Male Voice: What treatment would you recommend for under eye hollows? I'd like some help with what I can do with my under eye area. I saw a plastic surgeon the other day, and he said my under eye hollows are due to naturally hollow cheek bones. So my under eye area isn't supported. Also, thin under eye skin and prominent brow. He also said, in his opinion, I would need a number of surgeries to correct this, including cheek implants, fat transfer, brow and nose shape too. Couldn't I just have a lower bleph to correct it, to bring up the lower area, and so there isn't so much thin skin?

Dr. Amiya Prasad: Thank you for your question. You submitted a photo, and you described in pretty nice detail your recent consultation with a plastic surgeon about the puffiness and the appearance of your under eye area. Interestingly, this plastic surgeon made an assessment about the relative prominence of your cheeks, and the recommendations that came from that included cheek implants, nasal surgery, et cetera. That's quite a lot.

Your question, of course, is can you just have a lower eyelid blepharoplasty. Well, assuming you already understand, but I'm just going to give you a brief overview of what your plastic surgeon was describing. When we look at a person's lower eyelids, we assess why are they puffy. Most commonly, they're puffy because of something called lower eyelid fat prolapse. Lower eyelid fat prolapse means that the fat that's normally around the eyes pushes forward, creates a bulged appearance. At the same time, a lot of people have skin discoloration.

So when we are addressing lower eyelid fat prolapse and skin discoloration, we do a combination of approaches. One is to do a procedure that's called a transconjunctival blepharoplasty. That's where we reduce the fat pockets from the inside of the eyelid. By doing that, we're able to reduce, reposition, and do whatever procedures are necessary in order to restore the contour.

When it comes to the discoloration of the skin, just briefly, we routinely try to help people with a material called platelet-rich plasma. Platelet-rich plasma is derived from your own blood. Essentially it's a concentration of the growth factors and the healing properties that are necessary for wound healing. We have found this helps people . . . the skin quality improve significantly.

Now, when we do this type of procedure, what we're doing is we're taking away the negative that dominates your face, the negative aspect which draws all of the attention. In the field of cosmetic surgery, we try to look at things both with a close-up view, as well as a holistic view. When I look at a patient, I just think, "What is the dominant feature that is drawing the attention? And is that dominant feature taking away from the face?"

Well, when someone has bags under their eyes, and they always look tired, it just affects everything on their whole face. Now, in terms of what the doctor was mentioning about the cheeks, it's something called negative vector. It means that the cheekbone is relatively less projected, compared to the eyeball or the front of the cornea. Now, that is a setup in certain patients for issues related to cosmetic eyelid surgery, such as lower eyelid retraction.

We see many patients from all over the world who unfortunately had surgeries done from an external approach. During that external approach, or what's called transcutaneous blepharoplasty, skin was removed. At the same time, nothing was done to support and control the position of the lower eyelid. What eventually happens during the healing process is the lower eyelid pulls down, and it creates retraction. In some cases, it actually everts, and it causes ectropian,or the eyelid being exposed from the inside.

So that being said, your doctor made a valid assessment as to your anatomy. In our practice, we're of course very sensitive to this. By doing the approach we do and by doing other things that are specific to my experience and expertise, we manage to avoid these types of issues 99% of the time. So that being said, I would agree with you that you may want to just start by just dealing with the issue on your face that is dominant and is the most negative, which is the puffiness under your eyes.

If, after that procedure is completed, you still feel that you want more cheek projection, or you want other things dealing with your nose, then you can pursue those other things. I think a lot of plastic surgeons are biased because when they look at a patient, they want to try to fix everything. Two, because they do everything under general anesthesia, they want to try to do as much as they can for that patient during that one general anesthesia session.

What's the Best Treatment For Under Eye Hollows?

Dr. Amiya Prasad discusses various treatments that address under eye issues such as puffy bags and discoloration. He also provides a word of warning against doctors who suggest doing too much at one time.