Female: Unbelievable bags under my eyes. Lower bleph, or facelift, or...? When I was younger, I always had deep hollows and the purple veins also showed through my thin skin. Bags started around age forty. They swell some days more than others, but are ever-present. I had upper bleph three years ago and loved the results, but lower bleph scares me.

Dr. Amiya Prasad: Thank you for your question. You submitted a question where you describe your eye bags as being unbelievable and that you are hesitant about pursuing lower eyelid surgery and you are somewhat confused about the decision on whether to do a facelift or a lower lid blepharoplasty and that the decision is a little tricky, based on your own observation that when you physically lift your face, that there is improvement. So as a cosmetic oculofacial plastic surgeon specializing in facial aging surgery for 20 years, I do a lot of lower eyelid, upper eyelid surgery, as well as face and face and neck lifts. So I can share with you my experience doing this for twenty years. First, let's understand that the lower eyelids and the upper eyelids are in a very unique space we will call the orbit. And although when you physically move everything, we call it the mirror lift, it may look better, but it is not at a level that is truly sustainable when you do aggressive facelifting. So the short answer to your question is the lower eyelid procedure and the facelifting procedure are two separate procedures. Although there can be some secondary benefit to the lower eyelid by repositioning the cheek, as occurs with a facelift, trying to change the lower eyelid position, tone, and overall appearance from a facelifting procedure is just not likely to succeed.

The lower eyelid is a very complex structure and I think that your hesitation is well-founded. Again, as a specialist, I deal with patients who come from all over the world, many from the United States, where they've had lower eyelid surgery by board-certified plastic surgeons. And they have had severe lower eyelid retraction, skin loss, exposure, their lower eyelid is disconnected from their outer corners, all kinds of things. Lower eyelid anatomy is fairly complex. And it's deceptive when people who have an understanding, and when I say people, I mean surgeons, who have an understanding but don't do this as a specialty will sometimes get themselves in trouble because of the limitations of what they know. So the lower eyelid tone and position is so critical that you really should make this an important point in your decision-making process when you meet prospective doctors and choosing who to do your lower eyelid surgery.

But separately from that, for the lower face and jowl area, a procedure such as a facelift or a face and neck lift is typically what we do. And very often, we'll combine the lower eyelid surgery with the face and neck lift surgery. So that being said, when you meet with a doctor, the way to help you understand if the doctor truly has a mastery level of the lower eyelid surgery, various tests are done to check the tonicity of the lower eyelid, such as a pull test or a snap test. And with that, there are options on how to ensure that the lower eyelid position is maintained or enhanced, in some cases where it's sagged significantly doing procedures such as lateral tarsal strip. So when you are doing your consultations, you may decide whether to do them together, the procedures together, that is, or to do them separately if you are that concerned. And it might be more practical for you, with that level of anxiety, to just do the lower eyelids first and make sure everything turns out right.

In our practice, we don't use general anesthesia routinely for any procedure, so we do everything under local with light sedation. By doing that, our patients have the benefit of being able to make their decisions based on their own comfort, rather than decisions where there's an incentive to do as much as you can because you're gonna go under general anesthesia. So that being said, learn more about the situation you have with your lower eyelids. When you said they're really unbelievable, it might reflect the fact that there's a lot of sagging and loss of structure and quality of the position and the function of the lower eyelid. So there may be a lot more needed in order to get a nice result and so your anxiety is probably well-founded. So that being said, meet with qualified, experienced cosmetic surgeons about your lower eyelids and the face and neck lift. And then once you feel comfortable, move forward and have these procedures done. I wish you the best of luck, I hope that was helpful, and thank you for your question.


Why A Facelift Will Not Solve Eye Bag Problems

Dr. Amiya Prasad details why a specialist in lower eyelid surgery has more knowledge of this complex area than many board certified plastic surgeons. He also shows why a facelift is a separate procedure.