Female: Tighten skin or bags under eyes. The skin under my eyes is loose, and it looks like I have small bags under my eyes. I need a surgeon to help me maybe tighten the skin. Any suggestions on what kind of doctor I should use? Plastic surgeon, but anything else I need to look for? I like in Beaverton, Oregon.

Dr. Amiya Prasad: Thank you for your question. You submitted two photos, and you stated you wanted to tighten up the loose skin under your eyes and that you've asked about what else you should look for in terms of the type of doctor that you want to perform your surgery. So you've asked a question that certainly has some element of controversy, but I'll share with you my perspective as a 20-year practicing cosmetic oculofacial plastic surgeon and understanding that it's critically important to just first define what the issues are that result in your lower eyelid appearance. Let's put aside which type of doctor is qualified or best for you, but first, analysis is very important.

As a specialist with an eye surgery background and specialized training in cosmetic surgery of the eyes, I could tell you that the anatomy of the lower eyelid is one of the most challenging areas to work with because of the critical structures needed for proper lower eyelid position. If you've looked at people who have had eyelid surgery, you'll probably find that a lot of people, their lower eyelids are pulled down around it and they look like their eyes are bulging. Now that, for me, is not an aesthetic that I like. In my practice, it's all about people looking natural. I actually wrote a book a few years ago, "The Fine Art of Looking Younger." I feel that the character of your face is critically important.

When I looked at your photo, I noticed the outer corners are slightly down. Now, it may be that you've never had a very high almond shape to your eyes, but I suspect, given your appearance, that a combination of genetics and aging changes have probably resulted in some looseness. And so what you interpret as loose skin can also be something contributing to something called lateral canthal tendon laxity. Now, the lateral canthal tendon is the support that keeps the eyelid attached to the bone. When I described the scenario of people having their eyes rounded or pulled down, most of the time, it's because a board certified plastic surgeon or somebody who was pretty qualified did not address that lateral canthal tendon.

So that's one aspect of the procedure that I think has to be important for you to understand. And when I do an evaluation of lateral canthal tendon, we do something called the pull test and the smack test to see how much spring there is to the lower eyelid. Then we look at the amount of fat that's under the eye and then whether or not there is extra skin.

Now, as far as choosing a surgeon is concerned, the field of cosmetic surgery, there are many types of specialists. And one of the things that is really good for patients is the ability to do research and learn about levels of specialization and training, but I think the factor that's even as important is experience. Every type of cosmetic surgeon, whether they're general plastic surgeons, ocular plastic surgeons, facial plastic surgeons, will do eyelid surgery. However, everyone has their own style, and there are different levels of experience and practice focus that helps distinguish one doctor from another. So understanding that the functional aspect of the lower eyelid and the complexity that is often missed on how lower eyelid surgery is done can be basically a caution for you to do the research and understand the level of expertise that your doctor has.

Now, usually, patients will look at pictures of before and afters and get a sense of the doctor's style. And in addition, I feel that it is important for a patient to feel that the doctor can handle the different levels of complications. Now there are first level, second level and of course, more very advanced issues, but I think that most patients feel that an experienced doctor who could handle any issues because no surgery is without some risk. And so feeling comfortable with that is something that I think would be advisable. So that being said, doing some research and meeting with doctors and understanding what the risks are of the surgery.


Eyelid Surgery: Choosing the Best Procedure and Surgeon

Dr. Amiya Prasad details the important aspects of lower eyelid surgery and how to choose the right cosmetic surgeon for the intricate and delicate areas around the eyes.