyelid bag and add volume to the hollow undereye area. It is important to ensure that surgery also supports your lower eyelids as a small amount of drooping in your lower eyelid can create a dry eye problem. I hope this information is helpful for you.Stephen Weber MD, FACSDenver Facial Plastic Surgeon

I agree with the other docs that you would benefit from a lower lid blepharoplasty with fat reposition.  Do not take out the fat or you will appear very hollow.  You will also need some skin excised, and would benefit from some ablative laser resurfacing to tighten the skin.

Thank you for the question and your photos. The combination of lower eyelid bags, hollowness around the orbital rim, and extra skin is best treated with an extended lower blepharoplasty with fat transposition. This procedure uses your fat bags to help fill in the hollow area, and removes the excess lower eyelid skin, while tightening the eyelid. In my practice, this procedure has a very high success rate and keeps the patient looking natural.

You have big eyes.  You have to be very careful where you go for lower eyelid surgery which is what I suspect you may need.  You might consider doing your homework and finding an oculoplastic surgeon in your area or more realistically in the closed big city (Denver?) for consultation.  It is possible you might have someone great where you live but it is unlikely.  Do your homework and proceed with caution.

Thank you for your photos.  It is very difficult to assess orbital fat herniation (fat pad around the eye ball) in a photo, but it appears that your right lower lid may have some fat herniation that can only be fixed completely with a lower eyelid lift.  I think finding a surgeon who does transconjunctival lower blephs using CO2 laser and surgically repositions the fat will fix that, but will not offer the most significant improvement.The best procedure to make you look younger and hide the under-eye bags is to target the cheek hollowness that is prominent below your eyelids using deep cheek filler.  I prefer Juvederm Voluma in this application and injections should target the periosteum to lift the lateral cheek (zygomatic arch) and medial cheek.  You can see in the picture without you smiling that the volume loss is significant.  In the picture with you smiling, your medial cheek is pulled laterally and the cheek looks pretty.  Adding volume will also apply some tension to those dynamic lines when you smile, making them more subtle.

Most expert experienced artistic plastic surgeons have a
variety of procedures, both non-surgical and surgical, at their disposal to
produce excellent cosmetic results in the appropriately selected patient:
temporary fillers, micro-fat grafts, and blepharoplasties. Each has
benefits and drawbacks and depends on desired outcome and individual anatomy.

In a patient with your inherited anatomy, a
blepharoplasty and micro-fat grafts or fat repositioning to fill the hollows will produce the best and longest lasting cosmetic result.

Following the advice of anyone who would presume
to tell you what to do without seeing photos and 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

The fine wrinkles you create in the lower lid when you grin can be improved with botox. Your lower eyelid and upper cheek hollowness would respond well to fat transfer from your eyelids. 

It looks like your lower eyelid bags are due to fat coming forward from the eye socket, as well as cheek fat that has moved down, causing a depression beneath the bag.  A lower lid blepharoplasty with fat transposition (moving some of the fat in the eyelid bags into the depression below) would smooth out the lower lids. Your lower lids already sit a little low, making you eyes look big, so it would be important to avoid any procedure that could cause further retraction of the lids downward.  If you are ever in the Salt Lake area, let us know if we can help you.